NL 00730.116:
“H” Paragraphs and Captions
Effective Dates: 08/01/2017 - Present- Effective Dates: 03/30/2018 - Present
TN 26 (08-17)- TN 28 (03-18)
- NL 00730.116 “H” Paragraphs and Captions
- A. List of “H” paragraphs and captions
- HBN001 – AUTOMATED CMS BILLING NOTICE USED WITH HIB225
- (appears after the signature page of the notice)
- NOTICE OF MEDICARE PREMIUM PAYMENT DUE
- CENTER FOR MEDICARE & MEDICAID SERVICES
- BILLING DATE: (1)
- MEDICAL PREMIUMS FOR
PERIOD ENDING (2)- PERIOD ENDING: (2)
CURRENT AMOUNT DUE (3)- CURRENT AMOUNT DUE: (3)
PAYMENT DUE BY (4)- PAYMENT DUE BY: (4)
- Return the bottom portion of this notice with your payment and use the enclosed envelope to mail your payment.
You must pay by check or money order. Show the claim number at the top of your check or money order. Make the check or money order payable to: CMS MEDICARE INSURANCE.- You must pay by check or money order. Include your Medicare number at the top of your check or money order. Make the check or money order payable to: CMS MEDICARE INSURANCE.
- If you have changed your address, be sure to write your new address in the space provided below.
- If you should have any questions concerning this Notice of Medicare Premium Payment Due, please write or visit any Social Security Office.
- PLEASE DETACH AT DOTTED LINE
- ------------------------------------------------------------------------------------------------------------
- CMS-500A
CLAIM NUMBER: (5) AMOUNT DUE: (6)- Medicare Number: (5) Amount Due: (6)
NAME: (7)- Name: (7)
MAKE CHECKS PAYABLE TO:- Make Checks Payable To:
- CMS MEDICARE INSURANCE
SEND TO:- Send To:
- Medicare Premium Collection Center
- PO Box 790355
- St. Louis, MO 63179-0355
- ( ) Check here if your address has changed. Show new address below.
- ________________________________________________________
-
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
- the date of the T2Redesign notice in the format June 27, 2001
Fill-in (2)- Fill-in (2)
- December of the current operating year, unless the COM is December of the COY, then December of the following COY in the format December 2001
Fill-in (3)- Fill-in (3)
- SMI premiums due
Fill-in (4)- Fill-in (4)
- the 20th day of the third calendar month after the date of the T2Redesign notice in the format September 20, 2001
Fill-in (5)- Fill-in (5)
CLAIM NUMBER- Medicare Beneficiary Identification (MBI) Number
Fill-in (6)- Fill-in (6)
- SMI premiums due
Fill-in (7)- Fill-in (7)
- BGN plus BLN (not possessive)
- B. “HDR” - Headings
- HDR030 - DATE AND BENEFICIARY NOTICE CONTROL NUMBER
- Fill-in values:
-
- Fill-in (1)
- Show T2R Run Date plus 7 days in the format Month DD, CCYY
BGN plus BLNB. “HIB” UNIVERSAL TEXT IDENTIFIERS – HEALTH INSURANCE BENEFITS- Fill-in (2)
- Show 13 character alphanumeric Beneficiary Notice Control # plus 1-4 character alphanumeric Beneficiary Identification Code in the format XXXXXXXXXXXXX-XXXX
- C. “HIB” UNIVERSAL TEXT IDENTIFIERS – HEALTH INSURANCE BENEFITS
- HIBC01 – CAPTION
- Information About Medicare
- HIBC02 – CAPTION
- Health Insurance For Children
- HIBC05 – CAPTION
- Why (1) Cannot Quality For Medicare
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
show the BGN plus BLN- show the BGN plus BLN (not possessive)
HIBC15 – CAPTION- HIBC15 – CAPTION
- To Cancel This Insurance
- HIBC19 – CAPTION
- Notice of Group Billing
- HIB001 – ENTITLED TO HI AND/OR SMI
- (1) Medicare (2) (3) (4) (5).
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- Your
Choice 2- Choice 2
- Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- Part A (hospital insurance) starts
Choice 2- Choice 2
- Part B (medical insurance) starts
Choice 3- Choice 3
- Part A (hospital insurance) and Part B (medical insurance) start
Fill-in (3)- Fill-in (3)
- Date in format Month CCYY
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- and Part B (medical insurance) starts
Choice 2- Choice 2
- Null
Fill-in (5)- Fill-in (5)
-
Choice 1- Choice 1
- Date in format Month CCYY
Choice 2- Choice 2
- Null
HIB005 – SMI PREMIUM BILLING- HIB002 - TEMPORARY SUBSTITUTION OF NOTICE FOR HEALTH INSURANCE CARD
- (1) will get a Medicare card within 2 weeks. (2) show this card when (3) medical care. To learn more about what Medicare covers, visit Medicare.gov. If (4) questions about (5) Medicare coverage, call 1-800-MEDICARE (1-800-633-4277).
- Fill-in values:
-
- Fill-in (1)
-
- Choice 1
- You
- Choice 2
- BGN plus BLN (not possessive)
- Fill-in (2)
-
- Choice 1
- You should
- Choice 2
- He should
- Choice 3
- She should
- Fill-in (3)
-
- Choice 1
- you need
- Choice 2
- he needs
- Choice 3
- she needs
- Fill-in (4)
-
- Choice 1
- you have
- Choice 2
- he has
- Choice 3
- she has
- Fill-in (5)
-
- Choice 1
- your
- Choice 2
- his
- Choice 3
- her
- HIB005 – SMI PREMIUM BILLING
- (1) monthly premium for Medicare Part B (medical insurance) is (2) beginning (3) (4) (5).
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- Your
Choice 2- Choice 2
- His
Choice 3- Choice 3
- Her
Fill-in (2)- Fill-in (2)
- Amount of Part B premium in $$$$$.¢¢ format
Fill-in (3)- Fill-in (3)
- Date in MMCCYY format
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- null
Choice 2- Choice 2
- and
Fill-in (5)- Fill-in (5)
-
Choice 1- Choice 1
- null
Choice 2- Choice 2
- Show the amount of the Part B premium in the format $$$$$¢¢ plus the word “beginning” plus show the start date that corresponding to the second premium rate returned from the HSA utility in the format MMCCYY
HIB008 – SMI PREMIUM DEDUCTIONS- HIB008 – SMI PREMIUM DEDUCTIONS
- We will start to take premiums out of (1) (2) check.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- next
Choice 2- Choice 2
- MMDDYYYY (using the PCI, show the calendar date for the month following COM (e.g. if PCI = 2 and the COM = 4/98, then fill-in 2 will equal the calendar date for the second Wednesday in May)
HIB011 – HI PREMIUM BILLING- HIB011 – HI PREMIUM BILLING
- The monthly premium for (1) hospital insurance is (2). We will bill you each month for (3).
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (2)- Fill-in (2)
- Show the current HI premium rate in the format 999.99
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- this premium
Choice 2- Choice 2
- the combined premium for hospital and medical insurance
HIB013 – MEDICARE HI/SMI PREMIUM PENALTY- HIB013 – MEDICARE HI/SMI PREMIUM PENALTY
- (1) a penalty because (2) enrolled later than (3) could have.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- This medical insurance premium includes
Choice 2- Choice 2
- This hospital insurance premium includes
Choice 3- Choice 3
- These hospital and medical insurance premiums include
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- he
Choice 2- Choice 2
- she
Choice 3- Choice 3
- you
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- he
Choice 2- Choice 2
- she
Choice 3- Choice 3
- you
HIB015 – PREMIUMS DEDUCTED FROM CIVIL SERVICE ANNUITY- HIB015 – PREMIUMS DEDUCTED FROM CIVIL SERVICE ANNUITY
- The Office of Personnel Management will deduct the premiums from (1) annuity checks. They will let (2) know when this will start.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
BGN plus BLN possessive- BGN plus BLN (possessive)
Choice 2- Choice 2
- your
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- him
Choice 2- Choice 2
- her
Choice 3- Choice 3
- you
HIB026 – 3RD PARTY BUYIN TP STARTS DATES/CODES DO NOT MATCH- HIB026 – 3RD PARTY BUYIN TP STARTS DATES/CODES DO NOT MATCH
- (1) (2) will pay (3) Medicare hospital insurance premiums beginning (4). (5)
- (6) (7) will pay (8) Medicare medical insurance premiums beginning (9). (10)
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- Leave Blank
Choice 2- Choice 2
- The State of
Fill-in (2)- Fill-in (2)
- show State name
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
BGN plus BLN possessive- BGN plus BLN (possessive)
Choice 2- Choice 2
- your
Fill-in (4)- Fill-in (4)
- Show the TP START DATE in the format MMCCYY
Fill-in (5)- Fill-in (5)
-
Choice 1- Choice 1
- This also means that he is entitled to this Medicare coverage for an earlier period than shown on his current Medicare card.
Choice 2- Choice 2
- This also means that she is entitled to this Medicare coverage for an earlier period than shown on her current Medicare card.
Choice 3- Choice 3
- This also means that you are entitled to this Medicare coverage for an earlier period than shown on your current Medicare card.
Choice 4- Choice 4
- Null
Fill-in (6)- Fill-in (6)
-
Choice 1- Choice 1
- Leave Blank
Choice 2- Choice 2
- The State of
Fill-in (7)- Fill-in (7)
- show State name
Fill-in (8)- Fill-in (8)
-
Choice 1- Choice 1
BGN plus BLN possessive- BGN plus BLN (possessive)
Choice 2- Choice 2
- your
Fill-in (9)- Fill-in (9)
- Show the TP START date in the format MMCCYY
Fill-in (10)- Fill-in (10)
-
Choice 1- Choice 1
- This also means that he is entitled to this Medicare coverage for an earlier period than shown on his current Medicare card.
Choice 2- Choice 2
- This also means that she is entitled to this Medicare coverage for an earlier period than shown on her current Medicare card.
Choice 3- Choice 3
- This also means that you are entitled to this Medicare coverage for an earlier period than shown on your current Medicare card.
Choice 4- Choice 4
- Null
HIB027 – 3RD PARTY BUYOUT TP STARTS DATES/CODES DO NOT MATCH- HIB027 – 3RD PARTY BUYOUT TP STARTS DATES/CODES DO NOT MATCH
- (1) (2) will no longer pay (3) Medicare hospital insurance premiums after (4).
- (5) must pay the premiums beginning (6).
- (7) (8) will no longer pay (9) Medicare medical insurance premiums after (10).
- (11) must pay the premiums beginning (12).
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- Leave Blank
Choice 2- Choice 2
- The State of
Fill-in (2)- Fill-in (2)
- Show State name
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
BGN plus BLN possessive- BGN plus BLN (possessive)
Choice 2- Choice 2
- your
Fill-in (4)- Fill-in (4)
- Show TP STOP date in the format MMCCYY
Fill-in (5)- Fill-in (5)
-
Choice 1- Choice 1
- He
Choice 2- Choice 2
- She
Choice 3- Choice 3
- You
Fill-in (6)- Fill-in (6)
- Show the TP STOP date plus 1 month in the format MMCCYY
Fill-in (7)- Fill-in (7)
-
Choice 1- Choice 1
- Leave Blank
Choice 2- Choice 2
- The State of
Fill-in (8)- Fill-in (8)
- Show State name
Fill-in (9)- Fill-in (9)
-
Choice 1- Choice 1
BGN plus BLN possessive- BGN plus BLN (possessive)
Choice 2- Choice 2
- your
Fill-in (10)- Fill-in (10)
- Show the TP STOP date in the format MMCCYY
Fill-in (5)- Fill-in (5)
-
Choice 1- Choice 1
- He
Choice 2- Choice 2
- She
Choice 3- Choice 3
- You
Fill-in (12)- Fill-in (12)
- Show the TP STOP date plus 1 month in the format MMCCYY
HIB029 – LIMITED BUYIN FOR HI/SMI DATES/CODES DO NOT MATCH- HIB029 – LIMITED BUYIN FOR HI/SMI DATES/CODES DO NOT MATCH
- (1) (2) paid (3) Medicare hospital insurance premium for (4).
