NL: Notices, Letters and Paragraphs
TN 25 (06-18)
HIBC01 Caption
Information About Medicare
HIBD01 Dictated Text
HIB001 Entitled to HI and/or SMI (This can also be an introductory statement (HIBI01))
(1) Medicare (2) (3) (4) (5) .
Fill-ins:
(1) “Your”/FN
(2) “Part A (hospital insurance) starts”/“Part B (medical insurance) starts”/“Part A (hospital insurance) and Part B (medical insurance) start”
(3) Date in format June 2013
(4) “and Part B (medical insurance) starts”
(5) Date in format June 2013
HIB002 New Medicare Card – PIC Change Conversion Award
(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 (1-800-633-4227).
Fill-ins:
(1) “You”/“BGN plus BLN”
(2) “You should”/“He should”/“She should”
(3) “you need”/“he needs”/“she needs”
(4) “you have”/“he has”/“she has”
(5) “your”/“his”/“her”
HIB003 Medicare Disallowance – Filed Before Initial Enrollment Period
(1) not entitled to (2) under Medicare because (3) application was filed too soon. (4) may apply again at any time during the period (5) through (6) . (7) must apply in the first three months of this period to make sure Medicare starts in the month (8) (9) age 65.
Fill-ins:
(1) “You are”/“She is”/“He is”
(2) “medical insurance coverage/medical or hospital insurance coverage”
(3) “your”/“her”/“his”
(4) “You”/“She”/“He”
(5) month and year
(6) month and year
(7) “You”/“She”/“He”
(8) “you”/“she”/“he”
(9) “reach”/“reaches”
HIB004 Medicare Disallowance – Not Timely Filed
(1) not entitled to (2) under Medicare because (3) application was filed too late. (4) should have filed before (5) . However, (6) 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-ins:
(1) “You are”/“She is”/“He is”
(2) “medical insurance coverage”
(3) “your”/“her”/“his”
(4) “You”/“She”/“He”
(5) month and year
(6) “you”/“she”/“he”
HIB005 SMI Premium Billing
(1) monthly premium for Medicare Part B (medical insurance) is (2) beginning (3) (4) (5) .
Fill-ins:
(1) “Your”/“His”/“Her”
(2) Amount of Part B premium in $$$$$.¢¢ format
(3) Date in MonthCCYY format
(4) null/“and”/Null
(5) Show the amount of the Part B premium in the format $$$$$¢¢ plus the word “beginning” plus show the start date that corresponds to the second premium rate returned from the HSA utility in the format MMCCYY
HIB008 Premium Deductions
We will start to take premiums out of (1) (2) check.
Fill-ins:
(1) “your”/“her”/“his”
(2) “next”/month, day and year
HIB009 SMI Premium Billing
We will send your first bill for the premiums within a month. Each bill will be for a 3-month period.
HIB010 SMI Premium Deductions Followed by Suspension
Because (1) monthly benefits are stopping, we will bill (2) every 3 months for the premiums.
Fill-ins:
(1) “your”/“null”/FN possessive
(2) “you”/“her”/“him”
HIB011 HIB Premium Billing
The monthly premium for (1) hospital insurance is (2) . We will bill you each month for (3) .
Fill-ins:
(1) “your”/“her”/“his”
(2) “[2a] beginning [2b]”/“[2c] beginning [2d] and [2e] beginning [2f]”
[2a] money amount/null
[2b] Month YYYY/null
[2c] money amount/null
[2d] Month YYYY/null
[2e] money amount/null
[2f] Month YYYY/null
(3) “this premium”/“the combined premium for hospital and medical insurance”
HIB013 Medicare Premium Penalty
(1) a premium surcharge because (2) enrolled later than (3) could have.
Fill-ins:
(1) “This medical insurance premium includes”/“This hospital insurance premium includes”/“These hospital and medical insurance premiums include”
(2) “you”/“she”/“he”
(3) “you”/“she”/“he”
HIB014 State Buy-in
(1) (2) will pay the premiums for (3) Medicare coverage (4) .
Fill-ins:
(1) “The State of”/null
(2) name of jurisdiction making payments
(3) “your”/“her”/“his”
(4) “in the future”/beginning [4a]
[4a] month and year
HIB015 Premiums Deducted from Civil Service Annuity
The Office of Personnel Management will deduct the medical insurance premiums from (1) annuity checks. They will let (2) know when this will start.
