BASIC (11-81)

10000A GENERAL DESCRIPTION OF MEDICARE PROGRAM

The Medicare program provides health insurance for people 65 and older, for persons entitled to disability monthly benefits, and for persons suffering chronic kidney disease. The two types of Medicare protection are hospital insurance, which helps to pay the cost of hospital and related care, and medical insurance, which helps to pay for the cost of physicians services and certain other medical and health services.

10000B MEDICAL INSURANCE IS VOLUNTARY

Everyone who gets social security checks has hospital insurance automatically at 65. This insurance also covers all under 65 who have been entitled to disability benefits for 24 months, as well as insured persons and dependents at any age who suffer chronic kidney disease. However, medical insurance is voluntary, so only those who enroll can have this supplementary protection. Those who enroll pay a premium of   (a)  a month beginning July 1, 19   (b)   , which is matched by the United States Government. The rate is subject to change on a yearly basis.

10000C INFORMATION REGARDING DISABLED BENEFICIARY

Disabled individuals who have been entitled to monthly social security disability benefits for 24 months are qualified automatically for hospital insurance under Medicare. Medical insurance, however, is voluntary, so only those who enroll can have this supplementary protection. Those who enroll pay a premium of  (a)  a month beginning July 1, 19 (b) , which is matched by the United States Government. The rate is subject to change on a yearly basis.

10000D MEDICARE OUTSIDE THE UNITED STATES

Persons living outside the United States usually cannot benefit from Medicare. This is because, generally speaking, the program provides protection against the cost of hospital and medical expenses incurred only in the United States. Of course, health insurance protection may be very important to anyone temporarily abroad who plans to return to the United States.

10005A BENEFICIARY WANTS INFORMATION ABOUT SMI ENROLLMENT

In deciding whether to enroll in the medical insurance program, you should consider the following factors. If you enroll in the program during your first enrollment period, premiums of  (a) $  (amount) will be withheld from your benefit check each month even though you will not be eligible for payment of any of your medical expenses incurred outside the United States. Your first enrollment period is  (b)  date . If you do not enroll during your first enrollment period, you may enroll during the first 3 months of each year thereafter.

10005B ENROLLMENT DURING G.E.P.

If you should enroll during a general enrollment period—January through March of each year—your coverage would not begin until the following July. Also, your monthly premium would be increased by 10 percent for each full year in which you were eligible for medical insurance but were not enrolled.

10005C CONSIDERATION REGARDING RETURN TO THE UNITED STATES

If you plan to return to the United States shortly after you are eligible for the medical insurance program, you may wish to enroll during your first enrollment period. If you expect to be abroad for a longer period of time, you may wish to enroll during a later general enrollment period.

10010 BENEFICIARY WANTS TO KNOW IF HIB AND/OR SMIB COVERS HIS FAMILY

Hospital insurance automatically covers each social security beneficiary who is at least age 65 and meets the other eligibility requirements. Medical insurance covers each social security beneficiary, age 65 or over, who enrolls in the program and authorizes the withholding of the monthly premium from his check. This insurance also covers all beneficiaries under 65 who have been entitled to disability benefits for 24 months, as well as insured persons and dependents at any age who suffer chronic kidney disease.

Although the worker's coverage under both of these programs does not cover other family members, they may obtain protection if they are social security beneficiaries over age 65.

10015 HEALTH INSURANCE COVERAGE—BENEFICIARY IN CURRENT PAY

Beginning (a) month and year , (b) name of payer stopped paying your medical insurance premiums. Therefore, it was necessary to withhold  $  (c) from your benefit check for (d) month  dated (e) month/date/year , to collect all the premiums due.

10016 PREMIUMS DUE/BENEFITS SUSPENDED

Beginning (a) month and year , (b) name of payer stopped paying your medical insurance premiums. Therefore, you are responsible for paying premiums of $  beginning (c) month and year .

10017 NOT ENROLLED TIMELY

We cannot accept your request for enrollment in the medical insurance program because it was not filed between January 1, and April 1, (a) year . Your next opportunity to enroll will begin on January 1, (b) year and end March 31, (c) year .

10018 PREMIUMS PAYABLE 1 YEAR IN ADVANCE

You may pay premiums up to 1 year in advance by adding another month's premium for each additional month you wish to pay.

10020 HIGHER PREMIUM COST

Persons who were eligible for medical insurance coverage, but are not enrolled because they did not sign up promptly, or signed up and then dropped out, are required by law to pay a premium that is 10 percent higher for each full year they could have been enrolled. Since the regular premium beginning July 1, 19  , is $ . ; a person delaying enrollment for 1 year would have to pay $ . ; a person delaying enrollment for 2 years would have to pay $ . ; and a person delaying enrollment for 3 years would have to pay $ . .

10115 WHY IS MEDICAL SERVICE OUTSIDE THE UNITED STATES NOT COVERED?

There are a number of considerations in covering medical service outside the United States. A basic responsibility of the Federal Government is to assure that the money paid out of the social security trust funds is properly spent. Adequate controls over the expenditure of funds can be applied toward payments made to hospitals in the United States. An equally effective control of payments to hospitals and other providers of services in many other countries would, at the present time, be impractical, and in most instances almost impossible.

