NL: Notices, Letters and Paragraphs
TN 28 (03-18)
A. List of “H” paragraphs and captions
HBN001 – AUTOMATED CMS BILLING NOTICE USED WITH HIB225
(appears after the signature page of the notice)
NOTICE OF MEDICARE PREMIUM PAYMENT DUE
CENTERS FOR MEDICARE & MEDICAID SERVICES
BILLING DATE: (1)
MEDICAL PREMIUMS FOR
PERIOD ENDING: (2)
CURRENT AMOUNT DUE: (3)
PAYMENT DUE BY: (4)
Return the bottom portion of this notice with your payment and use the enclosed envelope to mail your payment.
You must pay by check or money order. Include your Medicare number at the top of your check or money order. Make the check or money order payable to: CMS MEDICARE INSURANCE.
If you have changed your address, be sure to write your new address in the space provided below.
If you should have any questions concerning this Notice of Medicare Premium Payment Due, please write or visit any Social Security Office.
PLEASE DETACH AT DOTTED LINE
------------------------------------------------------------------------------------------------------------
CMS-500A
Medicare Number: (5) Amount Due: (6)
Name: (7)
Make Checks Payable To:
CMS MEDICARE INSURANCE
Send To:
Medicare Premium Collection Center
PO Box 790355
St. Louis, MO 63179-0355
( ) Check here if your address has changed. Show new address below.
________________________________________________________
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Fill-in values: |
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|---|---|
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Fill-in (1) |
the date of the T2Redesign notice in the format June 27, 2001 |
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Fill-in (2) |
December of the current operating year, unless the COM is December of the COY, then December of the following COY in the format December 2001 |
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Fill-in (3) |
SMI premiums due |
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Fill-in (4) |
the 20th day of the third calendar month after the date of the T2Redesign notice in the format September 20, 2001 |
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Fill-in (5) |
Medicare Beneficiary Identification (MBI) Number |
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Fill-in (6) |
SMI premiums due |
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Fill-in (7) |
BGN plus BLN (not possessive) |
B. “HDR” - Headings
HDR030 - DATE AND BENEFICIARY NOTICE CONTROL NUMBER
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Fill-in values: |
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|---|---|
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Fill-in (1) |
Show T2R Run Date plus 7 days in the format Month DD, CCYY |
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Fill-in (2) |
Show 13 character alphanumeric Beneficiary Notice Control # plus 1-4 character alphanumeric Beneficiary Identification Code in the format XXXXXXXXXXXXX-XXXX |
C. “HIB” UNIVERSAL TEXT IDENTIFIERS – HEALTH INSURANCE BENEFITS
HIBC01 – CAPTION
Information About Medicare
HIBC02 – CAPTION
Health Insurance For Children
HIBC05 – CAPTION
Why (1) Cannot Quality For Medicare
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Fill-in values: |
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|---|---|
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Fill-in (1) |
show the BGN plus BLN (not possessive) |
HIBC15 – CAPTION
To Cancel This Insurance
HIBC19 – CAPTION
Notice of Group Billing
HIB001 – ENTITLED TO HI AND/OR SMI
(1) Medicare (2) (3) (4) (5).
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Fill-in values: |
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|---|---|
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Fill-in (1) |
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Choice 1 |
Your |
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Choice 2 |
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) |
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Fill-in (2) |
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Choice 1 |
Part A (hospital insurance) starts |
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Choice 2 |
Part B (medical insurance) starts |
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Choice 3 |
Part A (hospital insurance) and Part B (medical insurance) start |
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Fill-in (3) |
Date in format Month CCYY |
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Fill-in (4) |
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Choice 1 |
and Part B (medical insurance) starts |
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Choice 2 |
Null |
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Fill-in (5) |
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Choice 1 |
Date in format Month CCYY |
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Choice 2 |
Null |
HIB002 - TEMPORARY SUBSTITUTION OF NOTICE FOR HEALTH INSURANCE CARD
(1) will get a Medicare card within 2 weeks. (2) show this card when (3) medical care. To learn more about what Medicare covers, visit Medicare.gov. If (4) questions about (5) Medicare coverage, call 1-800-MEDICARE (1-800-633-4227).