- (5) (6) paid (7) Medicare medical insurance premium for (8).
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- Leave Blank
Choice 2- Choice 2
- The State of
Fill-in (2)- Fill-in (2)
- Show the State name
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
BGN plus BLN possessive- BGN plus BLN (possessive)
Choice 2- Choice 2
- your
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- MMCCYY
Choice 2- Choice 2
- MMCCYY and MMCCYY
Choice 3- Choice 3
- MMCCYY through MMCCYY
Fill-in (5)- Fill-in (5)
-
Choice 1- Choice 1
- Leave Blank
Choice 2- Choice 2
- The State of
Fill-in (6)- Fill-in (6)
- Show the State name
Fill-in (7)- Fill-in (7)
-
Choice 1- Choice 1
BGN plus BLN possessive- BGN plus BLN (possessive)
Choice 2- Choice 2
- your
Fill-in (8)- Fill-in (8)
-
Choice 1- Choice 1
- MMCCYY
Choice 2- Choice 2
- MMCCYY and MMCCYY
Choice 3- Choice 3
- MMCCYY through MMCCYY
HIB030 – GROUP PAYER STOPS FOR HI/SMI DATES NOT EQUAL- HIB030 – GROUP PAYER STOPS FOR HI/SMI DATES NOT EQUAL
- The organization that was paying (1) Medicare hospital insurance premium will no longer pay it after (2). (3) must pay the premium beginning (4).
- The organization that was paying (5) Medicare medical insurance premium will no longer pay it after (6). (7) must pay the premium beginning (8).
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
BGN plus BLN possessive- BGN plus BLN (possessive)
Choice 2- Choice 2
- your
Fill-in (2)- Fill-in (2)
- MMCCYY
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- He
Choice 2- Choice 2
- She
Choice 3- Choice 3
- You
Fill-in (4)- Fill-in (4)
- MMCCYY
Fill-in (5)- Fill-in (5)
-
Choice 1- Choice 1
- BGN plus BLN possessive
Choice 2- Choice 2
- your
Fill-in (6)- Fill-in (6)
- MMCCYY
Fill-in (7)- Fill-in (7)
-
Choice 1- Choice 1
- He
Choice 2- Choice 2
- She
Choice 3- Choice 3
- You
Fill-in (8)- Fill-in (8)
- MMCCYY
HIB034 –ADVISE THAT SMI DEDUCTION WILL CONTINUE- HIB034 –ADVISE THAT SMI DEDUCTION WILL CONTINUE
- We will continue to deduct Medicare Part B (medical. insurance) premium of (1) from (2) payments.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
- Show the total of DAH-ITEMS = 430, 435 and 440 in the format $$$$$
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- your
Choice 2- Choice 2
BGN plus BLN possessive- BGN plus BLN (possessive)
HIB038 – MEDICARE DISALLOWANCE CRIME AGAINST UNITED STATES- HIB038 – MEDICARE DISALLOWANCE CRIME AGAINST UNITED STATES
- (1) cannot qualify for Medicare because (2) been convicted of a crime against the Security of the United States.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- He
Choice 2- Choice 2
- She
Choice 3- Choice 3
- You
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- he has
Choice 2- Choice 2
- she has
Choice 3- Choice 3
- you have
HIB042 – MEDICARE DISALLOWANCE FEHB ACT OF 1959- HIB042 – MEDICARE DISALLOWANCE FEHB ACT OF 1959
- (1) cannot qualify for Medicare because (2) covered under the Federal Employees Health Benefits Act
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- He
Choice 2- Choice 2
- She
Choice 3- Choice 3
- You
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- he is
Choice 2- Choice 2
- she is
Choice 3- Choice 3
- you are
Choice 4- Choice 4
- he could be
Choice 5- Choice 5
- she could be
Choice 6- Choice 6
- you could be
HIB050 – MED DISAL NH AGE 65 BEFORE END OF WAITING PERIOD- HIB050 – MED DISAL NH AGE 65 BEFORE END OF WAITING PERIOD
- You do not qualify for Medicare based on disability because your coverage cannot start before you reach age 65.
- To receive Medicare coverage before age 65, a person must be disabled under our rules for 29 months before coverage begins. Based on the date you said you became disabled, coverage could not begin until after you reach age 65. For this reason, we have not decided whether or not you are disabled.
- You may qualify for Medicare when you reach age 65, whether or not you are disabled under our rules.
- HIB053 – PREMIUM HI DENIED AND/OR SMI DISALLOWED (RDD 107)
- (1) not entitled to (2) insurance coverage under Medicare because (3) application was filed too late. However, (4) may apply for coverage again during the next general enrollment period. A general enrollment period takes place in January, February and March of each year.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- Beneficiary Full Name plus the word “is”
Choice 2- Choice 2
You are- You are
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- medical
Choice 2- Choice 2
- hospital
Choice 3- Choice 3
- hospital and medical
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- he
Choice 2- Choice 2
- she
Choice 3- Choice 3
- you
HIB054 – HI AND/OR SMI PERIOD NOT PREVIOUSLY COVERED- HIB054 – HI AND/OR SMI PERIOD NOT PREVIOUSLY COVERED
- If (1) had any expenses that (2) should be covered by Medicare (3) insurance, please contact your local Social Security office. The telephone number and address are shown below.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- BGN plus BLN the word “has”
Choice 2- Choice 2
- Beneficiary First Name plus the word “has”
Choice 3- Choice 3
- you have
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- he believes
Choice 2- Choice 2
- she believes
Choice 3- Choice 3
- you believe
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- hospital
Choice 2- Choice 2
- medical
Choice 3- Choice 3
- hospital and medical
HIB060 – SUSPENSE FOR PRISON/MENTAL ADVISES OF SMI PREMIUMS- HIB060 – SUSPENSE FOR PRISON/MENTAL ADVISES OF SMI PREMIUMS
- Generally, Medicare will not pay for hospital or medical items or services (1) while (2) (3). However, you may want to pay (4) Medicare medical insurance premiums for two reasons:
- * The premiums may be higher if you cancel the Medicare medical insurance now and reenroll after (5) released from (6).
- * (7) may not have medical insurance for a period of time after (8) released from (9). This is because (10) will have to wait until a general enrollment period to reenroll. A general enrollment period takes place in January, February and March of each year.
- If you want to cancel (11) medical insurance, please let us know. If you decide to keep Medicare medical insurance, we will bill you for the premium. The first bill we send will be for all premiums now due. After that, each bill we send will be for a 3-month period and will be sent to you shortly before the payment is due.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- BGN plus BLN plus the word “receives”
Choice 2- Choice 2
- you receive
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- he is
Choice 2- Choice 2
- she is
Choice 3- Choice 3
- you are
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- imprisoned
Choice 2- Choice 2
- confined in an institution
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (5)- Fill-in (5)
-
Choice 1- Choice 1
- he is
Choice 2- Choice 2
- she is
Choice 3- Choice 3
- you are
Fill-in (6)- Fill-in (6)
-
Choice 1- Choice 1
- prison
Choice 2- Choice 2
- the institution
Fill-in (7)- Fill-in (7)
-
Choice 1- Choice 1
- BGN plus BLN
Choice 2- Choice 2
- You
Fill-in (8)- Fill-in (8)
-
Choice 1- Choice 1
- he is
Choice 2- Choice 2
- she is
Choice 3- Choice 3
- you are
Fill-in (9)- Fill-in (9)
-
Choice 1- Choice 1
- prison
Choice 2- Choice 2
- the institution
Fill-in (10)- Fill-in (10)
-
Choice 1- Choice 1
- he
Choice 2- Choice 2
- she
Choice 3- Choice 3
- you
Fill-in (11)- Fill-in (11)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
HIB061 – SMI PREMIUM CONTINUES DEDUCTION FROM CS ANNUITY- HIB061 – SMI PREMIUM CONTINUES DEDUCTION FROM CS ANNUITY
- The Office of Personnel Management will continue to deduct (1) medical insurance premiums from (2) annuity checks.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
Beneficiary Full Name possessive- Beneficiary Full Name (possessive)
Choice 2- Choice 2
- your
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
HIB066 – HI/SMI PREMIUMS ALREADY PAID- HIB066 – HI/SMI PREMIUMS ALREADY PAID
- Any (1) insurance premiums (2) already paid will be credited to (3) record.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- medical
Choice 2- Choice 2
- hospital
Choice 3- Choice 3
- hospital and medical
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- BGN plus BLN plus “has”
Choice 2- Choice 2
- BGN plus “has”
Choice 3- Choice 3
- you have
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
HIB067 – SMI PREMIUM BILLING- HIB067 – SMI PREMIUM BILLING
- We will send (1) first bill for the premiums within a month. Each bill after that will be for a 3-month period.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
HIB068 – HI/SMI EQUITABLE RELIEF- HIB068 – HI/SMI EQUITABLE RELIEF
- If (1) these benefits earlier, (2) can choose (3) insurance benefits beginning (4). To start benefits earlier, within 60 days after the date of this notice (5) must tell us in writing that (6) (7) insurance benefits beginning (8). In addition, (9) must:
- * pay us (10) (this covers premiums due from (11) through (12)); or
- (13)
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- he wants
Choice 2- Choice 2
- she wants
Choice 3- Choice 3
- you want
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- he
Choice 2- Choice 2
- she
Choice 3- Choice 3
- you
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- hospital
Choice 2- Choice 2
- medical
Choice 3- Choice 3
- hospital and medical
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- Show the HI-NONEQRELST date in MMCCYY
Choice 2- Choice 2
- Show the SMI-NONEQRELST date in MMCCYY
Fill-in (5)- Fill-in (5)
-
Choice 1- Choice 1
- he
Choice 2- Choice 2
- she
Choice 3- Choice 3
- you
Fill-in (6)- Fill-in (6)
-
Choice 1- Choice 1
- he wants
Choice 2- Choice 2
- she wants
Choice 3- Choice 3
- you want
Fill-in (7)- Fill-in (7)
-
Choice 1- Choice 1
- hospital
Choice 2- Choice 2
- medical
Choice 3- Choice 3
- hospital and medical
Fill-in (8)- Fill-in (8)
-
Choice 1- Choice 1
- Show the HI-NONEQRELST date in MMCCYY
Choice 2- Choice 2
- Show the SMI-NONEQRELST date in MMCCYY
Fill-in (9)- Fill-in (9)
-
Choice 1- Choice 1
- he
Choice 2- Choice 2
- she
Choice 3- Choice 3
- you
Fill-in (10)- Fill-in (10)
-
Choice 1- Choice 1
- Show the total amount for HI premiums calculated
Choice 2- Choice 2
- Show the total amount for SMI premiums calculated
Choice 3- Choice 3
- Show the combined total amount for HI and SMI premiums calculated
Fill-in (11)- Fill-in (11)
-
Choice 1- Choice 1
- Show the HI-NONEQRELST date in MMCCYY
Choice 2- Choice 2
- Show the SMI-NONEQRELST date in MMCCYY
Fill-in (12)- Fill-in (12)
- Show the COM month in MMCCYY
Fill-in (13)- Fill-in (13)
-
Choice 1- Choice 1
- tell us we can withhold this amount from the check.
Choice 2- Choice 2
- tell us to bill you for this amount.