In some countries, particularly those in which the patterns of medical practice and hospital organization differ radically from those in the United States, it would not be feasible to get the cost information needed to make payment. It would also be difficult to determine whether services for which benefits were claimed were actually provided and whether the services were medically necessary. Also, there would often be no way to be sure that the services in some other countries were provided in facilities that met the requirements for participation set out in the law.

10120 INQUIRY ABOUT KEEPING PRIVATE INSURANCE COVERAGE

This is in reply to your question about the social security health insurance programs and your present private insurance plan.

As a person age 65 or over and entitled to social security monthly benefits, you will be automatically covered under the hospital insurance program, regardless of whether you sign up for the medical insurance program under the Social Security Act.

You may, if you wish, keep your present health insurance even though you sign up for medical insurance under social Security. Benefits will be payable under either social security health insurance program regardless of any other health insurance you may have. However, you may wish to get in touch with your private health insurance organization for information as to how the social security health insurance programs may affect your private insurance plan.

10122 NOT ENTITLED TO SOCIAL SECURITY (RAILROAD RETIREMENT) BENEFITS AND LIVING OUTSIDE THE UNITED STATES

A person who is not entitled to monthly social security (railroad retirement) benefits is not eligible for insurance under the social security health insurance programs unless he is a resident of the United States. In addition, he must be either a U.S. citizen, or an alien, lawfully admitted to the United States for permanent residence, who has been residing continuously during the 5-year period immediately preceding the month in which his application is filed.

Generally, payment under these insurance programs can be made only for services provided in the United States. Any person entering the United States should contact the nearest social security office to obtain information relative to these programs. Citizens over 65 returning to the United States to live are eligible at that time to enroll for protection under the supplemental medical insurance program. Since there is a time limit for enrolling, they should contact the nearest social security office promptly.

10125 INFORMATIONAL ENCLOSURES

The enclosed publication contains additional information relative to the health insurance programs covered under the Social Security Act.

NOTE TO TYPIST: Enclose SSA Publication No. 75-10078 (or current revision)

10127A HEALTH INSURANCE PAYMENTS OUTSIDE THE U.S.

For the most part, Medicare pays medical expenses incurred only in the United States. There are, however, certain very limited exceptions which permit Medicare payments for residents of the United States who:

1. Receive treatment in a hospital outside the United States (in Canada or Mexico) because that hospital is closer or more accessible than the nearest United States hospital; or

2. Receive hospital treatment in Canada because of an emergency suffered while traveling between Alaska and some State in the United States.

10127B REIMBURSEMENT IN U.S.

If you should come to the United States to live or to receive medical services, you may be reimbursed for part of your medical expenses.

10127C REFERRAL TO PUBLICATION

The enclosed publication contains information which explains the health insurance programs as they apply to persons outside the United States.

NOTE TO TYPIST: Enclose SSA Publication No. 79-10050 (or current revision).

10128 CHRONIC KIDNEY DISEASE

Medicare—both hospital and medical insurance—covers treatment in the United States of chronic kidney disease when it is of such severity as to require hemodialysis or kidney transplant. Individuals may qualify at any age if they are insured, or if they are married to or are the children of an insured worker.

10131 APPLIED FOR SOCIAL SECURITY OR RAILROAD BENEFITS BEFORE AGE 65 AND INQUIRIES ABOUT MEDICARE

Persons who are receiving social security or railroad cash benefits (or have established eligibility for such benefits) before age 65 are automatically covered by hospital insurance at age 65. However, enrollment is required for medical insurance. An enrollment card is mailed to persons about 3 months before the month they attain age 65. Those who want medical insurance coverage should check the “Yes” box, and sign and return the enrollment card.

10136A WITHDRAWAL OF PERSONS OUTSIDE THE U.S.

You may withdraw from the medical insurance program at any time. Your coverage would end at the close of the calendar quarter following the quarter in which we receive your written notice of cancellation.

10136B REENROLLMENT INFORMATION

If you do not intend to return to the United States to live or receive medical care, it would probably be advisable for you to withdraw from the medical insurance program. However, if you do intend to return to the United States to live or visit, this protection may be important to you and you should realize the limitations on reenrollment.

You may enroll for medical insurance an unlimited number of times. If your current enrollment is ended, you may reenroll during January, February, or March of any year. Coverage would not begin until the following July, and your premiums would be higher than for your first enrollment.

10136C MEDICAL INSURANCE WITHDRAWAL DOES NOT AFFECT HOSPITAL INSURANCE

Stopping your medical insurance does not affect your hospital insurance. Hospital insurance is provided free of charge and may be used by you if you ever return to the United States.

10137 REQUEST FOR CANCELLATION OF HOSPITAL INSURANCE

You recently informed us that you  (a) or (b)  .

(a)

have not signed up for hospital insurance.