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Fill-in values: |
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|---|---|
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Fill-in (1) |
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Choice 1 |
You |
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Choice 2 |
BGN plus BLN (not possessive) |
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Fill-in (2) |
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Choice 1 |
You should |
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Choice 2 |
He should |
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Choice 3 |
She should |
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Fill-in (3) |
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Choice 1 |
you need |
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Choice 2 |
he needs |
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Choice 3 |
she needs |
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Fill-in (4) |
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Choice 1 |
you have |
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Choice 2 |
he has |
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Choice 3 |
she has |
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Fill-in (5) |
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Choice 1 |
your |
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Choice 2 |
his |
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Choice 3 |
her |
HIB005 – SMI PREMIUM BILLING
(1) monthly premium for Medicare Part B (medical insurance) is (2) beginning (3) (4) (5).
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Fill-in values: |
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|---|---|
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Fill-in (1) |
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Choice 1 |
Your |
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Choice 2 |
His |
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Choice 3 |
Her |
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Fill-in (2) |
Amount of Part B premium in $$$$$.¢¢ format |
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Fill-in (3) |
Date in MMCCYY format |
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Fill-in (4) |
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Choice 1 |
null |
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Choice 2 |
and |
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Fill-in (5) |
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Choice 1 |
null |
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Choice 2 |
Show the amount of the Part B premium in the format $$$$$¢¢ plus the word “beginning” plus show the start date that corresponding to the second premium rate returned from the HSA utility in the format MMCCYY |
HIB008 – SMI PREMIUM DEDUCTIONS
We will start to take premiums out of (1) (2) check.
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Fill-in values: |
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|---|---|
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Fill-in (1) |
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Choice 1 |
his |
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Choice 2 |
her |
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Choice 3 |
your |
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Fill-in (2) |
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Choice 1 |
next |
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Choice 2 |
MMDDYYYY (using the PCI, show the calendar date for the month following COM (e.g. if PCI = 2 and the COM = 4/98, then fill-in 2 will equal the calendar date for the second Wednesday in May) |
HIB011 – HI PREMIUM BILLING
The monthly premium for (1) hospital insurance is (2). We will bill you each month for (3).
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Fill-in values: |
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|---|---|
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Fill-in (1) |
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Choice 1 |
his |
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Choice 2 |
her |
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Choice 3 |
your |
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Fill-in (2) |
Show the current HI premium rate in the format 999.99 |
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Fill-in (3) |
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Choice 1 |
this premium |
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Choice 2 |
the combined premium for hospital and medical insurance |
HIB013 – MEDICARE HI/SMI PREMIUM PENALTY
(1) a penalty because (2) enrolled later than (3) could have.
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Fill-in values: |
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|---|---|
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Fill-in (1) |
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Choice 1 |
This medical insurance premium includes |
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Choice 2 |
This hospital insurance premium includes |
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Choice 3 |
These hospital and medical insurance premiums include |
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Fill-in (2) |
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Choice 1 |
he |
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Choice 2 |
she |
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Choice 3 |
you |
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Fill-in (3) |
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Choice 1 |
he |
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Choice 2 |
she |
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Choice 3 |
you |
HIB015 – PREMIUMS DEDUCTED FROM CIVIL SERVICE ANNUITY
The Office of Personnel Management will deduct the premiums from (1) annuity checks. They will let (2) know when this will start.
