POMS Reference

Table of contents Recent changes
Contact
Back
This change was made on Mar 30, 2018. See latest version.
Text removed
Text added

NL 00730.126: “M” Paragraphs and Captions

changes
← * →
  • Effective Dates: 04/15/2015 - Present
  • Effective Dates: 03/30/2018 - Present
  • TN 19 (08-14)
  • TN 28 (03-18)
  • NL 00730.126 “M” Paragraphs and Captions
  • List of “M” Paragraphs and Captions
  • A. “MAN” Universal Text Identifier - Manual
  • MAN001 – MANUAL NOTICE NEEDED TO EXPLAIN TITLE II REDESIGN ACTION(S)
  • MANUAL NOTICE NEEDED – (1)
  • Fill-in values:
  •  
  • Fill-in (1)
  •  
  • Choice 1
  • LIMITED GROUP PAYER
  • Choice 2
  • THIRD-PARTY WIPEOUT PROCESSED
  • Choice 3
  • MEDICARE CLAIM WITHDRAWAL PROCESSED
  • Choice 4
  • MBA LESS SMI PAST PREMIUMS
  • Choice 5
  • MULTIPLE 3RD PARTY CLOSED PERIODS
  • Choice 6
  • SPA OPA POSTED TO BOUD TERM TO TERM
  • Choice 7
  • SUSPENSION FOR WITHDRAWAL CLAIM
  • Choice 8
  • NEW OPA AND PRIOR OPA UNDER PROTEST
  • Choice 9
  • MULTIPLE FFEL CHANGED OCCURRENCES
  • Choice 10
  • WARRANT ISSUING AGENCY IS BLANK
  • Choice 11
  • MBR ORI AND WARRANTDT NO MATCH ON FFSCF
  • Choice 12
  • WC/PDB STOPS AND NO AMOF DATA PRESENT
  • Choice 13
  • FFEL SUSP NO CHANGE IN FFEL OCCURRENCES
  • Choice 14
  • ICF INPUT WC DATA DELETED ON POST-MBR
  • Choice 15
  • MULTIPLE ARD DATA LINES FOR SAME YEAR (YOER)
  • B. “MAR” Universal Text Identifiers - Marriage
  • MAR008 – MARRIAGE DOES NOT AFFECT SOCIAL SECURITY ADMINISTRATION BENEFITS
  • Thank you for telling us that (1) married. However, this marriage will not affect (2) benefits.
  • Fill-in values:
  •  
  • Fill-in (1)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)
  • Choice 2
  • you
  • Fill-in (2)
  •  
  • Choice 1
  • his
  • Choice 2
  • her
  • Choice 3
  • your
  • MAR009 – DIVORCE DOES NOT AFFECT SOCIALSECURITY ADMINISTRATION BENEFITS
  • Thank you for telling us about (1) divorce. However, the divorce will not affect (2) benefits.
  • Fill-in values:
  •  
  • Fill-in (1)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • your
  • Fill-in (2)
  •  
  • Choice 1
  • his
  • Choice 2
  • her
  • Choice 3
  • your
  • C. “MHP” Universal Text Identifiers – Medicare Health Plan
  • MHPC02 – CAPTION
  • Information About (1) Health Plan Premiums
  • Fill-in values:
  •  
  • Fill-in (1)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • Your
  • MHPC03 – CAPTION
  • Information About (1) Medicare Prescription Drug Plan Costs
  • Fill-in values:
  •  
  • Fill-in (1)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • Your
  • MHPC04 – CAPTION
  • Information About (1) Health Plan Premiums and Medicare Prescription Drug Plan Costs
  • Fill-in values:
  •  
  • Fill-in (1)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • Your
  • MHP008 – MEDICARE ADVANTAGE PART B PREMIUM REDUCED
  • MONTH CCYY    MONTH CCYY    $$$$$$¢¢    $$$$$$¢¢
  • NOTE: The fill-ins for MHP008 will be repeated for each occurrence of MARD data that needs to be displayed in the notice.
  • Fill-in values:
  •  
  • Fill-in (1)
  • Medicare Advantage Reduction Start Date (MARD-START-REL) for the first occurrence of MARD data that has changed when comparing the pre- and post-MBRs
  • NOTE: for Fill-in (1), the date will be displayed in the numeric format showing the slash after the month and before the year (e.g., 01/2006)
  • Fill-in (2)
  • Medicare Advantage Reduction Stop Date (MARD-STOP-REL) that corresponds to the MARD start date
  • NOTE: the MARD stop date may not have a value if there is no stop date on the post-MBR
  • Fill-in (3)
  • Medicare Advantage Reduction Amount (MARD-AMOUNT) that corresponds to the start/stop occurrence
  • NOTE: If an MARD occurrence on the pre-MBR is wiped-out, then the value for this fill-in will be zero and displayed as 0.00
  • Fill-in (4)
  • Show the Part B premium after the Medicare Advantage Reduction Amount (MARD-AMOUNT) is applied.
  • NOTE: if the MARD occurrence displayed is for a wiped-out occurrence on the pre-MBR, the value for this fill-in will be the Part B SMI rate
  • NOTE: The decision to display MARD occurrence from the pre-MBR that is wiped-out was made by CMS notice policy when creating the revised language to use for Medicare Advantage reduction of Part B premium amount.