Fill-ins:
(1) “your”/“Beneficiary's name (possessive)”
(2) “you”/“her”/“him”
HIB019 Premium Hospital Insurance (HI)
(1) cannot get Medicare Part A (hospital insurance) for free. However, (2) may be able to buy Medicare Part A for (3) a month. Please contact us for more information.
Fill-ins:
(1) “You”/FN
(2) “you”/“he”/“she”
(3) monthly premium HI amount
HIB020 Foreign Address
Normally Medicare will only pay for hospital and medical services which (1) (2) in the United States.
Fill-ins:
(1) “you”/“she”/“he”
(2) “receive”/“receives”
HIB021 Subsequent Award – Medicare Not Affected
This letter does not affect (1) Medicare benefits.
Fill-in:
(1) “your”/“her”/“his”
HIBR30 Equitable Relief, Untimely Processing
We did not give (1) earlier medical insurance because we did not process it timely. If you want to have these benefits earlier, you can choose medical insurance benefits beginning (2) . If you want this benefit to start earlier, you must do the following things within 30 days after the date of this notice:
tell us in writing that you want medical insurance benefits beginning (3) ;
pay us $ (4) . (this covers premiums due from (5) through (6) );or,
tell us we can withhold this amount from the check.
Fill-ins:
(1) “you”/FN
(2) Earlier SMI entitlement date *
(3) Earlier SMI entitlement date *
(4) Amount of SMI premium from earlier date *
(5) Earlier SMI entitlement date *
(6) Month prior to current operating month
(*) indicates that fill-in is manual
HIB031 Private Third Party Buy-in
Another individual or organization will pay the premiums for (1) Medicare coverage beginning (2) . Even though the bill will be sent to them, you are still responsible for seeing that (3) premiums are paid. If they decide that they will no longer send the payments, we will start to send the premium notices to you.
Fill-ins:
(1) “your”/SN possessive
(2) date buy-in begins in format MMMM d, YYYY
(3) “your”/SN possessive
HIB032 SMI Option Presumed Refused, Puerto Rico
(1) (2) eligible for medical insurance beginning (3) . If you want this coverage or need more information, you should contact your nearest Social Security office.
Fill-ins:
(1) “You”/SN
(2) “are”/“is”
(3) date of entitlement to SMI - month and year
HIB035 SMI Deductions
We deduct medical insurance premiums from monthly benefit payments. If (1) (2) benefit payments, we will not bill (3) for (4) premiums.
Fill-ins:
(1) “you”/“she”/“he”
(2) “receive”/“receives”
(3) “you”/“her”/“him”
(4) “your”/“her”/“his”
HIB037 Equitable Relief, Untimely Processing (Used Only with HIBR30)
If you want the benefits beginning (1) but find it hard to pay the premium amount in a lump sum, ask us about other ways to pay the money.
Fill-in:
(1) earlier SMI entitlement date - month and year
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-ins:
(1) “You”/“She”/“He”
(2) “you have”/“she has”/“he has”
HIB042 Claimant Could be or is Covered Under the Federal Employees Health Benefits Act of 1959
(1) cannot qualify for Medicare because (2) covered under the Federal Employees Health Benefits Act.
Fill-ins:
(1) “You”/“She”/“He”
(2) ““you are”/“she is”/“he is”/you could be/she could be/he could be”
HIB044 Not Entitled, Application Filed too Late
(1) not entitled to medical insurance coverage under Medicare because (2) application was filed too late. (3) should have filed before (4) . However, (5) 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-ins:
(1) “You are”/“She is”/“He is”
(2) “your”/“her”/“his”
(3) “You”/“She”/“He”
(4) age 65 + 4 months in format (“April 1992”)
(5) “you”/“she”/“he”
HIB050 Number Holder 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.
HIB051 Death Within 29 Months of Onset
To receive Medicare coverage before age 65, a person must qualify for disability benefits for 29 months before coverage begins. We were told that (1) became disabled on (2) , and died on (3) . Therefore (4) did not qualify for Medicare.
Fill-ins:
(1) NH Name
(2) onset date
(3) date of death - NH
(4) “she”/“he”
HIB052 SMIB Refusal Statement
If you do not want medical insurance, please complete the enclosed card and return it to us in the envelope we have provided. You will need to do this by the date shown on the card. If you decide you do not want the insurance, we will return any premiums that you have paid.
HIBR60 Prisoner Suspension
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 re-enroll 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 re-enroll. 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 a 3-month period and will be sent to you shortly before the payment is due.
