NL: Notices, Letters and Paragraphs

Effective Dates: 03/30/2018 - Present

TN 28 (03-18)

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 3^RD 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) (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) (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.

Fill-in values:
Fill-in (1)
Choice 1	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.

Fill-in values:
Fill-in (1)
Choice 1	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) (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) (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 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

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 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

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

Previous:
HI: Health Insurance

Up:
Table of Contents: SSA Program Operations Manual System (POMS)

Next:
VB: Special Veterans Benefits