  • MHP009 – PART C HEALTH PLAN PREMIUMS DEDUCTION FROM SSA BENEFITS STARTS
  • As (1) requested, we will begin deducting (2) health plan premiums from (3) monthly benefit.
  • Fill-in values:
  •  
  • Fill-in (1)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
  • Choice 2
  • you
  • Fill-in (2)
  •  
  • Choice 1
  • his
  • Choice 2
  • her
  • Choice 3
  • your
  • Fill-in (3)
  •  
  • Choice 1
  • his
  • Choice 2
  • her
  • Choice 3
  • your
  • MHP012 – PART C HEALTH PLAN PREMIUMS DEDUCTED FROM A PRIOR MONTHLY ACCRUAL (PMA) OR CURRENT MONTHLY ACCRUAL (CMA)
  • This represents all health plan premiums due to date.
  • MHP013 – SUPPLEMENTAL MEDICAL INSURANCE (SMI) PART B PREMIUM REDUCED
  • Some Medicare plans may reduce (1) Medicare Part B premium as a plan benefit.
  • Fill-in values:
  •  
  • Fill-in (1)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • your
  • MHP014 – MEDICARE ADVANTAGE PART B PREMIUM REDUCED
  • Below we show the changes to the monthly deduction to (1) medical insurance (Part B) premium:
  • Start Date
  • Stop Date
  • Amount of Reduction
  • Amount of Premium After the Reduction
  • (2)
  • Fill-in values:
  •  
  • Fill-in (1)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • your
  • Fill-in (2)
  • a blank line is required for Fill-in (2) for formatting purposes
  • MHP015 – PART C HEALTH PLAN PREMIUM DEDUCTED FROM MONTHLY BENEFIT PAYABLE (MBP) > $0.00
  • Each month, we will continue to deduct (1) for (2) health plan premiums.
  • Fill-in values:
  •  
  • Fill-in (1)
  • For every Deductions Additions History (DAH) occurrence on the post-MBR with the Deductions Additions History Update Date (DAH-UPDDT) equal to the Run Date that has a Deductions Additions History Type of Payment Code (DAH-TOP) = MBP (M) and has a Deductions Additions History Item Code (DAH-ITEM) = 445, 450, 455 and/or 460, add the Deductions Additions History Amount (DAH-AMOUNT) for each of these occurrences together and show this total as the fill-in value
  • Fill-in (2)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • your
  • MHP016 – PART C HEALTH PLAN PREMIUM DEDUCTION AMOUNT CHANGES
  • There has been a change in the amount withheld for (1) health plan premiums.
  • Fill-in values:
  •  
  • Fill-in (1)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • your
  • MHP017 – PART C HEALTH PLAN PREMIUMS NO LONGER DEDUCTED FROM SSA BENEFITS
  • We will no longer deduct money for (1) health plan premium(s) from (2) monthly benefits.
  • Fill-in values:
  •  
  • Fill-in (1)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • your
  • Fill-in (2)
  •  
  • Choice 1
  • his
  • Choice 2
  • her
  • Choice 3
  • your
  • MHP018 – ADVISES BENEFICIARY TO CONTACT THEIR HEALTH PLAN ABOUT PART C HEALTH PLAN OR ABOUT THE REDUCTION OF PART B PREMIUM AMOUNT
  • If you have any questions about (1) health plan premiums, please contact (2) health plan(s).
  • Fill-in values:
  •  
  • Fill-in (1)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • your
  • Fill-in (2)
  •  
  • Choice 1
  • his
  • Choice 2
  • her
  • Choice 3
  • your
  • MHP027 – REFUND FOR PART C HEALTH PLAN PREMIUMS ONLY PAID IN THE PRIOR MONTH ACCRUAL AMOUNT (PAMT) OR CURRENT MONTH ACCRUAL AMOUNT (CAMT)
  • This payment includes a refund of (1) health plan premiums.
  • Fill-in values:
  •  
  • Fill-in (1)
  •  
  • Choice 1
  • his
  • Choice 2
  • her
  • Choice 3
  • your
  • MHP028 – REFUND FOR PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS PAID IN A PRIOR MONTH ACCRUAL AMOUNT (PAMT) OR CURRENT MONTH ACCRUAL AMOUNT (CAMT)
  • This payment includes a refund of (1) Medicare prescription drug plan costs.
  • Fill-in values:
  •  
  • Fill-in (1)
  •  
  • Choice 1
  • his
  • Choice 2
  • her
  • Choice 3
  • your
  • MHP029 – REFUND FOR PART C HEALTH PLAN PREMIUMS AND ALSO PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS
  • This payment includes a refund of (1) health plan premiums and (2) Medicare prescription drug plan costs.
  • Fill-in values:
  •  
  • Fill-in (1)
  •  
  • Choice 1
  • his
  • Choice 2
  • her
  • Choice 3
  • your
  • Fill-in (2)
  •  
  • Choice 1
  • his
  • Choice 2
  • her
  • Choice 3
  • your
  • MHP030 – REFUND FOR PART D ONLY MEDICARE PRESCRIPTION DRUG PLAN COSTS AND NO OTHER TITLE II REDESIGN PARAGRAPH GENERATED AS INTRODUCTORY PARAGRAPH
  • Based on the information we have (1) (2) due a refund for Medicare prescription drug plan costs.