HIB069 – HI/SMI TERMINATION FOR NON-PAYMENT OF PREMIUMS- HIB069 – HI/SMI TERMINATION FOR NON-PAYMENT OF PREMIUMS
- (1) Medicare premium amount of (2) for (3) insurance was not paid within the time limit. Therefore, (4) (5) insurance coverage has stopped. (6) last month of coverage (7) (8). Benefits will not be paid for any (9) services (10) after (11) last month of coverage.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
BGN plus BLN possessive- BGN plus BLN (possessive)
Choice 2- Choice 2
- Your
Fill-in (2)- Fill-in (2)
- Show money amount for HI/SMI premiums due in 99999.99
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- hospital
Choice 2- Choice 2
- medical
Choice 3- Choice 3
- hospital and medical
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (5)- Fill-in (5)
-
Choice 1- Choice 1
- hospital
Choice 2- Choice 2
- medical
Choice 3- Choice 3
- hospital and medical
Fill-in (6)- Fill-in (6)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (7)- Fill-in (7)
-
Choice 1- Choice 1
- is
Choice 2- Choice 2
- was
Fill-in (8)- Fill-in (8)
-
Choice 1- Choice 1
- Show the HI TERM date minus 1 month in MMCCYY
Choice 2- Choice 2
- Show the SMI TERM date minus 1 month in MMCCYY
Fill-in (9)- Fill-in (9)
-
Choice 1- Choice 1
- hospital
Choice 2- Choice 2
- medical
Choice 3- Choice 3
hospital and medical- hospital and medical
Fill-in (10)- Fill-in (10)
-
Choice 1- Choice 1
- he receives
Choice 2- Choice 2
- she receives
Choice 3- Choice 3
- you receive
Fill-in (11)- Fill-in (11)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
HIB070 – PREMIUM HI DWI CONTINUES SMI TERMINATES NON-PAYMENT- HIB070 – PREMIUM HI DWI CONTINUES SMI TERMINATES NON-PAYMENT
- This decision does not affect (1) (2) insurance coverage. (3) should continue to pay (4) insurance premiums to keep this coverage.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- medical
Choice 2- Choice 2
- hospital
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- He
Choice 2- Choice 2
- She
Choice 3- Choice 3
- You
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- medical
Choice 2- Choice 2
- hospital
HIB071 – RRB JURIS STARTS AND COLLECTS MEDICARE PREMIUMS- HIB071 – RRB JURIS STARTS AND COLLECTS MEDICARE PREMIUMS
- The Social Security Administration is no longer responsible for deducting Medicare premiums from Social Security payments. The Railroad Retirement Board (RRB) is now responsible for collecting medical insurance premiums for all railroad beneficiaries and their families. This includes beneficiaries who are also entitled to Social Security benefits.
- HIB072 – RRB JURIS STARTS AND COLLECTS MEDICARE PREMIUMS
- Since (1) (2) a railroad beneficiary, the RRB will start to withhold medical insurance premiums from (3) Railroad Retirement annuity. If (4) not currently receiving a Railroad Retirement annuity, the Social Security Administration will let the RRB know when (5) next premium is due. The RRB will send (6) a bill for premiums.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- BGN plus BLN
Choice 2- Choice 2
- You
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- is
Choice 2- Choice 2
- are
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- he is
Choice 2- Choice 2
- she is
Choice 3- Choice 3
- you are
Fill-in (5)- Fill-in (5)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (6)- Fill-in (6)
-
Choice 1- Choice 1
- him
Choice 2- Choice 2
- her
Choice 3- Choice 3
- you
HIB073 – RRB SENDS NEW MEDICARE CARD- HIB073 – RRB SENDS NEW MEDICARE CARD
- (1) protection under Medicare will continue without any change in coverage.
- The RRB will send (2) a new Medicare card. Until then, (3) may use (4) old card.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
BGN plus BLN possessive- BGN plus BLN (possessive)
Choice 2- Choice 2
- Your
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- him
Choice 2- Choice 2
- her
Choice 3- Choice 3
- you
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- he
Choice 2- Choice 2
- she
Choice 3- Choice 3
- you
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
HIB074 – NEW MEDICARE CARD- HIB074 – NEW MEDICARE CARD
- We will send (1) a new health insurance card. It will show that (2) entitled to (3) insurance.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
BGN plus BLN- BGN plus BLN (not possessive)
Choice 2- Choice 2
BGN- BGN (not possessive)
Choice 3- Choice 3
- you
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- he is
Choice 2- Choice 2
- she is
Choice 3- Choice 3
- you are
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- hospital
Choice 2- Choice 2
- medical
Choice 3- Choice 3
- hospital and medical
HIB075 – EQUITABLE RELIEF/HARDSHIP- HIB075 – EQUITABLE RELIEF/HARDSHIP
- If (1) benefits beginning (2) but (3) it hard to pay the premium amount in a lump sum, ask us about other ways to pay the money.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- he wants
Choice 2- Choice 2
- she wants
Choice 3- Choice 3
- you want
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- Show the HI NONEQRELST date in MMCCYY
Choice 2- Choice 2
- Show the SMI NONEQRELST date in MMCCYY
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- find
Choice 2- Choice 2
- finds
HIB076 – HI/SMI TERMINATION INFORMATIONAL- HIB076 – HI/SMI TERMINATION INFORMATIONAL
If (1) not sign up for Part B when (2) first eligible, (3) may have to pay a late enrollment penalty for as long as (4) Part B. (5) monthly premium may go up 10 percent for each full 12-month period that (6) could have had Part B coverage, but did not sign up for it. Usually, (7) will not have to pay a late enrollment penalty if (8) up during a special enrollment period. If (9) to sign up for (10) later, (11) will usually have to wait until the general enrollment period. The general enrollment period takes place in January, February, and March of each year. If (12) up in the general enrollment period, (13) Part B coverage will start July 1 of the year (14) up.- If (1) not sign up for Part B when (2) first eligible, (3) may have to pay a late enrollment penalty for as long as (4) Part B. (5) monthly premium may go up 10 percent for each full 12-month period that (6) could have had Part B coverage, but did not sign up for it. Usually, (7) will not have to pay a late enrollment penalty if (8) up during a special enrollment period. If (9) to sign up for (10) later, (11) will usually have to wait until the general enrollment period. The general enrollment period takes place in January, February, and March of each year. If (12) up in the general enrollment period, (13) Part B coverage will start July 1 of the year (14) up.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- you do
Choice 2- Choice 2
- he does
Choice 3- Choice 3
- she does
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- you are
Choice 2- Choice 2
- he is
Choice 3- Choice 3
- she is
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- you
Choice 2- Choice 2
- he
Choice 3- Choice 3
- she
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- you have
Choice 2- Choice 2
- he has
Choice 3- Choice 3
- she has
Fill-in (5)- Fill-in (5)
-
Choice 1- Choice 1
- Your
Choice 2- Choice 2
- His
Choice 3- Choice 3
- Her
Fill-in (6)- Fill-in (6)
-
Choice 1- Choice 1
- you
Choice 2- Choice 2
- he
Choice 3- Choice 3
- she
Fill-in (7)- Fill-in (7)
-
Choice 1- Choice 1
- you
Choice 2- Choice 2
- he
Choice 3- Choice 3
- she
Fill-in (8)- Fill-in (8)
-
Choice 1- Choice 1
- you sign
Choice 2- Choice 2
- he signs
Choice 3- Choice 3
- she signs
Fill-in (9)- Fill-in (9)
-
Choice 1- Choice 1
- you want
Choice 2- Choice 2
- BGN plus BLN plus “wants”
Fill-in (10)- Fill-in (10)
-
Choice 1- Choice 1
- Part A
Choice 2- Choice 2
- Part B
Choice 3- Choice 3
- Part A and Part B
Fill-in (11)- Fill-in (11)
-
Choice 1- Choice 1
- you
Choice 2- Choice 2
- he
Choice 3- Choice 3
- she
Fill-in (12)- Fill-in (12)
-
Choice 1- Choice 1
- you sign
Choice 2- Choice 2
- he signs
Choice 3- Choice 3
- she signs
Fill-in (13)- Fill-in (13)
-
Choice 1- Choice 1
- your
Choice 2- Choice 2
- his
Choice 3- Choice 3
- her
Fill-in (14)- Fill-in (14)
-
Choice 1- Choice 1
- you sign
Choice 2- Choice 2
- he signs
Choice 3- Choice 3
- she signs
HIB077 – SMI TERMINATION INFORMATIONAL- HIB077 – SMI TERMINATION INFORMATIONAL
- People who have Medicare Part B (medical insurance) pay a monthly premium. If (1) not sign up for Part B when (2) first eligible, (3) may have to pay a late enrollment penalty for as long as (4) Part B. (5) monthly premium may go up 10 percent for each full 12-month period that (6) could have had Part B coverage, but did not sign up for it. Usually, (7) will not have to pay a late enrollment penalty if (8) up during a special enrollment period.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- you do
Choice 2- Choice 2
- he does
Choice 3- Choice 3
- she does
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- you are
Choice 2- Choice 2
- he is
Choice 3- Choice 3
- she is
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- you
Choice 2- Choice 2
- he
Choice 3- Choice 3
- she
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- you have
Choice 2- Choice 2
- he has
Choice 3- Choice 3
- she has
Fill-in (5)- Fill-in (5)
-
Choice 1- Choice 1
- Your
Choice 2- Choice 2
- His
Choice 3- Choice 3
- Her
Fill-in (6)- Fill-in (6)
-
Choice 1- Choice 1
- you
Choice 2- Choice 2
- he
Choice 3- Choice 3
- she
Fill-in (7)- Fill-in (7)
-
Choice 1- Choice 1
- you
Choice 2- Choice 2
- he
Choice 3- Choice 3
- she
Fill-in (8)- Fill-in (8)
-
Choice 1- Choice 1
- you sign
Choice 2- Choice 2
- he signs
Choice 3- Choice 3
- she signs
HIB078 – HI TERMINATION INFORMATIONAL- HIB078 – HI TERMINATION INFORMATIONAL
- (1) monthly premium for hospital insurance may be 10 percent higher when (2).
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- His
Choice 2- Choice 2
- Her
Choice 3- Choice 3
- Your
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- he re-enrolls
Choice 2- Choice 2
- she re-enrolls
Choice 3- Choice 3
- you re-enroll
HIB079 – VOLUNTARY TERMINATION FOR PREMIUM HI OR SMI- HIB079 – VOLUNTARY TERMINATION FOR PREMIUM HI OR SMI
- Because (10) canceling (2) (3) insurance coverage, (4) no longer entitled to (5) insurance coverage. (6) hospital and medical insurance coverage ends on the last day of (7).
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- BGN plus BLN plus the word “is”
Choice 2- Choice 2
- BGN plus the word “is”
Choice 3- Choice 3
- you are
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- medical
Choice 2- Choice 2
- hospital
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- he is
Choice 2- Choice 2
- she is
Choice 3- Choice 3
- you are
Fill-in (5)- Fill-in (5)
-
Choice 1- Choice 1
- hospital
Choice 2- Choice 2
- medical
Fill-in (6)- Fill-in (6)
-
Choice 1- Choice 1
- His
Choice 2- Choice 2
- Her
Choice 3- Choice 3
- Your
Fill-in (7)- Fill-in (7)
Show the HI TERM date minus 1 month in MMCCYY format- Show the HI TERM date minus 1 month in MMCCYY format
HIB080 – VOLUNTARY SMI TERMINATION CIVIL SERVICE INVOLVED- HIB080 – VOLUNTARY SMI TERMINATION CIVIL SERVICE INVOLVED
- The Office of Personnel Management will no longer deduct the medical insurance premiums from (1) annuity checks. They will let (2) know when the deductions will stop.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
BGN plus BLN possessive- BGN plus BLN (possessive)
Choice 2- Choice 2
BGN possessive- BGN (possessive)
Choice 3- Choice 3
- your
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- him
Choice 2- Choice 2
- her
Choice 3- Choice 3
- you
HIB082 – HI AND/OR SMI VOLUNTARY TERMINATION- HIB082 – HI AND/OR SMI VOLUNTARY TERMINATION
- (1) asked that we stop (2) (3) insurance coverage under Medicare. This coverage ends the last day of (4).
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- BGN plus BLN
Choice 2- Choice 2
- You
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- hospital
Choice 2- Choice 2
- medical
Choice 3- Choice 3
- hospital and medical
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- Show the HI TERM date minus 1 month in MMCCYY format
Choice 2- Choice 2
- Show the SMI TERM date minus 1 month in MMCCYY format
HIB083 – SPECIAL ENROLLMENT PERIOD DISABILITY- HIB083 – SPECIAL ENROLLMENT PERIOD DISABILITY
- (1) may also be able to enroll during a special enrollment period. (2) can do this if (3) (4) one of the conditions listed below:
- * (5) covered under a group health plan through (6) current work or (7) spouse's current work, or
- * (8) covered under a large group health plan through (9) current work or any family member's current work.