(b)

did not want hospital insurance.

10137.1 HOW HOSPITAL INSURANCE IS FINANCED

Hospital insurance is financed through the contributions of employees, employers, and self-employed persons during the person's working lifetime. There is no change for hospital insurance at age 65, except for the contributions made if you continue to work for earnings covered by social security.

10137.2 HEALTH INSURANCE CARD RETURNED

Since you have already earned the entitlement to hospital insurance and there are no monthly premiums to pay for this coverage, we are returning your health insurance card. We suggest that you keep this card and use it if you need hospital or related services when in the United States.

10138 PREMIUM RATES FOR MEDICAL INSURANCE

The medical insurance premium rate was $3.00 a month for the period July 1, 1966, through March 31, 1968; $4.00 a month from April 1, 1968, through June 30, 1970; $5.30 a month from July 1, 1970, through June 30, 1972; $5.80 a month from July 1, 1972, through June 30, 1973; $6.30 a month from July 1, 1973, through June 30, 1974; $6.70 a month from July 1, 1974, through June 30, 1976; and $7.20 from July 1, 1976, through June 30, 1977.

(A)

Effective July 1,        , the regular premium is $         a month.

(B)

Starting July 1,    , the regular premium is $    a month.

For current rate, see applicable instructions.

10140 CONTRIBUTION RATES ON WAGES FOR HOSPITAL INSURANCE AND RSDI

Under the Federal Insurance Contributions Act, an employer is required to withhold hospital insurance contributions and other social security contributions from an employee's earnings and to add an equal amount as his own contribution.  (OPTION A OR B)  .

(A)

The table below shows the hospital insurance contribution rate and other information for the period indicated.

(B)

The table below shows information for the period in which you are interested.

¹ (See applicable instructions for current information.)

(P)

The employer is not required to add to the contribution he withholds on cash tips his employee reports to him.

(Q)

The hospital insurance contribution was not payable before 1966.

10141 CONTRIBUTION RATES ON SELF-EMPLOYMENT INCOME FOR HOSPITAL AND RSDI

The Self-Employment Contributions Act requires a self-employed person to pay hospital insurance contributions and other social security contributions on his self-employment income. (OPTION A OR B) .

(A)

The table below shows the hospital insurance contribution rate and other information for the period indicated.

(B)

The table below shows information for the period in which you are interested.

NOTE: The hospital insurance contribution was not payable before 1966.

¹ (See applicable POMS instructions for current information.)

10145 BENEFICIARY CHANGES HIS SMI ELECTION TO "NO" PRIOR TO ATTAINING AGE 65

Your request to withdraw from the medical insurance part of Medicare has been approved. We will refund any premiums that may have been withheld from your benefit checks or that you have paid directly.

10146 WITHDRAWAL EFFECTIVE SOME FUTURE MONTH

Your request to withdraw from the medical insurance part of Medicare has been approved and will be effective  (date) .

Add as appropriate paragraphs 10149 and 10152 below.

10147 WITHDRAWAL EFFECTIVE IN SOME PRIOR MONTH

Your request to withdraw from the medical insurance part of Medicare was approved and your coverage ended on   (date) . A refund of $ for premiums withheld from your benefits after that date will be included in your next check.

Add paragraph 10151, if appropriate.

10148 WITHDRAWAL EFFECTIVE SOME FUTURE MONTH PREMIUMS STILL OUTSTANDING

Your request to withdraw from the medical insurance part of Medicare has been approved and will be effective (date). However, you are responsible for all premiums due through that month.

10149 CONSIDERATIONS REGARDING WITHDRAWAL

If you do not intend to return to the United States, your decision to withdraw from the medical insurance program may be wise. However, if there is a possibility that you may return to the United States in the future, to live or to receive medical services, you may wish to consider continuing your medical insurance protection. You should also consider the limitations on reenrollment in the program.

10151 REENROLLMENT INFORMATION-ENDING FIRST ENROLLMENT

A person has a number of opportunities to enroll in the medical insurance program. This ends your first enrollment. If you wish to enroll again, you must sign up during January, February, or March of any year. Coverage would not begin until the following July and your premiums may be higher than they would be if you had not withdrawn from the program.

10152 REQUEST TO CANCEL WITHDRAWAL BEFORE COVERAGE ENDS

If you change your mind and wish to continue your medical insurance coverage, please notify this office by   (date coverage ends) . You will also need to pay all premiums due for your period of coverage.

10153 EXPLANATION OF EFFECTIVE SMI TERMINATION DATE AFTER REQUESTING WITHDRAWAL

Medical insurance coverage and your obligation to pay premiums stop at the end of the calendar quarter after the quarter in which a written request for cancellation is received. (A calendar quarter is a 3-month period which ends March 31, June 30, September 30 or December 31 of any year.) Since your first written request was received on  (a) date  , your medical insurance coverage will end  (b) date  . You are responsible for all premiums due through that month.

NOTE TO DICTATOR: Add paragraphs 10149, 10150, 10151, or 10152, as appropriate.