  • Fill-in values:
  •  
  • Fill-in (1)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
  • Choice 2
  • you
  • Fill-in (2)
  •  
  • Choice 1
  • is
  • Choice 2
  • are
  • MHP031 – REFUND FOR PART C ONLY HEALTH PLAN PREMIUMS AND NO OTHER TITLE II REDESIGN PARAGRAPH GENERATED AS INTRODUCTORY PARAGRAPH
  • Based on the information, we have (1) (2) due a refund for health plan premiums.
  • Based on the information we have (1) (2) due a refund for health plan premiums.
  • Fill-in values:
  •  
  • Fill-in (1)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
  • Choice 2
  • you
  • Fill-in (2)
  •  
  • Choice 1
  • is
  • Choice 2
  • are
  • MHP032 – REFUND FOR PART C HEALTH PLAN PREMIUMS AND ALSO REFUND FOR PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS AND NO OTHER TITLE II REDESIGN PARAGRAPH GENERATED AS INTRODUCTORY PARAGRAPH
  • Based on the information, we have (1) (2) due a refund for (3) health plan premiums and (4) Medicare prescription drug plan costs.
  • Based on the information we have, (1) (2) due a refund for (3) health plan premiums and (4) Medicare prescription drug plan costs.
  • Fill-in values:
  •  
  • Fill-in (1)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
  • Choice 2
  • you
  • Fill-in (2)
  •  
  • Choice 1
  • is
  • Choice 2
  • are
  • Fill-in (3)
  •  
  • Choice 1
  • his
  • Choice 2
  • her
  • Choice 3
  • your
  • Fill-in (4)
  •  
  • Choice 1
  • his
  • Choice 2
  • her
  • Choice 3
  • your
  • MHP033 – BENEFICIARY REQUESTS THAT ONLY PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS DEDUCTED FROM SOCIAL SECURITY ADMINISTRATION BENEFITS
  • As (1) requested, we will begin deducting (2) Medicare prescription drug plan costs from (3) monthly benefit.
  • Fill-in values:
  •  
  • Fill-in (1)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
  • Choice 2
  • you
  • Fill-in (2)
  •  
  • Choice 1
  • his
  • Choice 2
  • her
  • Choice 3
  • your
  • Fill-in (3)
  •  
  • Choice 1
  • his
  • Choice 2
  • her
  • Choice 3
  • your
  • MHP034 – BENEFICIARY REQUESTS THAT PART C HEALTH PLAN PREMIUMS AND ALSO PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS DEDUCTED FROM SOCIAL SECURITY ADMINISTRATION BENEFITS
  • As (1) requested, we will begin deducting (2) health plan premiums and Medicare prescription drug plan costs from (3) monthly benefit.
  • Fill-in values:
  •  
  • Fill-in (1)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
  • Choice 2
  • you
  • Fill-in (2)
  •  
  • Choice 1
  • his
  • Choice 2
  • her
  • Choice 3
  • your
  • Fill-in (3)
  •  
  • Choice 1
  • his
  • Choice 2
  • her
  • Choice 3
  • your
  • MHP035 – PART C ONLY HEALTH PLAN PREMIUMS DEDUCTED FROM PRIOR MONTH ACCRUAL AMOUNT (PAMT) CHECK
  • We deducted (1) for (2) health plan premiums from the check you will receive on or about (3).
  • Fill-in values:
  •  
  • Fill-in (1)
  • Total amount of the Part C health plan premiums deducted from the Prior Month Accrual Amount (PAMT) check; this amount includes any Part C arrearages show in Deductions Additions History (DAH) data from the PAMT
  • Fill-in (2)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • your
  • Fill-in (3)
  • Run date plus 15 days as the date in the format Month DD, CCYY
  • MHP036 – PART D ONLY MEDICARE PRESCRIPTION DRUG PLAN COSTS DEDUCTED FROM PRIOR MONTH ACCRUAL AMOUNT (PAMT) CHECK
  • We deducted (1) for (2) Medicare prescription drug plan costs from the check you will receive on or about (3).
  • Fill-in values:
  •  
  • Fill-in (1)
  • Total amount of the Part D Medicare prescription drug plan costs deducted from the Prior Month Accrual Amount (PAMT) check; this amount includes any Part D arrearages show in Deductions Additions History (DAH) data from the PAMT
  • Fill-in (2)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • your
  • Fill-in (3)
  • Run date plus 15 days as the date in the format Month DD, CCYY
  • MHP037 – PART C HEALTH PLAN PREMIUMS AND ALSO PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS DEDUCTED FROM PRIOR MONTH ACCRUAL AMOUNT (PAMT) CHECK
  • We deducted (1) for (2) health plan premiums and (3) for (4) Medicare prescription drug plan costs from the check you will receive on or about (5).