- (10) may enroll for Medicare (11) insurance at any time (12) covered under the group health plan. However, (13) may wait and enroll during the 8-month period that begins when the work ends or (14) coverage under the plan ends, whichever occurs first. (15) may also enroll if the type of plan (16) changes.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
BGN plus BLN- BGN plus BLN (not possessive)
Choice 2- Choice 2
BGN- BGN (not possessive)
Choice 3- Choice 3
- You
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- He
Choice 2- Choice 2
- She
Choice 3- Choice 3
- You
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- he
Choice 2- Choice 2
- she
Choice 3- Choice 3
- you
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- meets
Choice 2- Choice 2
- meet
Fill-in (5)- Fill-in (5)
-
Choice 1- Choice 1
- He is
Choice 2- Choice 2
- She is
Choice 3- Choice 3
- You are
Fill-in (6)- Fill-in (6)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (7)- Fill-in (7)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (8)- Fill-in (8)
-
Choice 1- Choice 1
- He is
Choice 2- Choice 2
- She is
Choice 3- Choice 3
- You are
Fill-in (9)- Fill-in (9)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (10)- Fill-in (10)
-
Choice 1- Choice 1
- He
Choice 2- Choice 2
- She
Choice 3- Choice 3
- You
Fill-in (11)- Fill-in (11)
-
Choice 1- Choice 1
- hospital
Choice 2- Choice 2
- medical
Choice 3- Choice 3
- hospital and medical
Fill-in (12)- Fill-in (12)
-
Choice 1- Choice 1
- he is
Choice 2- Choice 2
- she is
Choice 3- Choice 3
- you are
Fill-in (13)- Fill-in (13)
-
Choice 1- Choice 1
- he
Choice 2- Choice 2
- she
Choice 3- Choice 3
- you
Fill-in (14)- Fill-in (14)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (15)- Fill-in (15)
-
Choice 1- Choice 1
- He
Choice 2- Choice 2
- She
Choice 3- Choice 3
- You
Fill-in (16)- Fill-in (16)
-
Choice 1- Choice 1
- he has
Choice 2- Choice 2
- she has
Choice 3- Choice 3
- you have
HIB084 – SPECIAL ENROLLMENT PERIOD AGED- HIB084 – SPECIAL ENROLLMENT PERIOD AGED
- (1) may also be able to enroll during a special enrollment period. (2) can do this if (3) all of the conditions listed below:
- * (4) health insurance coverage is under an employer's plan because (5) or (6) spouse is working, and
- * (7) had health insurance coverage under that plan since (8) became age 65.
- (9) may enroll for Medicare (10) insurance at any time (11) covered under the group health plan. However, (12) may wait and enroll during the 8-month period that begins when the work ends or (13) coverage under the plan ends, whichever occurs first.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
BGN plus BLN- BGN plus BLN (not possessive)
Choice 2- Choice 2
BGN- BGN (not possessive)
Choice 3- Choice 3
- You
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- He
Choice 2- Choice 2
- She
Choice 3- Choice 3
- You
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- he meets
Choice 2- Choice 2
- she meets
Choice 3- Choice 3
- you meet
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- His
Choice 2- Choice 2
- Her
Choice 3- Choice 3
- Your
Fill-in (5)- Fill-in (5)
-
Choice 1- Choice 1
- he
Choice 2- Choice 2
- she
Choice 3- Choice 3
- you
Fill-in (6)- Fill-in (6)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (7)- Fill-in (7)
-
Choice 1- Choice 1
- He has
Choice 2- Choice 2
- She has
Choice 3- Choice 3
- You have
Fill-in (8)- Fill-in (8)
-
Choice 1- Choice 1
- he
Choice 2- Choice 2
- she
Choice 3- Choice 3
- you
Fill-in (9)- Fill-in (9)
-
Choice 1- Choice 1
- He
Choice 2- Choice 2
- She
Choice 3- Choice 3
- You
Fill-in (10)- Fill-in (10)
-
Choice 1- Choice 1
- hospital
Choice 2- Choice 2
- medical
Choice 3- Choice 3
- hospital and medical
Fill-in (11)- Fill-in (11)
-
Choice 1- Choice 1
- he is
Choice 2- Choice 2
- she is
Choice 3- Choice 3
- you are
Fill-in (12)- Fill-in (12)
-
Choice 1- Choice 1
- he
Choice 2- Choice 2
- she
Choice 3- Choice 3
- you
Fill-in (13)- Fill-in (13)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
HIB085 – VOLUNTARY SMI TERMINATION CURRENT PAY- HIB085 – VOLUNTARY SMI TERMINATION CURRENT PAY
- We will stop taking premiums for medical insurance out of (1) checks.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
BGN plus BLN possessive- BGN plus BLN (possessive)
Choice 2- Choice 2
BGN possessive- BGN (possessive)
Choice 3- Choice 3
- your
HIB086 – VOLUNTARY HI/SMI TERMINATION PREMIUMS DUE(1) should send us (2) to pay for the premiums (3) through (4). Please make- HIB086 – VOLUNTARY HI/SMI TERMINATION PREMIUMS DUE
(5) check or money order payable to the “Centers for Medicare & Medicaid Services” and mail it to us in the enclosed envelope. Include (6) claim number (shown above) on the check or money order.- (1) (2) (3) in premiums through (4). Please make (5) check or money order payable to the "Centers for Medicare & Medicaid Services" and mail it to us in the enclosed envelope. Include (6) Medicare number on (7) check or money order.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
BGN plus BLN- BGN plus BLN (not possessive)
Choice 2- Choice 2
BGN- You
Choice 3- Fill-in (2)
-
BGN plus BLN- Choice 1
Choice 4- owes
You- Choice 2
Fill-in (2) - owe
Choice 1- Fill-in (3)
Show total Part A and Part B past due premiums due in $9999.99 format- Show total past due amount in $999,999.99 format
Choice 2- Fill-in (4)
Show total Part A or Part B past due premiums due in $9999.99 format- Show the HI/SMI termination date minus 1 month in the format May 1999
Fill-in (3)- Fill-in (5)
-
Choice 1- Choice 1
he owes- your
Choice 2- Choice 2
she owes- his
Choice 3- Choice 3
you owe- her
Fill-in (4)- Fill-in (6)
-
Choice 1Show the HI TERM date minus 1 month in the format May 1999 Choice 2Show the SMI TERM date minus 1 month in the format May 1999- Choice 1
Fill-in (5) - your
Choice 1- Choice 2
- his
Choice 2- Choice 3
- her
Choice 3- Fill-in (7)
-
your- Choice 1
Fill-in (6) - your
Choice 1- Choice 2
- his
Choice 2- Choice 3
- her
Choice 3your HIB087 – VOLUNTARY SMI TERMINATION HI CONTINUES- HIB087 – VOLUNTARY SMI TERMINATION HI CONTINUES
- (1) hospital insurance coverage will continue.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
BGN plus BLN possessive- BGN plus BLN (possessive)
Choice 2- Choice 2
BGN possessive- BGN (possessive)
Choice 3- Choice 3
- your
HIB088 – HI/SMI FOREIGN ADDRESS- HIB088 – HI/SMI FOREIGN ADDRESS
- Normally, Medicare will only pay for (1) services which (2) (3) in the United States. Since (4) living outside the U.S., Medicare will not pay for (5) services unless (6) to the U.S. for services.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- hospital
Choice 2- Choice 2
- medical
Choice 3- Choice 3
- hospital and medical
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
BGN plus BLN- BGN plus BLN (not possessive)
Choice 2- Choice 2
BGN- BGN (not possessive)
Choice 3- Choice 3
- you
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- receives
Choice 2- Choice 2
- receive
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- he is
Choice 2- Choice 2
- she is
Choice 3- Choice 3
- you are
Fill-in (5)- Fill-in (5)
-
Choice 1- Choice 1
- hospital
Choice 2- Choice 2
- medical
Choice 3- Choice 3
- hospital and medical
Fill-in (6)- Fill-in (6)
-
Choice 1- Choice 1
- he returns
Choice 2- Choice 2
- she returns
Choice 3- Choice 3
- you return
HIB089 – BENE AT FRA PROVISION PAYMENTS END HI/SMI ENDS- HIB089 – BENE AT FRA PROVISION PAYMENTS END HI/SMI ENDS
- Since (1) no longer receiving provisional monthly Social Security benefits, we are stopping (2) (3) insurance coverage. This coverage ends the last day of (4). Please destroy (5) Medicare card after coverage ends.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- BGN plus BLN plus the word “is”
Choice 2- Choice 2
you are- you are
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- hospital
Choice 2- Choice 2
- hospital and medical
Fill-in (4)- Fill-in (4)
- Show HI-TERM date in MMCCYY format
Fill-in (5)- Fill-in (5)
-
Choice 1- Choice 1
BGN plus BLN possessive- BGN plus BLN (possessive)
Choice 2- Choice 2
- your
HIB090 – TERMINATION ALL MEDICARE COVERAGE- HIB090 – TERMINATION ALL MEDICARE COVERAGE
- (1) Medicare card will not be valid when (2) (3) coverage ends. Please destroy (4) card after (5) coverage ends.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
BGN plus BLN possessive- BGN plus BLN (possessive)
Choice 2- Choice 2
- Your
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- Medicare Part A (hospital insurance) and Part B (medical insurance)
Choice 2- Choice 2
- Medicare Part B (medical insurance)
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (5)- Fill-in (5)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
HIB092 – STATE/LOCAL GOVT CONTINUES TO PAY SMI PREMIUM- HIB092 – STATE/LOCAL GOVT CONTINUES TO PAY SMI PREMIUM
- (1) State or local government retirement system will continue to pay (2) Medicare medical insurance late enrollment premium penalty. (3) must continue to pay the basic Medicare medical insurance premium.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
BGN plus BLN possessive- BGN plus BLN (possessive)
Choice 2- Choice 2
- Your
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- He
Choice 2- Choice 2
- She
Choice 3- Choice 3
- You
HIB093 – STATE OR GROUP CONTINUES TO PAY SMI PREMIUMS- HIB093 – STATE OR GROUP CONTINUES TO PAY SMI PREMIUMS
- Our records show that (1) will continue to pay the premiums for (2) Medicare (3) insurance coverage.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- the State
Choice 2- Choice 2
- an organization
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- hospital and medical
Choice 2- Choice 2
- medical
HIB101 – MEDICARE STATE BUY-IN- HIB101 – MEDICARE STATE BUY-IN
- (1) (2) will pay (3) Medicare (4) insurance premium beginning (5). (6)
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- Leave blank
Choice 2- Choice 2
- The State of
Fill-in (2)- Fill-in (2)
- show state corresponding to the HITP-CODE or the SMTP-CODE
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
BGN plus BLN possessive- BGN plus BLN (possessive)
Choice 2- Choice 2
- your
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- hospital
Choice 2- Choice 2
- medical
Choice 3- Choice 3
- hospital and medical
Fill-in (5)- Fill-in (5)
- TP START date in MMCCYY format
Fill-in (6)- Fill-in (6)
-
Choice 1- Choice 1
- This also means that he is entitled to this Medicare coverage for an earlier period than shown on his current Medicare card.
Choice 2- Choice 2
- This also means that she is entitled to this Medicare coverage for an earlier period than shown on her current Medicare card.
Choice 3- Choice 3
- This also means that you are entitled to this Medicare coverage for an earlier period than shown on your current Medicare card.
Choice 4- Choice 4
- NULL
HIB102 – STATE BUY-OUT- HIB102 – STATE BUY-OUT
- (1) (2) will no longer pay (3) Medicare (4) insurance premiums after (5). (6) must pay the premiums beginning (7).