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Fill-in values: |
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|---|---|
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Fill-in (1) |
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Choice 1 |
BGN plus BLN (possessive) |
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Choice 2 |
your |
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Fill-in (2) |
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Choice 1 |
him |
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Choice 2 |
her |
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Choice 3 |
you |
HIB026 – 3RD PARTY BUYIN TP STARTS DATES/CODES DO NOT MATCH
(1) (2) will pay (3) Medicare hospital insurance premiums beginning (4). (5)
(6) (7) will pay (8) Medicare medical insurance premiums beginning (9). (10)
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Fill-in values: |
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|---|---|
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Fill-in (1) |
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Choice 1 |
Leave Blank |
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Choice 2 |
The State of |
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Fill-in (2) |
show State name |
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Fill-in (3) |
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Choice 1 |
BGN plus BLN (possessive) |
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Choice 2 |
your |
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Fill-in (4) |
Show the TP START DATE in the format MMCCYY |
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Fill-in (5) |
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Choice 1 |
This also means that he is entitled to this Medicare coverage for an earlier period than shown on his current Medicare card. |
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Choice 2 |
This also means that she is entitled to this Medicare coverage for an earlier period than shown on her current Medicare card. |
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Choice 3 |
This also means that you are entitled to this Medicare coverage for an earlier period than shown on your current Medicare card. |
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Choice 4 |
Null |
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Fill-in (6) |
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Choice 1 |
Leave Blank |
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Choice 2 |
The State of |
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Fill-in (7) |
show State name |
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Fill-in (8) |
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Choice 1 |
BGN plus BLN (possessive) |
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Choice 2 |
your |
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Fill-in (9) |
Show the TP START date in the format MMCCYY |
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Fill-in (10) |
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Choice 1 |
This also means that he is entitled to this Medicare coverage for an earlier period than shown on his current Medicare card. |
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Choice 2 |
This also means that she is entitled to this Medicare coverage for an earlier period than shown on her current Medicare card. |
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Choice 3 |
This also means that you are entitled to this Medicare coverage for an earlier period than shown on your current Medicare card. |
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Choice 4 |
Null |
HIB027 – 3RD PARTY BUYOUT TP STARTS DATES/CODES DO NOT MATCH
(1) (2) will no longer pay (3) Medicare hospital insurance premiums after (4).
(5) must pay the premiums beginning (6).
(7) (8) will no longer pay (9) Medicare medical insurance premiums after (10).
(11) must pay the premiums beginning (12).
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Fill-in values: |
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|---|---|
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Fill-in (1) |
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Choice 1 |
Leave Blank |
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Choice 2 |
The State of |
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Fill-in (2) |
Show State name |
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Fill-in (3) |
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Choice 1 |
BGN plus BLN (possessive) |
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Choice 2 |
your |
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Fill-in (4) |
Show TP STOP date in the format MMCCYY |
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Fill-in (5) |
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Choice 1 |
He |
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Choice 2 |
She |
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Choice 3 |
You |
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Fill-in (6) |
Show the TP STOP date plus 1 month in the format MMCCYY |
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Fill-in (7) |
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Choice 1 |
Leave Blank |
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Choice 2 |
The State of |
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Fill-in (8) |
Show State name |
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Fill-in (9) |
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Choice 1 |
BGN plus BLN (possessive) |
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Choice 2 |
your |
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Fill-in (10) |
Show the TP STOP date in the format MMCCYY |
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Fill-in (5) |
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Choice 1 |
He |
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Choice 2 |
She |
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Choice 3 |
You |
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Fill-in (12) |
Show the TP STOP date plus 1 month in the format MMCCYY |
HIB029 – LIMITED BUYIN FOR HI/SMI DATES/CODES DO NOT MATCH
(1) (2) paid (3) Medicare hospital insurance premium for (4).
(5) (6) paid (7) Medicare medical insurance premium for (8).
