HI 01001.275: Sample Notice- State or Local Government Retirement System Will Pay the Premium Surcharge for Medicare Part B -- Beneficiary in Current Pay Status
Effective Dates: 01/15/2004 - Present
- TN 25 (01-04)
HI 01001.275 Sample Notice- State or Local Government Retirement System Will Pay the Premium Surcharge for Medicare Part B -- Beneficiary in Current Pay StatusNortheastern Program Service Center1 Jamaica Center PlazaJamaica, New York 11432-3898 Date: October 16, 1997 Claim Number: 000-00-0000A Tony Scott1212 Oak StreetAlexandria, VA ZIP
- We must charge a premium surcharge on your Medicare medical insurance because you enrolled later than you could have. Your State or local government retirement system will pay your late enrollment premium surcharge beginning MM/YYYY. However, you must pay the basic Medicare medical insurance premium.
- What We Plan To Do
- We will deduct the basic Medicare Part B premium of $XX.XX from your monthly payment. After we deduct this amount, you will receive a monthly benefit payment of $XXX.XX around MM/DD/YYYY. Below we tell you what to do if you disagree with this change in the amount of your monthly payment.
- If You Disagree With The Decision
- If you disagree with the change we have made to your monthly payment, you have the right to appeal. We will review your case again and consider any new facts you have. A person who did not make the first decision will decide your case.
- * You have 60 days to ask for an appeal.
- * The 60 days start the day after you receive this letter. We assume you got this letter 5 days after the date on it unless you show us that you did not get it within the 5-day period.
- * You must have a good reason if you wait more than 60 days to ask for an appeal.
- * You have to ask for an appeal in writing. We will ask you to sign a Form SSA-561-U2, called
- [ ] Request for Reconsideration.
- [ ] Contact one of our offices if you want help.
- If You Have Any Questions
- If you have any questions about the State or local government retirement system, please contact that office.
If you have any questions about Medicare, you may call us toll-free at 1-800-772-1213, or call your local Social Security office. The office that serves your area is located at:District OfficeSuite 2206295 Edsall RoadAlexandria, VA 22312
- If you do call or visit an office, please have this letter with you. It will help us answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.
- Assistant Regional Commissioner,
- Processing Center Operations
x← This means that the line was removed and was added – in other words, the "Effective Dates" line at the top of the document has been updated to reflect that the new version is effective as of the date the change was made.