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- Leave blank
Choice 2- Choice 2
- The State of
Fill-in (2)- Fill-in (2)
- show state corresponding to the HITP-CODE or the SMTP-CODE
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
BGN plus BLN possessive- BGN plus BLN (possessive)
Choice 2- Choice 2
- your
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- hospital
Choice 2- Choice 2
- medical
Choice 3- Choice 3
- hospital and medical
Fill-in (5)- Fill-in (5)
- Show the TP STOP date in MMCCYY format
Fill-in (6)- Fill-in (6)
-
Choice 1- Choice 1
- He
Choice 2- Choice 2
- She
Choice 3- Choice 3
- You
Fill-in (7)- Fill-in (7)
- Show the TP STOP date plus 1 month in MMCCYY format
HIB103 – LIMITED BUY-IN AND BUY-OUT- HIB103 – LIMITED BUY-IN AND BUY-OUT
- (1) (2) paid (3) Medicare (4) insurance premium for (5).
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- Leave blank
Choice 2- Choice 2
- The State of
Fill-in (2)- Fill-in (2)
- Show state corresponding to the HITP-CODE or the SMTP-CODE
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
BGN plus BLN possessive- BGN plus BLN (possessive)
Choice 2- Choice 2
- your
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- hospital
Choice 2- Choice 2
- medical
Choice 3- Choice 3
- hospital and medical
Fill-in (5)- Fill-in (5)
-
Choice 1- Choice 1
- MMCCYY
Choice 2- Choice 2
- MMCCYY and MMCCYY
Choice 3- Choice 3
- MMCCYY through MMCCYY
HIB104 – LIMITED ST BUY-IN/BUY-OUT NO CHANGE IN COVERAGE- HIB104 – LIMITED ST BUY-IN/BUY-OUT NO CHANGE IN COVERAGE
- This does not change our records, which show that (1) Medicare (2) insurance coverage.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- he currently has
Choice 2- Choice 2
- she currently has
Choice 3- Choice 3
- you currently have
Choice 4- Choice 4
- he does not currently have
Choice 5- Choice 5
- she does not currently have
Choice 6- Choice 6
- you do not currently have
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- hospital
Choice 2- Choice 2
- medical
Choice 3- Choice 3
- hospital and medical
HIB105 – RETRO BUYIN/BUYOUT PAST DUE PREMIUMS- HIB105 – RETRO BUYIN/BUYOUT PAST DUE PREMIUMS
- Our records also show that (1) premiums through (2).
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- he still owes
Choice 2- Choice 2
- she still owes
Choice 3- Choice 3
- you still owe
Fill-in (2)- Fill-in (2)
- MMCCYY
HIB106 – STATE BUYIN FOR SMI PREMIUM PENALTY ONLY- HIB106 – STATE BUYIN FOR SMI PREMIUM PENALTY ONLY
- We must charge a premium penalty on (1) Medicare medical insurance because (2) enrolled later than (3) could have. (4) State or local government retirement system will pay (5) medical insurance late enrollment premium penalty beginning (6). However, (7) must pay the basic Medicare medical insurance premium.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
BGN plus BLN possessive- BGN plus BLN (possessive)
Choice 2- Choice 2
- your
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- he
Choice 2- Choice 2
- she
Choice 3- Choice 3
- you
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- he
Choice 2- Choice 2
- she
Choice 3- Choice 3
- you
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- His
Choice 2- Choice 2
- Her
Choice 3- Choice 3
- Your
Fill-in (5)- Fill-in (5)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (6)- Fill-in (6)
- MM/YYYY
Fill-in (7)- Fill-in (7)
-
Choice 1- Choice 1
- he
Choice 2- Choice 2
- she
Choice 3- Choice 3
- you
HIB107 – STATE STOPS PAYING SMI PREMIUM PENALTY- HIB107 – STATE STOPS PAYING SMI PREMIUM PENALTY
- (1) State or local government retirement system will no longer pay (2) Medicare medical insurance late enrollment premium penalty after (3). (4) must pay the basic premium and the penalty beginning (5).
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
BGN plus BLN possessive- BGN plus BLN (possessive)
Choice 2- Choice 2
- Your
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (4)- Fill-in (4)
- show date in MMCCYY format
Fill-in (5)- Fill-in (5)
-
Choice 1- Choice 1
- He
Choice 2- Choice 2
- She
Choice 3- Choice 3
- You
Fill-in (6)- Fill-in (6)
- show date in MMCCYY format
HIB108 – GROUP PAYER BUY-OUT- HIB108 – GROUP PAYER BUY-OUT
- The organization that was paying (1) Medicare (2) insurance premium will no longer pay it after (3). (4) must pay the premium beginning (5).
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
BGN plus BLN possessive- BGN plus BLN (possessive)
Choice 2- Choice 2
- your
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- hospital
Choice 2- Choice 2
- medical
Choice 3- Choice 3
- hospital and medical
Fill-in (3)- Fill-in (3)
- show date in MMCCYY format
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- He
Choice 2- Choice 2
- She
Choice 3- Choice 3
- You
Fill-in (5)- Fill-in (5)
- Show date in MMCCYY format
HIB109 – 3RD Party SMI PREMIUM DEDUCTED FROM MBA- HIB109 – 3RD Party SMI PREMIUM DEDUCTED FROM MBA
- We will deduct the (1) of (2) from (3) monthly payment. Later in this letter, we tell (4) what to do if (5) with this change in the amount of (6) monthly payment.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
- Medicare medical insurance premium
Fill-in (2)- Fill-in (2)
- SMI premium amount in $9999.99 format
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- him
Choice 2- Choice 2
- her
Choice 3- Choice 3
- you
Fill-in (5)- Fill-in (5)
-
Choice 1- Choice 1
- he disagrees
Choice 2- Choice 2
- she disagrees
Choice 3- Choice 3
- you disagree
Fill-in (6)- Fill-in (6)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
HIB110 – SMI PREMIUM DEDUCTED FROM MBA PAST DUE PREMIUMS- HIB110 – SMI PREMIUM DEDUCTED FROM MBA PAST DUE PREMIUMS
- We will deduct the (1) of (2) from (3) monthly payment. We will also deduct the past due premiums, which total (4). Later in this letter, we tell (5) what to do if (6) with this change in the amount of (7) monthly payment.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
- Medicare medical insurance premium
Fill-in (2)- Fill-in (2)
- SMI premium amount in $9999.99 format
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (4)- Fill-in (4)
- premium amount due in 99999.99 format
Fill-in (5)- Fill-in (5)
-
Choice 1- Choice 1
- him
Choice 2- Choice 2
- her
Choice 3- Choice 3
- you
Fill-in (6)- Fill-in (6)
-
Choice 1- Choice 1
- he disagrees
Choice 2- Choice 2
- she disagrees
Choice 3- Choice 3
- you disagree
Fill-in (7)- Fill-in (7)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
HIB111 – BUY-IN AND REFUND OF MEDICARE PREMIUMS- HIB111 – BUY-IN AND REFUND OF MEDICARE PREMIUMS
- This is the money due (1) for the Medicare insurance premiums that (2) already paid.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- him
Choice 2- Choice 2
- her
Choice 3- Choice 3
- you
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- he
Choice 2- Choice 2
- she
Choice 3- Choice 3
- you
HIB112 – BUYIN PREMIUM NO LONGER DEDUCTED FROM MBA- HIB112 – BUYIN PREMIUM NO LONGER DEDUCTED FROM MBA
- We will no longer deduct the premium from (1) monthly payment. Later in this letter, we tell (2) what to do if (3) with this change in the amount of (4) monthly payment.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- you
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- you disagree
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
HIB113 – BUY-OUT NOT IN PAY STATUS PREMIUM BILLING- HIB113 – BUY-OUT NOT IN PAY STATUS PREMIUM BILLING
- We will send (1) first bill for the (2) within a month. The monthly (3) (4). (5) Please contact us if (6) not receive the first bill within a month.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
BGN plus BLN possessive- BGN plus BLN (possessive)
Choice 2- Choice 2
BGN possessive- BGN (possessive)
Choice 3- Choice 3
- your
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- Medicare hospital insurance premium
Choice 2- Choice 2
- Medicare medical insurance premium
Choice 3- Choice 3
- Medicare hospital and medical insurance premiums
Fill-in (3)- Fill-in (3)
-
Choice 1premium is Choice 2premiums total Fill-in (4)money amount in format 999,999.99 Fill-in (5) Choice 1After that, we will bill him each month for this premium. (Use in Medicare Part A and combined Part A and Part B billing.) Choice 2After that, we will bill her each month for this premium. (Use in Medicare Part A and combined Part A and Part B billing.) Choice 3After that, we will bill you each month for this premium. (Use in Medicare Part A and combined Part A and Part B billing.) Choice 4Each bill after that will be for a 3-month period. (Use in Medicare Part B billing situations including those which include a premium penalty.) Fill-in (6) Choice 1he does Choice 2she does Choice 3you do HIB114 – BENEFITS TERM PROFRA MEDICARE CONTINUES(1) Medicare coverage will continue because (2) age 65 or older.Fill-in values: Fill-in (1) Choice 1BGN plus BLN possessive Choice 2Your Fill-in (2) Choice 1he is Choice 2she is Choice 3you are HIB115 – HI/SMI BUY-OUTIf (1) to cancel this insurance, please contact the local Social Security office at the telephone number and address shown below. Remember that the date (2) insurance coverage ends depends on when (3) it:If (4) it within 30 days from the date of this notice, (5) coverage will end at the same time the State stopped paying the premiums.If (6) it after 30 days but within six months of when the State stopped paying the premiums, coverage will stop at the end of the same month in which (7) us.If (8) more than 6 months to contact us, coverage will stop at the end of the month after the month in which (9) us.Fill-in values: Fill-in (1) Choice 1BGN plus BLN plus “wants” Choice 2you want- Choice 1
Fill-in (2) - premium is
Choice 1- Choice 2
his- premiums total
Choice 2- Fill-in (4)
her- money amount in format 999,999.99
Choice 3- Fill-in (5)
-
your- Choice 1
Fill-in (3) - After that, we will bill him each month for this premium. (Use in Medicare Part A and combined Part A and Part B billing.)
Choice 1- Choice 2
he cancels- After that, we will bill her each month for this premium. (Use in Medicare Part A and combined Part A and Part B billing.)
Choice 2- Choice 3
she cancels- After that, we will bill you each month for this premium. (Use in Medicare Part A and combined Part A and Part B billing.)
Choice 3- Choice 4
you cancel- Each bill after that will be for a 3-month period. (Use in Medicare Part B billing situations including those which include a premium penalty.)
Fill-in (4)- Fill-in (6)
-
Choice 1- Choice 1
he cancels- he does
Choice 2- Choice 2
she cancels- she does
Choice 3- Choice 3
you cancel- you do
- HIB114 – BENEFITS TERM PROFRA MEDICARE CONTINUES
Fill-in (5) - (1) Medicare coverage will continue because (2) age 65 or older.
Choice 1- Fill-in values:
-
his- Fill-in (1)
-
Choice 2her- Choice 1
- BGN plus BLN (possessive)
Choice 3your- Choice 2
- Your
Fill-in (6) - Fill-in (2)
-
Choice 1he cancels- Choice 1
- he is
Choice 2she cancels- Choice 2
- she is
Choice 3you cancel- Choice 3
- you are
Fill-in (7) - HIB115 – HI/SMI BUY-OUT
- If (1) to cancel this insurance, please contact the local Social Security office at the telephone number and address shown below. Remember that the date (2) insurance coverage ends depends on when (3) it:
- If (4) it within 30 days from the date of this notice, (5) coverage will end at the same time the State stopped paying the premiums.
Choice 1- If (6) it after 30 days but within six months of when the State stopped paying the premiums, coverage will stop at the end of the same month in which (7) us.
