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HI 01001.276: Sample Notice- State or Local Government Retirement System Discontinues Paying the Premium Surcharge for Medicare Part B -- Beneficiary in Current Pay Status

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  • Effective Dates: 01/15/2004 - Present
  • Effective Dates: 01/31/2018 - Present
  • TN 25 (01-04)
  • HI 01001.276 Sample Notice- State or Local Government Retirement System Discontinues Paying the Premium Surcharge for Medicare Part B -- Beneficiary in Current Pay StatusNortheastern Program Service Center1 Jamaica Center PlazaJamaica, New York 11432-3898
  • HI 01001.276 Sample Notice- State or Local Government Retirement System Discontinues Paying the Premium Surcharge for Medicare Part B -- Beneficiary in Current Pay StatusNortheastern Program Service Center 1 Jamaica Center Plaza Jamaica, New York 11432-3898
  •       Date: October 16, 1997
  •       Date: October 16, 1997
  •        Claim Number: 000-00-0000ATony Scott1212 Oak StreetAlexandria, VA ZIP   
  •       BNC#: 00A0000A00000-A John Doe 1212 Oak Street Alexandria, VA ZIP   
  • Your State or local government retirement system will no longer pay your Medicare medical insurance late enrollment surcharge after MM/YYYY. You must pay the premium surcharge beginning MMYYYY. This surcharge is in addition to the basic Medicare premium you pay now.
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  • What We Plan To Do
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  • We will deduct the combined premium surcharge and 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.
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  • If You Disagree With The Decision
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  • 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.
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  • * 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.
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  • If You Have Any Questions
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  • If you have any questions about the State or local government retirement system, please contact that office.
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  • 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 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 Office Suite 220 6295 Edsall Road Alexandria, 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
The materials available at this web site are provided free of charge, for informational purposes only, and without warrant by True Link Financial, Inc., and are not legal advice or Social Security benefits advice. You should contact your attorney to obtain advice with respect to any particular issue or problem, or the Social Security Administration with any general inquiries. Click here to view this section of the POMS on the Social Security Administration website.