  • Fill-in values:
  •  
  • Fill-in (1)
  • Total amount of the Part C health plan premiums deducted from the Prior Month Accrual Amount (PAMT) check; this amount includes any Part C arrearages show in Deductions Additions History (DAH) data from the PAMT
  • Fill-in (2)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • your
  • Fill-in (3)
  • Total amount of the Part D Medicare prescription drug plan costs deducted from the Prior Month Accrual Amount (PAMT) check; this amount includes any Part D arrearages show in Deductions Additions History (DAH) data from the PAMT
  • Fill-in (4)
  •  
  • Choice 1
  • his
  • Choice 2
  • her
  • Choice 3
  • your
  • Fill-in (5)
  • Run date plus 15 days as the date in the format Month DD, CCYY
  • MHP038 – PART C ONLY HEALTH PLAN PREMIUMS DEDUCTED FROM CURRENT AMOUNT (CAMT) CHECK
  • We deducted (1) for (2) health plan premiums from the check you will receive for (3) on or about (4).
  • Fill-in values:
  •  
  • Fill-in (1)
  • Total amount of the Part C health plan premiums deducted from the Current Amount (CAMT) check; this amount includes any Part C arrearages show in Deductions Additions History (DAH) data from the CAMT
  • Fill-in (2)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • your
  • Fill-in (3)
  • Current Operating Month (COM) in the format Month CCYY
  • Fill-in (4)
  • Using the PCI (Payment Cycle Indicator) show the calendar date in which the Current Operating Month (COM) check will be paid in the format Month DD, CCYY
  • MHP039 – PART D ONLY MEDICARE PRESCRIPTION DRUG PLAN COSTS DEDUCTED FROM CURRENT AMOUNT (CAMT) CHECK
  • We deducted (1) for (2) Medicare prescription drug plan costs from the check you will receive for (3) on or about (4).
  • Fill-in values:
  •  
  • Fill-in (1)
  • Total amount of the Part D Medicare prescription drug plan costs deducted from the Current Amount (CAMT) check; this amount includes any Part C arrearages show in Deductions Additions History (DAH) data from the CAMT
  • Fill-in (2)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • your
  • Fill-in (3)
  • Current Operating Month (COM) in the format Month CCYY
  • Fill-in (4)
  • Using the Payment Cycle Indicator (PCI), show the calendar date in which the Current Operating Month (COM) check will be paid in the format Month DD, CCYY
  • MHP040 – PART C HEALTH PLAN PREMIUMS AND ALSO PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS DEDUCTED FROM THE CURRENT MONTHLY ACCRUAL (CMA) CHECK
  • We deducted (1) for (2) Medicare approved health plan premiums and (3) for (4) Medicare prescription drug plan costs. We deducted these amounts from the payment (5) will receive for (6) on or about (7).
  • Fill-in values:
  •  
  • Fill-in (1)
  • Total amount of the Part C health plan premiums deducted from the Current Monthly Accrual (CMA) check; this amount includes any Part C arrearages show in Deductions Additions History (DAH) data from the CMA
  • Fill-in (2)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • your
  • Fill-in (3)
  • Total amount of the Part D Medicare prescription drug plan costs deducted from the Current Amount (CAMT) check; this amount includes any Part C arrearages shown in Deductions Additions History (DAH) data from the Current Monthly Accrual (CMA)
  • Fill-in (4)
  •  
  • Choice 1
  • his
  • Choice 2
  • her
  • Choice 3
  • your
  • Fill-in (5)
  •  
  • Choice 1
  • he
  • Choice 2
  • she
  • Choice 3
  • you
  • Fill-in (6)
  • Current Operating Month (COM) in the format Month CCYY
  • Fill-in (7)
  • Using the Payment Cycle Indicator (PCI) show the calendar date in which the Current Operating Month (COM) check will be paid in the format Month DD, CCYY
  • MHP041 – PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS FROM THE PRIOR MONTH ACCRUAL AMOUNT (PAMT) AND/OR CURRENT AMOUNT (CAMT)
  • This represents all Medicare prescription drug plan costs due to date.
  • MHP042 – PART C HEALTH PLAN PREMIUMS AND ALSO PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS FROM THE PRIOR MONTH ACCRUAL AMOUNT (PAMT) AND/OR CURRENT AMOUNT (CAMT)
  • This represents all health plan premiums and Medicare prescription drug plan costs due to date.
  • MHP043 – PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS ONLY DEDUCTED FROM MONTHLY BENEFIT PAYABLE (MBP)
  • Each month, we will continue to deduct (1) for (2) Medicare prescription drug plan costs.
  • Fill-in values:
  •  
  • Fill-in (1)
  • Amount of the Part D Medicare prescription drug plan costs deducted from the Monthly Benefit Payable (MBP)
  • Fill-in (2)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • your
  • MHP044 – PART C HEALTH PLAN PREMIUM AND PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS DEDUCTED FROM THE MONTHLY BENEFIT PAYABLE (MBP)
  • Each month, we will continue to deduct (1) for (2) health plan premiums and (3) for (4) Medicare prescription drug plan costs.
  • Fill-in values:
  •  
  • Fill-in (1)
  • Amount of the Part C health plan premium deducted from the Monthly Benefit Payable (MBP)
  • Fill-in (2)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • your
  • Fill-in (3)
  • Amount of the Part D Medicare prescription drug plan costs deducted from the Monthly Benefit Payable (MBP)
  • Fill-in (4)
  •  
  • Choice 1
  • his
  • Choice 2
  • her
  • Choice 3
  • your
  • MHP045 – CHANGE IN THE DEDUCTION AMOUNT FOR PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS FROM SOCIAL SECURITY ADMINISTRATION BENEFITS
  • There has been a change in the amount withheld for (1) Medicare prescription drug plan costs.