- If (8) more than 6 months to contact us, coverage will stop at the end of the month after the month in which (9) us.
he contacts Choice 2- Fill-in values:
-
she contacts- Fill-in (1)
-
Choice 3- Choice 1
you contact- BGN plus BLN plus “wants”
Fill-in (8) - Choice 2
Choice 1- you want
he waits- Fill-in (2)
-
Choice 2- Choice 1
she waits- his
Choice 3- Choice 2
you wait- her
Fill-in (9) - Choice 3
Choice 1- your
he contacts- Fill-in (3)
-
Choice 2- Choice 1
she contacts- he cancels
Choice 3- Choice 2
you contact HIB118 – HI/SMI ENTITLEMENT RECEIPT OF CARD IN 4 WEEKS- she cancels
If (1) not receive (2) health insurance card within 4 weeks after the receipt of this notice, please get in touch with us. If (3) medical care before (4) the card, use this letter as proof that (5) covered by Medicare (6) insurance.- Choice 3
Fill-in values: - you cancel
Fill-in (1)- Fill-in (4)
-
Choice 1- Choice 1
BGN plus BLN plus “does”- he cancels
Choice 2- Choice 2
BGN plus “does”- she cancels
Choice 3- Choice 3
you do- you cancel
Fill-in (2)- Fill-in (5)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (3)- Fill-in (6)
-
Choice 1- Choice 1
he needs- he cancels
Choice 2- Choice 2
she needs- she cancels
Choice 3- Choice 3
you need- you cancel
Fill-in (4)- Fill-in (7)
-
Choice 1- Choice 1
he receives- he contacts
Choice 2- Choice 2
she receives- she contacts
Choice 3- Choice 3
you receive- you contact
Fill-in (5)- Fill-in (8)
-
Choice 1- Choice 1
he is- he waits
Choice 2- Choice 2
she is- she waits
Choice 3- Choice 3
you are- you wait
Fill-in (6)- Fill-in (9)
-
Choice 1- Choice 1
hospital- he contacts
Choice 2- Choice 2
medical- she contacts
Choice 3- Choice 3
hospital and medical- you contact
HIB119 – BILLING TO CONFIRM GROUP PAYER- HIB119 – BILLING TO CONFIRM GROUP PAYER
- (1) recently arranged for an organization to pay (2) Medicare (3) insurance premium. Although we will send the bills to this organization, (4) responsible for seeing that they are paid.
- If this organization decides to stop paying (5) premium, we will again send the bills to (6).
- If there is any other change in (7) Medicare premium, we will let (8) know.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- BGN plus BLN
Choice 2- Choice 2
- You
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- hospital
Choice 2- Choice 2
- medical
Choice 3- Choice 3
- hospital and medical
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- he is
Choice 2- Choice 2
- she is
Choice 3- Choice 3
- you are
Fill-in (5)- Fill-in (5)
- Choice 1
- Choice 2
- Choice 3
- his
- her
- your
Fill-in (6)- Fill-in (6)
-
Choice 1- Choice 1
- him
Choice 2- Choice 2
- her
Choice 3- Choice 3
- you
Fill-in (7)- Fill-in (7)
-
Choice 1- Choice 1
BGN plus BLN possessive- BGN plus BLN (possessive)
Choice 2- Choice 2
- your
Fill-in (8)- Fill-in (8)
-
Choice 1- Choice 1
- him
Choice 2- Choice 2
- her
Choice 3- Choice 3
- you
HIB120 – BUY-OUT FOR HI AND SMI- HIB120 – BUY-OUT FOR HI AND SMI
- (1) can cancel hospital insurance coverage and keep medical insurance coverage, or cancel both. However, (2) cannot keep hospital insurance coverage without medical insurance coverage. So if (3) medical insurance coverage, hospital insurance coverage will end at the same time.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- He
Choice 2- Choice 2
- She
Choice 3- Choice 3
- You
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- he
Choice 2- Choice 2
- she
Choice 3- Choice 3
- you
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- he cancels
Choice 2- Choice 2
- she cancels
Choice 3- Choice 3
- you cancel
HIB131 – MEDICARE CONTINUES BASED ON AGE, DIB, OR ESRD- HIB131 – MEDICARE CONTINUES BASED ON AGE, DIB, OR ESRD
- However, Medicare coverage will continue because (1) (2).
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- he is
Choice 2- Choice 2
- she is
Choice 3- Choice 3
- you are
Choice 4- Choice 4
- he has
Choice 5- Choice 5
- she has
Choice 6- Choice 6
- you have
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- disabled
Choice 2- Choice 2
- over age 65
Choice 3- Choice 3
- end stage renal disease
HIB132 – ESRD TERMINATES AND RRB JURISDICTION- HIB132 – ESRD TERMINATES AND RRB JURISDICTION
- However, since the Railroad Retirement Board (RRB) handles (1) hospital and medical insurance (2) Medicare coverage will continue unless the RRB tells (3) they are stopping (4) coverage.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- him
Choice 2- Choice 2
- her
Choice 3- Choice 3
- you
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
HIB133 – ESRD TERMINATION - SAME HI/SMI TERMINATION DATES- HIB133 – ESRD TERMINATION - SAME HI/SMI TERMINATION DATES
- We are writing to tell (1) that Medicare coverage based on (2) kidney condition ends with the last day of (3).
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
BGN plus BLN- BGN plus BLN (not possessive)
Choice 2- Choice 2
- you
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (3)- Fill-in (3)
- Show HI-TERM date minus 1 month in MMCCYY format
HIB134 – ESRD TERM HI TERM DATE EARLIER THAN SMI TERM DATE- HIB134 – ESRD TERM HI TERM DATE EARLIER THAN SMI TERM DATE
- We are writing to tell (1) that (2) hospital insurance coverage ended on the last day of (3). (4) medical insurance coverage will end on the last day of (5).
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
BGN plus BLN- BGN plus BLN (not possessive)
Choice 2- Choice 2
- you
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (3)- Fill-in (3)
- Show HI-TERM date minus 1 month in MMCCYY format
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- His
Choice 2- Choice 2
- Her
Choice 3- Choice 3
- Your
Fill-in (5)- Fill-in (5)
- Show SMI-TERM date minus 1 month in MMCCYY format
HIB135 – ESRD TERM HI TERM DATE EARLIER THAN SMI TERM DATE- HIB135 – ESRD TERM HI TERM DATE EARLIER THAN SMI TERM DATE
- Medicare coverage based on a kidney condition usually ends the last day of the (1) month after the month (2) unless before then (3) again:
- * (4) regular dialysis, or
- * (5) a kidney transplant
- Since (6) in (7), (8) Medicare coverage should have ended the last day of (9). (10) hospital insurance did end on that date. But, because we didn't take action in time, we must continue (11) medical insurance coverage until the date shown above.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- 12th
Choice 2- Choice 2
- 36th
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- he gets a transplant
Choice 2- Choice 2
- she gets a transplant
Choice 3- Choice 3
- you get a transplant
Choice 4- Choice 4
- regular dialysis stops
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- he
Choice 2- Choice 2
- she
Choice 3- Choice 3
- you
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- begins
Choice 2- Choice 2
- begin
Fill-in (5)- Fill-in (5)
-
Choice 1- Choice 1
- gets
Choice 2- Choice 2
- get
Fill-in (6)- Fill-in (6)
-
Choice 1- Choice 1
- he got a kidney transplant
Choice 2- Choice 2
- she got a kidney transplant
Choice 3- Choice 3
- you got a kidney transplant
Choice 4- Choice 4
- his dialysis stopped
Choice 5- Choice 5
- her dialysis stopped
Choice 6- Choice 6
- your dialysis stops
Fill-in (7)- Fill-in (7)
-
Choice 1- Choice 1
- Show KDNY-TRNSDATE date in MMCCYY format
Choice 2- Choice 2
- Show DLYS-STOP date in MMCCYY format
Fill-in (8)- Fill-in (8)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (9)- Fill-in (9)
- Show HI-TERM date minus 1 month in format MMCCYY
Fill-in (10)- Fill-in (10)
-
Choice 1- Choice 1
- His
Choice 2- Choice 2
- Her
Choice 3- Choice 3
- Your
Fill-in (11)- Fill-in (11)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
HIB136 – TERMINATION OF ESRD COVERAGE- HIB136 – TERMINATION OF ESRD COVERAGE
- Let us know right away if (1) regular dialysis again or (2) a kidney transplant so (3) can file a new claim for Medicare coverage based on (4) kidney condition.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- he resumes
Choice 2- Choice 2
- she resumes
Choice 3- Choice 3
- you resume
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- gets
Choice 2- Choice 2
- get
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- he
Choice 2- Choice 2
- she
Choice 3- Choice 3
- you
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
HIB137 – ESRD TERMINATES SAME HI/SMI TERMINATION DATES- HIB137 – ESRD TERMINATES SAME HI/SMI TERMINATION DATES
- Medicare coverage based on a kidney condition ends the last day of the (1) month after (2), unless before then (3):
- * a kidney transplant, or
- * resume regular dialysis.
- Our records show that (4) (5) (6).
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- 12th
Choice 2- Choice 2
- 36th
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- regular dialysis stops
Choice 2- Choice 2
- a kidney transplant
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- he gets
Choice 2- Choice 2
- she gets
Choice 3- Choice 3
- you get
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- he
Choice 2- Choice 2
- she
Choice 3- Choice 3
- you
Fill-in (5)- Fill-in (5)
-
Choice 1- Choice 1
- stopped regular dialysis
Choice 2- Choice 2
- received a kidney transplant
Fill-in (6)- Fill-in (6)
-
Choice 1- Choice 1
- Show DLYS-STOP date for the latest DLYS occurrence on the POST-MBR in format MMCCYY
Choice 2- Choice 2
- Show KDNY-TRNSDATE date for the latest KDNY occurrence on the POST-MBR in format MMCCYY
HIB142 – CURRENT PAY TO SUSPENSE OR DEFERRED STATUS- HIB142 – CURRENT PAY TO SUSPENSE OR DEFERRED STATUS
- We will continue to charge a monthly premium for (1) medical insurance under Medicare.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
BGN plus BLN possessive- BGN plus BLN (possessive)
Choice 2- Choice 2
- your
HIB143 – SMI PENALTY RATE TO BASE RATE AT AGE 65- HIB143 – SMI PENALTY RATE TO BASE RATE AT AGE 65
- Under a special provision of the Social Security Act, now that (1) (2) for Medicare medical insurance based on (3) age, (4) monthly medical insurance premium amount has been reduced from (5) to (6).
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
BGN plus BLN- BGN plus BLN (not possessive)
Choice 2- Choice 2
- you
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- qualifies
Choice 2- Choice 2
- qualify
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (5)- Fill-in (5)
- Show the SMI premium penalty rate
Fill-in (6)- Fill-in (6)
- Show the SMI premium base rate
HIB151 – LIMITED BUY-IN/BUY-OUT - COVERAGE CONTINUES- HIB151 – LIMITED BUY-IN/BUY-OUT - COVERAGE CONTINUES
- (1) must pay the premium beginning (2).
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- You
Choice 2- Choice 2
- He
Choice 3- Choice 3
- She
Fill-in (2)- Fill-in (2)
- MMCCYY
HIB154 – EXPLANATION OF BENFITS WHEN MEDICARE IS THE SECONDARY PAYER WHEN THE BENEFICARY IS WORKING AND COVERED BY HIS OR HER EMPLOYER- HIB154 – EXPLANATION OF BENFITS WHEN MEDICARE IS THE SECONDARY PAYER WHEN THE BENEFICARY IS WORKING AND COVERED BY HIS OR HER EMPLOYER
- (1) working for an employer who has 20 or more employees? (2) covered under this employer's group health plan? If so, the employer's plan will pay first for health care services. Medicare will pay secondary benefits when the employer's plan doesn't cover all of the expenses.