Fill-ins:
(1) “you receive”/“FN receives”
(2) “you are”/“she is”/“he is”
(3) “imprisoned”/“confined in an institution” *
(4) “your”/“her”/“his”
(5) “you are”/“she is”/“he is”
(6) “prison”/“the institution” *
(7) “You”/“She”/“He”
(8) “you are”/“she is”/“he is”
(9) “prison”/“the institution” *
(10) “you”/“she”/“he”
(11) “your”/“her”/“his”
(*) indicates that the fill-in is manual
HIB062 Not Enrolling in SMI
(1) (2) through (3) to sign up for Medicare Part B (medical insurance).
People who have Medicare Part B pay a monthly premium. If (4) not sign up for Part B when (5) first eligible, (6) may have to pay a late enrollment penalty for as long as (7) Part B. (8) monthly premium may go up 10 percent for each full 12-month period that (9) could have had Part B coverage, but did not sign up for it. Usually, (10) will not have to pay a late enrollment penalty if (11) up during a special enrollment period.
If (12) to sign up for Part B after (13) , (14) 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 (15) up in the general enrollment period, (16) Part B coverage will start July 1 of the year (17) up.
(18) may be able to get Part B in a special enrollment period if (19) all of these conditions:
(20) age 65 or older, and
(21) health insurance under an employer's group plan because (22) spouse currently works, and
(23) had health insurance coverage under that plan since (24) became age 65.
NOTE: COBRA and Retiree health coverage do not count as health insurance based on current employment.
(25) can sign up in a special enrollment period during these times:
-
At any time (26) coverage under that employer's group plan,
or
During the 8 months after the work ends or (27) coverage under that plan ends, whichever occurs first.
Deciding when to sign up for Part B may depend on how (28) health insurance works with Medicare. For example, a group health plan is usually not the primary insurance if the employer has less than 20 employees. In this case, it is important to have Medicare coverage, and you may want to sign up now.
If (29) help deciding what to do, please contact (30) employee benefits office or contact us.
Fill-ins:
(1) “You”/FN
(2) “have”/“has”
(3) Date initial enrollment period ends (age 65 plus 3 months, in Month CCYY format)
(4) “you do”/“he does”/“she does”
(5) “you are”/“he is”/“she is”
(6) “you”/“he”/“she”
(7) “you have”/“he has”/“she has”
(8) “Your”/“His”/“Her”
(9) “you”/“he”/“she”
(10) “you”/“he”/“she”
(11) “you sign”/“he signs”/“she signs”
(12) “you want”/“he wants”/“she wants”
(13) Date initial enrollment period ends (age 65 plus 3 months, in Month CCYY format)
(14) “you”/“he”/“she”
(15) “you sign”/“he signs”/“she signs”
(16) “your”/“his”/“her”
(17) “you sign”/“he signs”/“she signs”
(18) “You”/“He”/“She”
(19) “you meet”/“he meets”/“she meets”
(20) “You are”/“He is”/“She is”
(21) “You have”/“He has”/“She has”
(22) “you or your”/“he or his”/“she or her”
(23) “You”/“He”/“She”
(24) “you”/“he”/“she”
(25) “You”/“He”/“She”
(26) “you or your spouse is working and you have”/“he or his spouse is working and he has”/“she or her spouse is working and she has”
(27) “your”/“his”/“her”
(28) “your”/“his”/“her”
(29) “you need”/“he needs”/“she needs”
(30) “your”/“his”/“her”
HIB068 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-ins:
(1) “you want/she wants/he wants”
(2) “you”/“she”/“he”
(3) “hospital/medical/hospital and medical”
(4) HI or SMI NONEQRELST
(5) “you”/“she”/“he”
(6) “you want/she wants/he wants”
(7) “hospital/medical/hospital and medical”
(8) HI or SMI NONEQRELST
(9) “you”/“she”/“he”
(10) money amount (total premium(s) due for HI/SMI
(11) HI or SMI NONEQRELST
(12) date in format MM/YYYY
(13) tell us we can withhold this amount from the check/tell us to bill you for this amount.
HIB072 Medicare with Railroad Annuity Inv.
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-ins:
(1) “you”/FN
(2) “are”/“is”
(3) “your”/“her”/“his”
(4) “you are”/“she is”/“he is”
(5) “your”/“her”/“his”
(6) “you”/“her”/“him”
HIB074 New Medicare Card Issued
We will send (1) a new health insurance card. It will show that (2) entitled to (3) insurance.