  • Fill-in values:
  •  
  • Fill-in (1)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • your
  • MHP046 – CHANGE IN THE DEDUCTION AMOUNT FOR PART C HEALTH PLAN PREMIUM AND ALSO A CHANGE IN THE DEDUCTION AMOUNT FOR PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS
  • There has been a change in the amount withheld for (1) health plan premiums and (2) Medicare prescription drug plan costs.
  • Fill-in values:
  •  
  • Fill-in (1)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • your
  • Fill-in (2)
  •  
  • Choice 1
  • his
  • Choice 2
  • her
  • Choice 3
  • your
  • MHP047 – PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS ONLY NO LONGER DEDUCTED FROM SOCIAL SECURITY ADMINISTRATION BENEFITS
  • We will no longer deduct money for (1) Medicare prescription drug plan costs from (2) monthly benefits.
  • Fill-in values:
  •  
  • Fill-in (1)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • your
  • Fill-in (2)
  •  
  • Choice 1
  • his
  • Choice 2
  • her
  • Choice 3
  • your
  • MHP048 – PART C HEALTH PLAN PREMIUMS AND ALSO PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS NO LONGER DEDUCTED FROM SOCIAL SECURITY ADMINISTRATION BENEFITS
  • We will no longer deduct money for (1) health plan premiums and (2) Medicare prescription drug plan costs from (3) monthly benefits.
  • Fill-in values:
  •  
  • Fill-in (1)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • your
  • Fill-in (2)
  •  
  • Choice 1
  • his
  • Choice 2
  • her
  • Choice 3
  • your
  • Fill-in (3)
  •  
  • Choice 1
  • his
  • Choice 2
  • her
  • Choice 3
  • your
  • MHP049 – REFERRAL LANGUAGE USED WHEN PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS ONLY ARE INVOLVED FOR ANY REASON
  • If you have any questions about (1) Medicare prescription drug plan costs, please contact (2) Medicare prescription drug plan.
  • Fill-in values:
  •  
  • Fill-in (1)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • your
  • Fill-in (2)
  •  
  • Choice 1
  • his
  • Choice 2
  • her
  • Choice 3
  • your
  • MHP050 – REFERRAL LANGUAGE USED WHEN PART C HEALTH PLAN PREMIUMS AND ALSO PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS ARE BOTH INVOLVED FOR ANY REASON
  • Please contact (1) Medicare health plan or (2) Medicare prescription drug plan if (3) questions about (4) premiums or costs.
  • Fill-in values:
  •  
  • Fill-in (1)
  •  
  • Choice 1
  • your
  • Choice 2
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Fill-in (2)
  •  
  • Choice 1
  • your
  • Choice 2
  • his
  • Choice 3
  • her
  • Fill-in (3)
  •  
  • Choice 1
  • you have
  • Choice 2
  • he has
  • Choice 3
  • she has
  • Fill-in (4)
  •  
  • Choice 1
  • your
  • Choice 2
  • his
  • Choice 3
  • her
  • MHP053 – INITIAL ENTITLEMENT TO HOSPITAL INSURANCE (HI)/SUPPLEMENTAL MEDICAL INSURANCE (SMI) WITH NO CURRENT DEDUCTION FOR MEDICARE PART D OR INCOME RELATED MONTHLY ADJUSTMENT AMOUNT (IRMAA) D
  • To learn more about the Medicare prescription drug plans and when (4) can enroll, visit (5) or call 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048). Medicare also can tell (6) about agencies in (7) area that can help (8) choose (9) prescription drug coverage.
  • If (10) limited income and resources, we encourage (11) to apply for the extra help that is available to assist with Medicare prescription drug costs.  The extra help can pay the monthly premiums, annual deductibles and prescription co-payments.  To learn more or apply, please visit (12), call 1-800-772-1213 (TTY 1-800-325-0778) or visit the nearest Social Security office.
  • Fill-in values:
  •  
  • Fill-in (1)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)
  • Choice 2
  • you
  • Fill-in (2)
  •  
  • Choice 1
  • is
  • Choice 2
  • are
  • Fill-in (3)
  •  
  • Choice 1
  • he
  • Choice 2
  • she
  • Choice 3
  • you
  • Fill-in (4)
  •  
  • Choice 1
  • he
  • Choice 2
  • she
  • Choice 3
  • you
  • Fill-in (5)
  • www.medicare.gov
  • Fill-in (6)
  •  
  • Choice 1
  • him
  • Choice 2
  • her
  • Choice 3
  • you
  • Fill-in (7)
  •  
  • Choice 1
  • his
  • Choice 2
  • her
  • Choice 3
  • your
  • Fill-in (8)
  •  
  • Choice 1
  • him
  • Choice 2
  • her
  • Choice 3
  • you
  • Fill-in (9)
  •  
  • Choice 1
  • his
  • Choice 2
  • her
  • Choice 3
  • your
  • Fill-in (10)
  •  
  • Choice 1
  • he has
  • Choice 2
  • she has
  • Choice 3
  • you have
  • Fill-in (11)
  •  
  • Choice 1
  • him
  • Choice 2
  • her
  • Choice 3
  • you
  • Fill-in (12)
  • www.socialsecurity.gov
  • D. “MIS” Universal Text Identifier - Miscellaneous
  • MIS050 – BENEFICIARY DIES IN OR BEFORE THEIR CURRENT DATE OF ENTITLEMENT (DOEC)
  • We are sorry to learn of your recent loss. Please accept our sincere sympathy.