- Contact your nearest Social Security office for more information about Part B Medicare special enrollment.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- The word 'Is' BGN plus BLN
Choice 2- Choice 2
- Are you
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- Is he
Choice 2- Choice 2
- Is she
Choice 3- Choice 3
- Are you
HIB157 – PIC C'S NOTICE WHEN CHILD < AGE 19 AND NO OPEN HI- HIB157 – PIC C'S NOTICE WHEN CHILD < AGE 19 AND NO OPEN HI
- If this notice is for a child under age 19 who is not covered by health insurance, there is a Children's Health Insurance Program that may help. To find out more, you can look on the Internet at (1) or call, toll free, 1-877-KIDS-NOW (1-877-543-7669). The number connects you to your state program.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
- www.insurekidsnow.gov
HIB160 – HI/SMI REVERSAL - NOT TIMELY BUT IN GEP- HIB160 – HI/SMI REVERSAL - NOT TIMELY BUT IN GEP
- We received (1) cancellation of (2) earlier request that (3) Medicare (4) insurance coverage be terminated. Although this cancellation request was filed too late for the coverage to be reinstated without interruption, it was filed during a period in which (5) could reenroll. This difference is important because there are months for which (6) not have Medicare (7) insurance coverage.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
- Choice 1
Choice 2- BGN plus BLN (possessive)
BGN plus BLN possessive- Choice 2
- your
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- hospital
Choice 2- Choice 2
- medical
Choice 3- Choice 3
- hospital and medical
Fill-in (5)- Fill-in (5)
-
Choice 1- Choice 1
- he
Choice 2- Choice 2
- she
Choice 3- Choice 3
- you
Fill-in (6)- Fill-in (6)
-
Choice 1- Choice 1
- he does
Choice 2- Choice 2
- she does
Choice 3- Choice 3
- you do
Fill-in (7)- Fill-in (7)
-
Choice 1- Choice 1
- hospital
Choice 2- Choice 2
- medical
Choice 3- Choice 3
- hospital and medical
HIB161 – HI/SMI REVERSAL NOT FILED TIMELY NOT IN GEP- HIB161 – HI/SMI REVERSAL NOT FILED TIMELY NOT IN GEP
- We stopped (1) Medicare (2) insurance at (3) request. Then (4) decided that (5) still wanted it. (6) decided too late for us to start (7) Medicare (8) insurance again at this time.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
BGN plus BLN possessive- BGN plus BLN (possessive)
Choice 2- Choice 2
- your
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- hospital
Choice 2- Choice 2
- medical
Choice 3- Choice 3
- hospital and medical
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- he
Choice 2- Choice 2
- she
Choice 3- Choice 3
- you
Fill-in (5)- Fill-in (5)
-
Choice 1- Choice 1
- he
Choice 2- Choice 2
- she
Choice 3- Choice 3
- you
Fill-in (6)- Fill-in (6)
-
Choice 1- Choice 1
- He
Choice 2- Choice 2
- She
Choice 3- Choice 3
- You
Fill-in (7)- Fill-in (7)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (8)- Fill-in (8)
-
Choice 1- Choice 1
- hospital
Choice 2- Choice 2
- medical
Choice 3- Choice 3
- hospital and medical
HIB162 – REFUSAL OVER AUTOMATIC ENROLLMENT- HIB162 – REFUSAL OVER AUTOMATIC ENROLLMENT
- (1) told us that (2) not want (3) insurance under Medicare.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
BGN plus BLN- BGN plus BLN (not possessive)
Choice 2- Choice 2
- You
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- he does
Choice 2- Choice 2
- she does
Choice 3- Choice 3
- you do
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- hospital
Choice 2- Choice 2
- medical
Choice 3- Choice 3
- hospital and medical
HIB163 – SMI REFUSAL CURRENT PAY REFUND OF PREMIUMS- HIB163 – SMI REFUSAL CURRENT PAY REFUND OF PREMIUMS
- (1) not have to pay a premium for any months (2) not entitled to Medicare Part B (medical insurance). If we took out premiums for any of these months, we will return the money to (3).
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- You do
Choice 2- Choice 2
- BGN plus BLN plus does
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- you were
Choice 2- Choice 2
- he was
Choice 3- Choice 3
- she was
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- you
Choice 2- Choice 2
- him
Choice 3- Choice 3
- her
HIB164 – SMI REFUSAL PREMIUM BILLING AND NO OPEN THIRD PARTY- HIB164 – SMI REFUSAL PREMIUM BILLING AND NO OPEN THIRD PARTY
- Since our records were previously annotated to show that (1) enrolled for Medicare (2) insurance, a premium billing notice may have been prepared for mailing to (3). If (4) a billing notice, (5) should destroy it.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- he was
Choice 2- Choice 2
- she was
Choice 3- Choice 3
- you were
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- hospital
Choice 2- Choice 2
- medical
Choice 3- Choice 3
- hospital and medical
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- him
Choice 2- Choice 2
- her
Choice 3- Choice 3
- you
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- he receives
Choice 2- Choice 2
- she receives
Choice 3- Choice 3
- you receive
Fill-in (5)- Fill-in (5)
-
Choice 1- Choice 1
- he
Choice 2- Choice 2
- she
Choice 3- Choice 3
- you
HIB165 – REFUSAL/WITHDRAWAL STATE BUY-IN ESTABLISHED- HIB165 – REFUSAL/WITHDRAWAL STATE BUY-IN ESTABLISHED
- Our records show that (1) State has agreed to pay the premiums for (2) Medicare (3) insurance coverage. Therefore, (4) will continue to be enrolled.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- hospital
Choice 2- Choice 2
- medical
Choice 3- Choice 3
- hospital and medical
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- he
Choice 2- Choice 2
- she
Choice 3- Choice 3
- you
HIB175 – SMI PREMIUMS/ARREARAGE DEDUCTED FROM PMA OR CMA- HIB175 – SMI PREMIUMS/ARREARAGE DEDUCTED FROM PMA OR CMA
- We are deducting past-due premiums from (1) check.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
Beneficiary's full name possessive- Beneficiary's full name (possessive)
Choice 2- Choice 2
- your
HIB176 – SMI PREMIUMS/ARREARAGE DEDUCTED FROM PMA OR CMA WHEN BENEFITS ARE RESUMED- HIB176 – SMI PREMIUMS/ARREARAGE DEDUCTED FROM PMA OR CMA WHEN BENEFITS ARE RESUMED
- Since benefits are again payable we will resume withholding (1) medical premiums due to date.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
BGN plus BLN possessive- BGN plus BLN (possessive)
Choice 2- Choice 2
- your
HIB182 – IRMAA AMOUNT STARTS, IRMAA AMOUNT CHANGES OR IRMAA AMOUNT NO LONGER APPLIED TO SMI PREMIUM (PART B)- HIB182 – IRMAA AMOUNT STARTS, IRMAA AMOUNT CHANGES OR IRMAA AMOUNT NO LONGER APPLIED TO SMI PREMIUM (PART B)
- In an earlier letter, we told you that (1) Medicare Part B
- (medical insurance) premium includes:
- * the standard Part B premium amount,
- * any surcharge that may apply for late enrollment or reenrollment, and
- * an income-related monthly adjustment amount (IRMAA).
- If (2) prescription drug coverage, (3) also must pay a prescription drug coverage IRMAA. The IRMAA is in addition to (4) monthly premium. We base the IRMAA on (5) income. We deduct the IRMAA from (6) monthly Social Security benefits, regardless of how (7) premiums.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- your
Choice 2- Choice 2
BGN plus BLN possessive- BGN plus BLN (possessive)
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- you have
Choice 2- Choice 2
- she has
Choice 3- Choice 3
- he has
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- you
Choice 2- Choice 2
- she
Choice 3- Choice 3
- he
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- your
Choice 2- Choice 2
- her
Choice 3- Choice 3
- his
Fill-in (5)- Fill-in (5)
-
Choice 1- Choice 1
- your
Choice 2- Choice 2
- her
Choice 3- Choice 3
- his
Fill-in (6)- Fill-in (6)
-
Choice 1- Choice 1
- your
Choice 2- Choice 2
- her
Choice 3- Choice 3
- his
Fill-in (7)- Fill-in (7)
-
Choice 1- Choice 1
- you pay your
Choice 2- Choice 2
- he pays his
Choice 3- Choice 3
- she pays her
HIB183 – USE WITH HIB182 WHEN IRMAA AFFECTS PART B RATE- HIB183 – USE WITH HIB182 WHEN IRMAA AFFECTS PART B RATE
- We sent (1) another letter that explained how we determined the amount of (2) premium.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- him
Choice 2- Choice 2
- her
Choice 3- Choice 3
- you
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
HIB184 – USE WITH HIB182 WHEN BENEFICIARY WILL CONTINUE TO BE BILLED FOR PART B SMI PREMIUMS- HIB184 – USE WITH HIB182 WHEN BENEFICIARY WILL CONTINUE TO BE BILLED FOR PART B SMI PREMIUMS
- We will continue to bill (1) for (2) Medicare Part B premiums.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- him
Choice 2- Choice 2
- her
Choice 3- Choice 3
- you
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
HIB185 – USE WHEN HIB182 IS GENERATED AS THE INTRODUCTORY UTI AND BENEFICIARY'S LAF IS CURRENT PAY OR DEFERRED- HIB185 – USE WHEN HIB182 IS GENERATED AS THE INTRODUCTORY UTI AND BENEFICIARY'S LAF IS CURRENT PAY OR DEFERRED
- The amount you will receive around (1) was changed because of a change in (2) monthly Medicare Part B premium.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- using the PCI show the calendar date of the COM check
Choice 2- Choice 2
- using the PCI show the calendar date of the DPD check
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
HIB186 – SMI MATURITY AND NO IRMAA DATA ON POST MBR- HIB186 – SMI MATURITY AND NO IRMAA DATA ON POST MBR
- IMPORTANT: A Medicare law requires some higher income persons to pay higher premiums. The law applies to premiums for Medicare Part B (medical insurance) and prescription drug coverage. The law generally affects individuals with incomes higher than (1) and couples with incomes higher than (2). We will contact the Internal Revenue Service to get information about (3) income. If we decide that (4) to pay higher premiums, we will send a letter explaining our decision. The higher amount will be effective (5). For more information, please visit www.socialsecurity.gov on the Internet or call us toll-free at 1-800-772-1213 (TTY 1-800-325-0778).
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
- Show the IRMAA level 1 yearly amount for singles
Fill-in (2)- Fill-in (2)
- Show the IRMAA level 1 yearly amount for couples
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- he has
Choice 2- Choice 2
- she has
Choice 3- Choice 3
- you have
Fill-in (5)- Fill-in (5)
- show the SMI START date
HIB215 – T2 BENEFITS TERMINATE HI/SMI TERMINATES- HIB215 – T2 BENEFITS TERMINATE HI/SMI TERMINATES
- Since (1) no longer entitled to monthly Social Security benefits, we are stopping (2) (3) insurance coverage under Medicare. (4) (5) insurance coverage ends on the last day of (6). Please destroy (7) Medicare card after the coverage ends.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- he is
Choice 2- Choice 2
- she is
Choice 3- Choice 3
- you are
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- hospital
Choice 2- Choice 2
- hospital and medical
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- His
Choice 2- Choice 2
- Her
Choice 3- Choice 3
- Your
Fill-in (5)- Fill-in (5)
-
Choice 1- Choice 1
- hospital
Choice 2- Choice 2
- hospital and medical
Fill-in (6)- Fill-in (6)
- Show HI-TERM date in format MMCCYY
Fill-in (7)- Fill-in (7)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
HIB225 – HRFST LESSDO MBA LESS THAN SMI PREMIUM- HIB225 – HRFST LESSDO MBA LESS THAN SMI PREMIUM
- (1) monthly medical insurance premium is (2). The monthly benefit that (3) should get is less than (4) medical insurance premiums. We are stopping (5) monthly benefits starting (6) to pay for part of this premium. After adjusting for (7) monthly benefits, we find that we must bill (8) for (9).