Fill-ins:
(1) “you”/SN
(2) “you are”/“she is”/“he is”
(3) “hospital/medical/hospital and medical”
HIB075 Equitable Relief
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-ins:
(1) “you want/she wants/he wants”
(2) show the HI/SMI NONEQRELST date in format “July 1999”
(3) “find”/“finds”
HIB090 Medicare Terminates, Destroy Card
(1) Medicare card will not be valid when (2) (3) coverage ends. Please destroy (4) card after (5) coverage ends.
Fill-ins:
(1) null plus FN possessive/“Your”
(2) “his”/“her”/“your”
(3) “Medicare Part A (hospital insurance) and Part B (medical insurance)”/“Medicare Part B (medical insurance)”/“Medicare Part A (hospital insurance)”
(4) “his”/“her”/“your”
(5) “his”/“her”/“your”
HIB094 Entitlement Conversion, No Change in HI/SMI
The decision on (1) (2) benefits does not affect (3) (4) coverage.
Fill-ins:
(1) “your”/SN possessive/FN possessive
(2) “retirement”/“disability”
(3) “your”/“her”/“his”
(4) “hospital insurance/medical insurance/hospital and medical insurance”
HIB095 Earlier HI/SMI Dates
We have changed the date of (1) entitlement to (2) under Medicare. (3) new entitlement date is (4) . We will take any premiums due for the insurance out of (5) next payment.
Fill-ins:
(1) “your”/SN possessive
(2) “hospital insurance/medical insurance/hospital and medical insurance”
(3) “Your”/“Her”/“His”
(4) current HI/SMI date of entitlement in format “July 1999”
(5) “your”/“her”/“his”
HIB096 RRB Cert Beneficiary Entitled to HI/SMI
(1) entitled to Medicare. The Railroad Retirement Board (RRB) has jurisdiction of (2) Medicare. The RRB will issue (3) Medicare card. If (4) not receive (5) Medicare card in two weeks, you should contact the local office of the Railroad Retirement Board.
Fill-ins:
(1) “You are”/“He is”/“She is”
(2) “your”/“his”/“her”
(3) “your”/“his”/“her”
(4) “you do”/“he does”/“she does”
(5) “your”/“his”/“her”
HIB103 Third Party Buy-in, Closed Period
(1) (2) paid (3) Medicare (4) insurance premium for (5) .
Fill-ins:
(1) The State of/null
(2) state or territory in the format “Washington, D.C.”/“The Virgin Islands”/“Maryland” or “Guam”
(3) “your”/SN possessive
(4) “hospital/medical/hospital and medical”
(5) date(s), in format “Month YYYY” or “Month YYYY and Month YYYY” or “Month YYYY through Month YYYY”
HIB108 Third Party, Group Payer – Billing Terminates
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-ins:
(1) “your”/SN possessive/FN possessive
(2) “hospital/medical/hospital and medical”
(3) date in format “MM/YYYY”
(4) “You”/“She”/“He”/FN possessive
(5) date in format “MM/YYYY”
HIB119 Third Party, Group Payer – Confirmation of Billing Arrangement
(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-ins:
(1) “You”/“beneficiary's given name”/“beneficiary's name”
(2) “your”/“her”/“his”
(3) “hospital/medical/hospital and medical”
(4) “you are”/“she is”/“he is”
(5) “your”/“her”/“his”
(6) “you”/“her”/“him”
(7) “your”/SN possessive
(8) “you”/“her”/“him”
HIB121 ESRD Awards (Introductory Paragraph)
We are writing to tell you that (1) entitled to Medicare coverage because of (2) kidney condition.
Fill-ins:
(1) NHFN plus “is”/you are
(2) “your”/“her”/“his”
HIB122 Entitlement Conversion Cases with Previous HI and/or SMI
(1) already entitled to (2) because (3) (4) . The date[s] of (5) entitlement to (6) did not change.
Fill-ins:
(1) “You are”/SN plus “is”
(2) “hospital insurance/medical insurance/hospital and medical insurance”
(3) “you are”/“he is”/“he is”
(4) disabled/over age 65
(5) “your”/“her”/“his”
(6) “hospital insurance/medical insurance/hospital and medical insurance”
HIB124 Awards – Previous SMI
However, (1) now (2) hospital insurance beginning (3) .
Fill-ins:
(1) “you”/“she”/“he”
(2) “has”/“have”
(3) Month CCYY hospital coverage begins
HIB125 DIB Awards, Beneficiary Previously Entitled to HI/SMI Based on ESRD
If (1) disability ends, (2) may still qualify for Medicare because of (3) kidney condition if:
(4) disability ends less than 12 months after (5) last regular dialysis, or
(6) disability ends less than 36 months after (7) last kidney transplant.