  • We are not processing the application for Social Security benefits for (1). This is because (2) could not have been entitled to benefits for any month before (3) death on (4).
  • Fill-in values:
  •  
  • Fill-in (1)
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)
  • Fill-in (2)
  •  
  • Choice 1
  • he
  • Choice 2
  • she
  • Fill-in (3)
  •  
  • Choice 1
  • his
  • Choice 2
  • her
  • Fill-in (4)
  • Beneficiary Date of Death (BDOD) in format Month CCYY
  • E. “MOE” Universal Text Identifiers – Month Of Entitlement
  • MOE003 – SINGLE ENTITLEMENT RECORD AND MONTH OF ENTITLEMENT (MOE) DATE CHANGE DUE TO WORK AND EARNINGS
  • We reviewed (1) record. When (2) applied for benefits, (3) asked us to start (4) benefits in (5). We changed the month (6) benefits start to (7) because of (8) (9) work and earnings.
  • Fill-in values:
  •  
  • Fill-in (1)
  •  
  • Choice 1
  • your
  • Choice 2
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Fill-in (2)
  •  
  • Choice 1
  • you
  • Choice 2
  • he
  • Choice 3
  • she
  • Fill-in (3)
  •  
  • Choice 1
  • you
  • Choice 2
  • he
  • Choice 3
  • she
  • Fill-in (4)
  •  
  • Choice 1
  • your
  • Choice 2
  • his
  • Choice 3
  • her
  • Fill-in (5)
  • Date of Entitlement (DOE) start date from the pre-MBR in the format Month CCYY
  • Fill-in (6)
  •  
  • Choice 1
  • your
  • Choice 2
  • his
  • Choice 3
  • her
  • Fill-in (7)
  • Date of Entitlement (DOE) new start date from the post-MBR in the format Month CCYY
  • Fill-in (8)
  •  
  • Choice 1
  • your
  • Choice 2
  • his
  • Choice 3
  • her
  • Fill-in (9)
  •  
  • Choice 1
  • Year prior to the Date of Entitlement (DOE) start in the format CCYY
  • Choice 2
  • Full Retirement Age (FRA) year in the format CCYY
  • Choice 3
  • Year prior to the Full Retirement Age (FRA) year in the format CCYY
  • Choice 4
  • Date of Entitlement (DOE) start year in the format CCYY
  • MOE004 – DUAL ENTITLEMENT RECORD AND THE MONTH OF ENTITLEMENT (MOE) DATES CHANGES DUE TO WORK AND EARNINGS FOR A CLOSED YEAR
  • We reviewed (1) record. When (2) applied, (3) asked us to start (4) benefits in (5). We changed the month (6) benefits start to (7) because of (8) (9) work and earnings.
  • (10) also receiving (11) benefits on claim number (12). We will send you another letter about (13) (14) benefits.
  • (10) also receiving benefits on another record. We will send you another letter about those benefits.
  • Fill-in values:
  •  
  • Fill-in (1)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • your
  • Fill-in (2)
  •  
  • Choice 1
  • he
  • Choice 2
  • she
  • Choice 3
  • you
  • Fill-in (3)
  •  
  • Choice 1
  • he
  • Choice 2
  • she
  • Choice 3
  • you
  • Fill-in (4)
  •  
  • Choice 1
  • his
  • Choice 2
  • her
  • Choice 3
  • your
  • Fill-in (5)
  • Date of Entitlement (DOE) start date in the format Month CCYY
  • Fill-in (6)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • your
  • Fill-in (7)
  • Date of Entitlement (DOE) new start date
  • Fill-in (8)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • Number Holder First Name plus Number Holder Last Name
  • Choice 3
  • your
  • Fill-in (9)
  •  
  • Choice 1
  • Year prior to the Date of Entitlement (DOE) start in the format CCYY
  • Choice 2
  • Full Retirement Age (FRA) year in the format CCYY
  • Choice 3
  • Year prior to the Full Retirement Age (FRA) year in the format CCYY
  • Choice 4
  • Date of Entitlement (DOE) start year in the format CCYY
  • Fill-in (10)
  •  
  • Choice 1
  • He is
  • Choice 2
  • She is
  • Choice 3
  • You are
  • Fill-in (11)
  •  
  • Choice 1
  • his own
  • Choice 2
  • her own
  • Choice 3
  • your own
  • Choice 4
  • spouse
  • Choice 5
  • child
  • Choice 6
  • widow(er)
  • Choice 7
  • mother
  • Choice 8
  • father
  • Choice 9
  • parent
  • Choice 10
  • disabled widow (er)
  • Fill-in (12)
  • Other account number and Beneficiary Identification Code (BIC)
  • Fill-in (13)
  •  
  • Choice 1
  • his
  • Choice 2
  • her
  • Choice 3
  • your
  • Fill-in (14)
  •  
  • Choice 1
  • own
  • Choice 2
  • spouse
  • Choice 3
  • child
  • Choice 4
  • widow(er)
  • Choice 5
  • mother
  • Choice 6
  • father
  • Choice 7
  • parent
  • Choice 8
  • disabled widow (er)
  • MOE005 – DUAL ENTITLEMENT RECORD AND MONTH OF ENTITLEMENT (MOE) CHANGES DUE TO WORK AND EARNINGS FOR A CLOSED YEAR FOR A BENEFICIARY WHO CHOSE AN EARLY MOE WITHOUT REDUCTION
  • We reviewed (1) record. When (2) applied, (3) asked us to start (4) benefits in (5). We changed the month (6) benefits start to (7) because of (8) (9) work and earnings. The change lets (10) get payments without permanently reducing (11) monthly benefits.