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
BGN plus BLN possessive- BGN plus BLN (possessive)
Choice 2- Choice 2
- Your
Fill-in (2)- Fill-in (2)
- Show the current SMI premium amount
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
BGN plus BLN- BGN plus BLN (not possessive)
Choice 2- Choice 2
- you
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (5)- Fill-in (5)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (6)- Fill-in (6)
- Show the first EFD in HIST Data that corresponds to LESSDO
Fill-in (7)- Fill-in (7)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (8)- Fill-in (8)
-
Choice 1- Choice 1
- him
Choice 2- Choice 2
- her
Choice 3- Choice 3
- you
Fill-in (9)- Fill-in (9)
- Show money amount for the remaining premiums
HIB226 – HRFST LESSDO MBA > SMI BUT LESS THAN A DOLLAR- HIB226 – HRFST LESSDO MBA > SMI BUT LESS THAN A DOLLAR
- We are stopping (1) monthly benefit starting (2). When we take (3) monthly medical insurance premium of (4) from (5) monthly benefit, the amount left is less than a dollar. At the end of the year, we will adjust (6) record and pay all money (7) due.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
BGN plus BLN possessive- BGN plus BLN (possessive)
Choice 2- Choice 2
your- your
Fill-in (2)- Fill-in (2)
- Show the first EFD in HIST Data that corresponds to LESSDO
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (4)- Fill-in (4)
- Show current SMI premium amount
Fill-in (5)- Fill-in (5)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (6)- Fill-in (6)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (7)- Fill-in (7)
-
Choice 1- Choice 1
- he is
Choice 2- Choice 2
- she is
Choice 3- Choice 3
- you are
HIB248 – PREMIUM HI REDUCTION WHEN 30 QUARTERS ATTAINED NO OPEN ENTITLEMENT TO PREMIUM HI- HIB248 – PREMIUM HI REDUCTION WHEN 30 QUARTERS ATTAINED NO OPEN ENTITLEMENT TO PREMIUM HI
- Currently, (1) not eligible for free Medicare hospital insurance. However, (2) may be eligible to buy hospital insurance for the reduced premium of (3) per month. You can get more information about this hospital insurance by contacting any Social Security office.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- BGN plus BLN plus the word “is”
Choice 2- Choice 2
you are- you are
Fill-in (2)- Fill-in (2)
- he / she / you
Choice 1- Choice 1
- he
Choice 2- Choice 2
- she
Choice 3- Choice 3
- you
Fill-in (3)- Fill-in (3)
- Show the premium HI amount that pertains to the HIRE-30QTR date in HIRE data in the format $$$$¢¢
HIB249 – OFFER RELIEF FOR SMI PREMIUMS (VSMI RATES)- HIB249 – OFFER RELIEF FOR SMI PREMIUMS (VSMI RATES)
- If you want your medical insurance to start earlier, you can choose to have it start in (1). To start your medical insurance earlier, you must do the following things within 60 days after the date of this notice:
- * tell us in writing that you want medical insurance beginning (2);
- AND
- * pay us (3) or tell us we can withhold this amount from your check. This amount covers the premiums due from (4) through (5).
- If you would find it hard to pay the premium amount you would owe in a lump sum, ask us about other ways to pay the premium.
- If you choose to have your medical insurance start in (6), your current monthly premium will be (7). If you do not choose the earlier date, your monthly premium will be (8).
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
- Show the SMI-NONEQRELST date
Fill-in (2)- Fill-in (2)
- Show the SMI-NONEQRELST date
Fill-in (3)- Fill-in (3)
- Show the total amount of the SMI premiums
Fill-in (4)- Fill-in (4)
- Show the SMI-NONEQRELST date
Fill-in (5)- Fill-in (5)
- Show the current operating month date
Fill-in (6)- Fill-in (6)
- Show the SMI-NONEQRELST date
Fill-in (7)- Fill-in (7)
- Show the current VSMI rate
Fill-in (8)- Fill-in (8)
- Show the current Part B premium rate
HIB260 – PREMIUM RELIEF ESTABLISHED DUE TO IRMAA B AND/OR IRMAA D- HIB260 – PREMIUM RELIEF ESTABLISHED DUE TO IRMAA B AND/OR IRMAA D
- As we told you in another letter, you owe more Medicare premiums because (1) income-related monthly adjustment amounts changed.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
BGN plus BLN possessive- BGN plus BLN (possessive)
Choice 2- Choice 2
your- your
HIB261 – PREMIUM RELIEF ESTABLISHED DUE TO IRMAA B- HIB261 – PREMIUM RELIEF ESTABLISHED DUE TO IRMAA B
- You owe (1) for Medicare Part B (medical insurance) premiums for (2) (3) (4).
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
- Show the total amount of the SMI arrearages for IRMAA B in the format $$$$$$¢¢
Fill-in (2)- Fill-in (2)
- Show the RLF-START date in the first occurrence of Premium Relief data in the format November 2009
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- null
Choice 2- Choice 2
- and
Choice 3- Choice 3
- through
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- Null
Choice 2- Choice 2
- Show the RLF-STOP date in the last occurrence of Premium Relief data in the format November 2009
HIB262 – PREMIUM RELIEF ESTABLISHED DUE TO IRMAA D- HIB262 – PREMIUM RELIEF ESTABLISHED DUE TO IRMAA D
- You owe (1) for Medicare prescription drug coverage income-related monthly adjustment amounts for (2) (3) (4).
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
- Show the total amount of IRMAA D equitable relief arrearages in the format $$$$$$¢¢
Fill-in (2)- Fill-in (2)
- Show the RLF-START date in the first occurrence of Premium Relief data in the format November 2009
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- null
Choice 2- Choice 2
- and
Choice 3- Choice 3
- through
Fill-in (4)- Fill-in (4)
-
Choice 1- Choice 1
- Null
Choice 2- Choice 2
- Show the RLF-STOP date in the last occurrence of Premium Relief data in the format November 2009
HIB263 – PREMIUM RELIEF ESTABLISHED DUE TO IRMAA B AND ALSO IRMAA D- HIB263 – PREMIUM RELIEF ESTABLISHED DUE TO IRMAA B AND ALSO IRMAA D
- The total past-due Medicare amounts you owe are (1).
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
- Show the sum of the total amount of the IRMAA B equitable relief arrearages plus the total amount of the IRMAA D equitable relief arrearages in the format $$$$$$¢¢
HIB264 – PREMIUM RELIEF ESTABLISHED - ALTERNATIVES TO FULL WITHHOLDING OF BENEFITS- HIB264 – PREMIUM RELIEF ESTABLISHED - ALTERNATIVES TO FULL WITHHOLDING OF BENEFITS
- If you would find it hard to pay the past-due Medicare amounts (1) at one time, please ask us about other ways to pay them. You may ask for waiver of these past-due Medicare amounts if paying them would be a severe financial hardship for you. If we do not hear from you within 30 days after the date of this letter, we will take the Medicare amounts (2) out of (3) monthly Social Security payments beginning (4).
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- he owes
Choice 2- Choice 2
- she owes
Choice 3- Choice 3
- you owe
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- he owes
Choice 2- Choice 2
- she owes
Choice 3- Choice 3
- you owe
Fill-in (3)- Fill-in (3)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (4)- Fill-in (4)
- Show the current operating month (COM) plus 2 months in the format July 2009
HIB265 – DEDUCTION OF CURRENT SMI PREMIUMS- HIB265 – DEDUCTION OF CURRENT SMI PREMIUMS
- We will deduct (1) current Medicare Part B (medical insurance) premium from (2) monthly Social Security payments beginning (3).
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
- BGN plus BLN possessive
Choice 2- Choice 2
- your
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- his
Choice 2- Choice 2
- her
Choice 3- Choice 3
- your
Fill-in (3)- Fill-in (3)
- Show the current operating month (COM) plus 2 months in the format July 2009
HIB266 – FULL WITHHOLDING OF PART B RELIEF PREMIUMS WHEN CURRENT SMI PREMIUMS ARE ALSO DEDUCTED- HIB266 – FULL WITHHOLDING OF PART B RELIEF PREMIUMS WHEN CURRENT SMI PREMIUMS ARE ALSO DEDUCTED
- We will also deduct (1) for past-due Medicare Part B (medical insurance) premiums.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
- Show the sum of the RCVBL-TOTAMT for current PART B only arrearages in the format $$$$$$¢¢
HIB267 – FULL WITHHOLDING OF IRMAA D RELIEF PREMIUMS WHEN CURRENT SMI PREMIUMS ARE BEING DEDUCTED- HIB267 – FULL WITHHOLDING OF IRMAA D RELIEF PREMIUMS WHEN CURRENT SMI PREMIUMS ARE BEING DEDUCTED
- We will also deduct (1) for past-due Medicare prescription drug coverage income-related monthly adjustment amounts.
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
- Show the sum of the RCVBL-TOTAMT for current IRMAA D only arrearages in the format $$$$$$¢¢
HIB268 – FULL WITHHOLDING OF IRMAA D RELIEF PREMIUMS WHEN NO CURRENT SMI PREMIUMS BEING DEDUCTED- HIB268 – FULL WITHHOLDING OF IRMAA D RELIEF PREMIUMS WHEN NO CURRENT SMI PREMIUMS BEING DEDUCTED
- We will deduct past-due Medicare prescription drug coverage income-related monthly adjustment amounts from your monthly Social Security payments beginning (1). The total amount we will deduct is (2).
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
- Show the current operating month (COM) in the format July 2009
Fill-in (2)- Fill-in (2)
- Show the sum of the IRMAA D arrearages in the format $$$$$$¢¢
HIB269 – FULL WITHHOLDING CONTINUES UNTIL PREMIUMS PAID IN FULL- HIB269 – FULL WITHHOLDING CONTINUES UNTIL PREMIUMS PAID IN FULL
- We will withhold (1) monthly payments until you have paid all of the past-due Medicare amounts (2).
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
-
Choice 1- Choice 1
BGN plus BLN possessive- BGN plus BLN (possessive)
Choice 2- Choice 2
- your
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
- he owes
Choice 2- Choice 2
- she owes
Choice 3- Choice 3
- you owe
HIB270 – FULL WITHHOLDING OF PART B RELIEF PREMIUMS WHEN NO CURRENT SMI PREMIUMS BEING DEDUCTED- HIB270 – FULL WITHHOLDING OF PART B RELIEF PREMIUMS WHEN NO CURRENT SMI PREMIUMS BEING DEDUCTED
- We will deduct past-due Medicare Part B (medical insurance) premiums from your monthly Social Security payments beginning (1). The total amount we will deduct is (2).
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
- Show the current operating month (COM) in the format July 2009
Fill-in (2)- Fill-in (2)
- Show the sum of the IRMAA B arrearages in the format $$$$$$¢¢
HIB271 – PARTIAL RECOVERY OF PART B OR IRMAA D RELIEF PREMIUMS- HIB271 – PARTIAL RECOVERY OF PART B OR IRMAA D RELIEF PREMIUMS
- We will deduct past-due Medicare Part B (medical insurance) premiums from your monthly Social Security payments beginning (1). The total amount we will deduct is (2).
- Fill-in values:
-
Fill-in (1)- Fill-in (1)
- Add the RCVBL-PARTAMT for each occurrence and show this sum in the format $$$$$$¢¢
Fill-in (2)- Fill-in (2)
-
Choice 1- Choice 1
BGN plus BLN possessive- BGN plus BLN (possessive)
Choice 2- Choice 2
- your
Fill-in (3)- Fill-in (3)
- Show the current operating month (COM) in the format July 2009
Fill-in (4)- Fill-in (4)
- Add the RCVBL-PARTAMT for each occurrence and show this sum in the format $$$$$$¢¢
- HIB288 – SUBSEQUENT NOTICE WITH CMS BILLING STATEMENT AND INSTRUCTIONS FOR COMPLETING THE PAYMENT COUPON
- We told you in another letter your Centers for Medicare & Medicaid Services (CMS) Billing Statement would be mailed in another envelope. At the end of this letter, you will find the CMS Billing Statement and instructions for completing the payment coupon.
- HIB289 – (CMS) BILLING STATEMENT WILL BE MAILED IN ANOTHER ENVELOPE
- Your Centers for Medicare & Medicaid Services (CMS) Billing Statement will be mailed in another envelope.
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.