Fill-ins:
(1) “your”/“her”/“his”
(2) “you”/“she”/“he”
(3) “your”/“her”/“his”
(4) “your”/“her”/“his”
(5) “your”/“her”/“his”
(6) “your”/“her”/“his”
(7) “your”/“her”/“his”
HIB126 ESRD Awards, Beneficiary Previously Receiving Premium HI
(1) will no longer have to pay premiums for hospital insurance.
Fill-in:
(1) “You”/SN
HIB127 ESRD Awards, Beneficiary Previously Receiving Premium HI
But, (1) will still have to pay premiums for medical insurance. The monthly medical insurance premium rate is $ (2) .
Fill-ins:
(1) “you”/“she”/“he”
(2) [2a] beginning [2b]./[2c] beginning [2d] and $[2e] beginning [2f]
[2a] money amount
[2b] date, in format “Month YYYY”
[2c] money amount
[2d] date, in format “Month YYYY”
[2e] money amount
[2f] date, in format “Month YYYY”
HIB128 ESRD Awards
Medicare coverage based on (1) kidney condition will end the last day of the (2) month after the month (3) (4) unless before then (5) again:
get(s) a kidney transplant, or
begin(s) regular dialysis.
Fill-ins:
(1) “your”/“her”/“his”
(2) 12th/36th
(3) “you”/“she”/“he”
(4) got your transplant/got her transplant/got his transplant/stops dialysis/stop dialysis
(5) “you”/“she”/“he”
HIB129 ESRD Awards, Previous Premium HI or SMI
Even if (1) no longer entitled to free hospital insurance based on (2) kidney condition, (3) will still be entitled to Medicare because (4) (5) .
Fill-ins:
(1) “you are”/“she is”/“he is”
(2) “your”/“her”/“his”
(3) “you”/“she”/“he”
(4) “you are”/“she is”/“he is”
(5) over age 65/disabled/a Railroad Retirement board beneficiary
HIB130 Closed Period ESRD Award
Our records show that (1) (2) in (3) . Therefore, (4) Medicare coverage based on (5) kidney condition ends the last day of (6) .
Fill-ins:
(1) “you”/“she”/“he”
(2) “stopped regular dialysis”/“received a kidney transplant”
(3) date of event in “Month CCYY” format
(4) “your”/“her”/“his”
(5) “your”/“her”/“his”
(6) month Medicare ends in “Month CCYY” format
HIB132 Closed Period Award for RRB Beneficiary
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-ins:
(1) “your”/“her”/“his”
(2) “your”/“her”/“his”
(3) “you”/“her”/“him”
(4) “your”/“her”/“his”
HIB136 ESRD Closed Period Awards
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-ins:
(1) “you resume”/“she resumes”/“he resumes”
(2) “get”/“gets”
(3) “you”/“she”/“he”
(4) “your”/“her”/“his”
HIB151 Closed Period Third Party Buy-in
(1) must pay the premium beginning (2) .
Fill-ins:
(1) “You”/“She”/“He”
(2) date, in format “Month CCYY”
HIB152
(1) (2) through (3) to enroll in Medicare Part B (medical insurance).
People who have Part B pay a monthly premium. If (4) not sign up for Part B when (5) first eligible, (6) may have to pay a late enrollment penalty for as long as (7) Part B. (8) monthly premium may go up 10 percent for each full 12-month period that (9) could have had Part B coverage, but did not sign up for it. Usually, (10) will not have to pay a late enrollment penalty if (11) up during a special enrollment period.
If (12) to sign up for Part B after (13) , (14) 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 (15) up in the general enrollment period, (16) Part B coverage will start July 1 of the year (17) up.
(18) may also be able to sign up during a special enrollment period. (19) can do this if (20) one of the conditions listed below:
(21) covered under a group health plan through (22) current work or (23) spouse's current work,
(24) covered under a large group health plan through (25) current work or any family member's current work.
(26) may sign up for medical insurance at any time (27) covered under the group health plan. However, (28) may wait and sign up during the 8-month period that begins when the work ends or (29) coverage under the plan ends, whichever occurs first. (30) may also sign up if the type of plan (31) changes.
NOTE: COBRA and Retiree health coverage do not count as health insurance based on current employment.
Deciding when to sign up for Part B may depend on how (32) health insurance works with Medicare. For example, a group health plan is usually not the primary insurance if the employer has less than 20 employees. In this case, it is important to have Medicare coverage, and you may want to sign up now.