  • (12) also, receiving (13) benefits on claim number (14). We will send you another letter about (15) (16) benefits.
  • (12) also receiving benefits on another record. We will send you another letter about those benefits.
  • Fill-in values:
  •  
  • Fill-in (1)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • your
  • Fill-in (2)
  •  
  • Choice 1
  • he
  • Choice 2
  • she
  • Choice 3
  • you
  • Fill-in (3)
  •  
  • Choice 1
  • he
  • Choice 2
  • she
  • Choice 3
  • you
  • Fill-in (4)
  •  
  • Choice 1
  • his
  • Choice 2
  • her
  • Choice 3
  • your
  • Fill-in (5)
  • Original Date of Entitlement (DOE) start date in the format Month CCYY
  • Fill-in (6)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • your
  • Fill-in (7)
  • New Month of Entitlement (MOE) start date
  • Fill-in (8)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • NH First Name plus NH Last Name
  • Choice 3
  • your
  • Fill-in (9)
  • Enforcement year in the format CCYY
  • Fill-in (10)
  •  
  • Choice 1
  • him
  • Choice 2
  • her
  • Choice 3
  • you
  • Fill-in (11)
  •  
  • Choice 1
  • his
  • Choice 2
  • her
  • Choice 3
  • your
  • Fill-in (12)
  •  
  • Choice 1
  • He is
  • Choice 2
  • She is
  • Choice 3
  • You are
  • Fill-in (13)
  •  
  • Choice 1
  • his own
  • Choice 2
  • her own
  • Choice 3
  • your own
  • Choice 4
  • spouse
  • Choice 5
  • child
  • Choice 6
  • widow(er)
  • Choice 7
  • mother
  • Choice 8
  • father
  • Choice 9
  • parent
  • Choice 10
  • disabled widow (er)
  • Fill-in (14)
  • Other account number and Beneficiary Identification Code (BIC)
  • Fill-in (15)
  •  
  • Choice 1
  • his
  • Choice 2
  • her
  • Choice 3
  • your
  • Fill-in (16)
  •  
  • Choice 1
  • own
  • Choice 2
  • spouse
  • Choice 3
  • child
  • Choice 4
  • widow(er)
  • Choice 5
  • mother
  • Choice 6
  • father
  • Choice 7
  • parent
  • Choice 8
  • disabled widow(er)
  • MOE006 – NEW MONTH OF ENTITLEMENT (MOE) TO AN AUXILIARY WHEN THE MOE CHANGED BASED ON THE NUMBER HOLDER'S MOE CHANGING
  • We changed the month (1) benefits start on (2) record from (3) to (4). We changed the month because of (5) (6) work and earnings. (7) is the earliest month (8) can get benefits on (9) record. (10) benefits must start before (11) benefits can start.
  • Fill-in values:
  •  
  • Fill-in (1)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • your
  • Fill-in (2)
  • NH First Name plus NH Last Name (possessive)
  • Fill-in (3)
  • Date of Entitlement (DOE) start date
  • Fill-in (4)
  • New Date of Entitlement (DOE) start date
  • Fill-in (5)
  • NH First Name plus NH Last Name
  • Fill-in (6)
  • Year of enforcement in the format CCYY
  • Fill-in (7)
  • Date of Entitlement (DOE) start date
  • Fill-in (8)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)
  • Choice 2
  • you
  • Fill-in (9)
  • NH First Name plus NH Last Name
  • Fill-in (10)
  • NH First Name plus NH Last Name
  • Fill-in (11)
  •  
  • Choice 1
  • NH First Name plus NH Last Name
  • Choice 2
  • your
  • MOE007 – SINGLE ENTITLEMENT RECORD AND THE MONTH OF ENTITLEMENT (MOE) DATE CHANGES DUE TO WORK AND EARNINGS FOR A CLOSED YEAR FOR A BENEFICIARY WHO CHOSE AN EARLY MOE WITHOUT REDUCTION
  • We reviewed (1) record. When (2) applied, (3) asked us to start (4) benefits in (5). We changed the month (6) benefits start to (7) because of (8) (9) work and earnings. This change lets (10) get payments without permanently reducing (11) monthly benefits.