If (33) help deciding what to do, please contact (34) employee benefits office or contact us.
Fill-ins:
(1) (1) FN/“You”
(2) (2) “have”/“has”
(3) (3) Hospital Insurance Start Date (HI-START) plus 3 months in Month CCYY format
(4) (4) “you do”/“he does”/“she does”
(5) (5) “you are”/“he is”/“she is”
(6) (6) “you”/“he”/“she”
(7) (7) “you have”/“he has”/“she has”
(8) (8) “Your”/“His”/“Her”
(9) (9) “you”/“he”/“she”
(10) (10) “you”/“he”/“she”
(11) (11) “you sign”/“he signs”/“she signs”
(12) (12) “you want”/“he wants”/“she wants”
(13) (13) Hospital Insurance Start Date (HI-START) plus 3 months in Month CCYY format
(14) (14) “you”/“he”/“she”
(15) (15) “you sign”/“he signs”/“she signs”
(16) (16) “your”/“his”/“her”
(17) (17) “you sign”/“he signs”/“she signs”
(18) (18) FN / “You”
(19) (19) “You”/“He”/“She”
(20) (20) “you meet”/“he meets”/“she meets”
(21) (21) “You are”/“He is”/“She is”
(22) (22) “your”/“his”/“her”
(23) (23) “your”/“his”/“her”
(24) (24) “You are”/“He is”/“She is”
(25) (25) “your”/“his”/“her”
(26) (26) “You”/“He”/“She”
(27) (27) “you are”/“he is”/“she is”
(28) (28) “you”/“he”/“she”
(29) (29) “your”/“his”/“her”
(30) (30) “You”/“He”/“She”
(31) (31) “you have”/“he has”/“she has”
(32) (32) “your”/“his”/“her”
(33) (33) “you need”/“he needs”/“she needs”
(34) (34) “your”/“his”/“her”
HIB157
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:
HIB170 ESRD, Monthly Benefits Terminating but HI/SMI Continuing
Even though (1) no longer receiving monthly checks, (2) will still have hospital and medical insurance coverage under Medicare. Please keep (3) Medicare card.
There is a monthly premium for (4) medical insurance. Because we are stopping monthly checks, we will bill (5) every 3 months for the premiums.
Fill-ins:
(1) “you are”/SN plus “is”
(2) “you”/“she”/“he”
(3) “your”/“her”/“his”
(4) “your”/“her”/“his”
(5) “you”/“her”/“him”
HIB171 ESRD, Monthly Benefits Terminating but HI/SMI with State Buy-in is Continuing
Even though (1) no longer receiving monthly checks, (2) will still have hospital and medical insurance coverage under Medicare. Please keep (3) Medicare card. The State where (4) will continue to pay the premiums for (5) medical insurance coverage under Medicare.
Fill-ins:
(1) “you are”/SN plus “is”
(2) “you”/“she”/“he”
(3) “your”/“her”/“his”
(4) “you live/she lives/he lives”
(5) “your”/“her”/“his”
HIB186 Information Regarding Income Related Monthly Adjustment Amount (IRMAA)
IMPORTANT: A new law changes how premiums for Medicare Part B are calculated for some higher income beneficiaries, generally individuals with incomes higher than (1) and couples with incomes higher than (2) . Social Security will be contacting the Internal Revenue Service, and if we determine that (3) to pay a higher premium, we will send (4) a notice explaining our decision, and the higher amount will be effective (5) . For more information, visit www.socialsecurity.gov on the Internet or call us toll-free at 1-800-772-1213 (TTY 1-800-325-0778).
Fill-ins:
(1) Show the IRMAA level 1 yearly amount for singles
(2) Show the IRMAA level 1 yearly amount for couples
(3) “he has”/“she has”/“you have”
(4) “her”/“him”/“you”
(5) SMI start date in format July 2013
HIB215 Closed Period DIB Award and 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-ins:
(1) “you are”/“she is”/“he is”
(2) “your”/“her”/“his”
(3) “hospital and medical”/“hospital”
(4) “Your”/“Her”/“His”
(5) “hospital and medical”/“hospital”
(6) HI termination date in the format May 1999
(7) “your”/“her”/“his”
HIB249 SMI Equitable Relief and Retroactive VSMI Exists
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-ins:
(1) date in format July 2013
(2) date in format July 2013
(3) Money amount
(4) date in format July 2013
(5) date in format July 2013
(6) date in format July 2013
(7) Money amount
(8) money amount