  • Fill-in values:
  •  
  • Fill-in (1)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • your
  • Fill-in (2)
  •  
  • Choice 1
  • he
  • Choice 2
  • she
  • Choice 3
  • you
  • Fill-in (3)
  •  
  • Choice 1
  • he
  • Choice 2
  • she
  • Choice 3
  • you
  • Fill-in (4)
  •  
  • Choice 1
  • his
  • Choice 2
  • her
  • Choice 3
  • your
  • Fill-in (5)
  • Original Month of Entitlement (MOE) in the format Month CCYY
  • Fill-in (6)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • your
  • Fill-in (7)
  • New Month of Entitlement (MOE) in the format Month CCYY
  • Fill-in (8)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • First name of NH plus Last name of NH
  • Choice 3
  • your
  • Fill-in (9)
  • Year of enforcement in the format CCYY
  • Fill-in (10)
  •  
  • Choice 1
  • him
  • Choice 2
  • her
  • Choice 3
  • you
  • Fill-in (11)
  •  
  • Choice 1
  • his
  • Choice 2
  • her
  • Choice 3
  • your
  • F. “MPD” Universal Text Identifiers – Medicare Prescription Drug Plan
  • MPDC19 – Caption
  • Medicare Prescription Drug Plan Enrollment
  • MPDC31 – Caption
  • Information About The Prescription Drug Coverage Income-Related Monthly
  • Adjustment Amount
  • MPD346 – INCOME-RELATED MONTHLY ADJUSTMENT AMOUNT (IRMAA) D PREMIUMS REFUND IN PRIOR MONTH ACCRUAL AMOUNT (PAMT) OR CURRENT AMOUNT (CAMT) - NO OTHER INTRODUCTORY UTI APPLIES
  • Based on the information, we have (1) (2) due a refund for prescription drug coverage income-related monthly adjustment amounts.
  • Fill-in values:
  •  
  • Fill-in (1)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)
  • Choice 2
  • you
  • Fill-in (2)
  •  
  • Choice 1
  • is
  • Choice 2
  • are
  • MPD347 – INCOME-RELATED MONTHLY ADJUSTMENT AMOUNT (IRMAA) D PREMIUMS REFUND IN PRIOR MONTH ACCRUAL AMOUNT (PAMT) OR CURRENT AMOUNT (CAMT)
  • This payment includes a refund of (1) prescription drug coverage income-related monthly adjustment amount.
  • Fill-in values:
  •  
  • Fill-in (1)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • your
  • MPD348 – INCOME-RELATED MONTHLY ADJUSTMENT AMOUNT (IRMAA) D PREMIUM DEDUCTED FROM CURRENT AMOUNT (CAMT)
  • We deducted (1) for (2) prescription drug coverage income-related monthly adjustment amount from the check (3) will receive for (4) on or about (5).
  • Fill-in values:
  •  
  • Fill-in (1)
  • Total Income Related Monthly Adjustment Amount (IRMAA) D amounts deducted from Current Amount (CAMT)
  • Fill-in (2)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • your
  • Fill-in (3)
  •  
  • Choice 1
  • he
  • Choice 2
  • she
  • Choice 3
  • you
  • Fill-in (4)
  • Current Operating Month (COM)
  • Fill-in (5)
  • Using the Payment Cycle Indicator (PCI), show the calendar date in which the Current Operating Month (COM) check will be paid
  • MPD349 - INCOME-RELATED MONTHLY ADJUSTMENT AMOUNT (IRMAA) D CONTINUES TO BE DEDUCTED FROM THE MONTHLY BENEFIT PAYABLE (MBP)
  • The monthly deduction for (1) prescription drug coverage income-related monthly adjustment amount is (2).
  • Fill-in values:
  •  
  • Fill-in (1)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • your
  • Fill-in (2)
  • Total Income Related Monthly Adjustment Amount (IRMAA) D amounts deducted from Monthly Benefit Payable (MBP)
  • MPD350 – INCOME-RELATED MONTHLY ADJUSTMENT AMOUNT (IRMAA) D PREMIUM DEDUCTED FROM PRIOR MONTH ACCRUAL AMOUNT (PAMT)
  • We deducted (1) for (2) prescription drug coverage income-related monthly adjustment amount from the check you will receive on or about (3).
  • Fill-in values:
  •  
  • Fill-in (1)
  • Total Income-Related Monthly Adjustment Amount (IRMAA) D amounts deducted from Prior Month Accrual Amount (PAMT)
  • Fill-in (2)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • your
  • Fill-in (3)
  • Run date plus 15 days
  • MPD351 – INCOME-RELATED MONTHLY ADJUSTMENT AMOUNT (IRMAA) D NO LONGER DEDUCTED FROM BENEFITS
  • We will no longer deduct (1) prescription drug coverage income-related monthly adjustment amount from (2) monthly benefits.
  • Fill-in values:
  •  
  • Fill-in (1)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • your
  • Fill-in (2)
  •  
  • Choice 1
  • his
  • Choice 2
  • her
  • Choice 3
  • your
  • MPD352 – INCOME-RELATED MONTHLY ADJUSTMENT AMOUNT (IRMAA) D ARREARAGES DEDUCTED FROM PRIOR MONTH ACCRUAL AMOUNT (PAMT) OR CURRENT AMOUNT (CAMT)
  • We are deducting past-due prescription drug coverage income-related monthly adjustment amounts from (1) check.
  • Fill-in values:
  •  
  • Fill-in (1)
  •  
  • Choice 1
  • Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
  • Choice 2
  • your
The materials available at this web site are provided free of charge, for informational purposes only, and without warrant by True Link Financial, Inc., and are not legal advice or Social Security benefits advice. You should contact your attorney to obtain advice with respect to any particular issue or problem, or the Social Security Administration with any general inquiries. Click here to view this section of the POMS on the Social Security Administration website.