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Fill-in values: |
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|---|---|
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Fill-in (1) |
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Choice 1 |
Leave Blank |
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Choice 2 |
The State of |
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Fill-in (2) |
Show the State name |
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Fill-in (3) |
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Choice 1 |
BGN plus BLN (possessive) |
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Choice 2 |
your |
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Fill-in (4) |
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Choice 1 |
MMCCYY |
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Choice 2 |
MMCCYY and MMCCYY |
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Choice 3 |
MMCCYY through MMCCYY |
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Fill-in (5) |
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Choice 1 |
Leave Blank |
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Choice 2 |
The State of |
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Fill-in (6) |
Show the State name |
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Fill-in (7) |
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Choice 1 |
BGN plus BLN (possessive) |
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Choice 2 |
your |
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Fill-in (8) |
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Choice 1 |
MMCCYY |
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Choice 2 |
MMCCYY and MMCCYY |
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Choice 3 |
MMCCYY through MMCCYY |
HIB030 – GROUP PAYER STOPS FOR HI/SMI DATES NOT EQUAL
The organization that was paying (1) Medicare hospital insurance premium will no longer pay it after (2). (3) must pay the premium beginning (4).
The organization that was paying (5) Medicare medical insurance premium will no longer pay it after (6). (7) must pay the premium beginning (8).
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Fill-in values: |
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|---|---|
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Fill-in (1) |
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Choice 1 |
BGN plus BLN (possessive) |
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Choice 2 |
your |
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Fill-in (2) |
MMCCYY |
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Fill-in (3) |
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Choice 1 |
He |
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Choice 2 |
She |
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Choice 3 |
You |
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Fill-in (4) |
MMCCYY |
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Fill-in (5) |
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Choice 1 |
BGN plus BLN possessive |
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Choice 2 |
your |
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Fill-in (6) |
MMCCYY |
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Fill-in (7) |
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Choice 1 |
He |
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Choice 2 |
She |
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Choice 3 |
You |
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Fill-in (8) |
MMCCYY |
HIB034 –ADVISE THAT SMI DEDUCTION WILL CONTINUE
We will continue to deduct Medicare Part B (medical. insurance) premium of (1) from (2) payments.
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Fill-in values: |
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|---|---|
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Fill-in (1) |
Show the total of DAH-ITEMS = 430, 435 and 440 in the format $$$$$ |
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Fill-in (2) |
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Choice 1 |
your |
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Choice 2 |
BGN plus BLN (possessive) |
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.
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Fill-in values: |
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|---|---|
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Fill-in (1) |
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Choice 1 |
He |
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Choice 2 |
She |
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Choice 3 |
You |
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Fill-in (2) |
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Choice 1 |
he has |
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Choice 2 |
she has |
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Choice 3 |
you have |
HIB042 – MEDICARE DISALLOWANCE FEHB ACT OF 1959
(1) cannot qualify for Medicare because (2) covered under the Federal Employees Health Benefits Act
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Fill-in values: |
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|---|---|
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Fill-in (1) |
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Choice 1 |
He |
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Choice 2 |
She |
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Choice 3 |
You |
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Fill-in (2) |
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Choice 1 |
he is |
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Choice 2 |
she is |
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Choice 3 |
you are |
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Choice 4 |
he could be |
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Choice 5 |
she could be |
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Choice 6 |
you could be |
HIB050 – MED DISAL NH AGE 65 BEFORE END OF WAITING PERIOD
You do not qualify for Medicare based on disability because your coverage cannot start before you reach age 65.
To receive Medicare coverage before age 65, a person must be disabled under our rules for 29 months before coverage begins. Based on the date you said you became disabled, coverage could not begin until after you reach age 65. For this reason, we have not decided whether or not you are disabled.
You may qualify for Medicare when you reach age 65, whether or not you are disabled under our rules.
HIB053 – PREMIUM HI DENIED AND/OR SMI DISALLOWED (RDD 107)
(1) not entitled to (2) insurance coverage under Medicare because (3) application was filed too late. However, (4) may apply for coverage again during the next general enrollment period. A general enrollment period takes place in January, February and March of each year.
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Fill-in values: |
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|---|---|
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Fill-in (1) |
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Choice 1 |
Beneficiary Full Name plus the word “is” |
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Choice 2 |
You are |
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Fill-in (2) |
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Choice 1 |
medical |
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Choice 2 |
hospital |
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Choice 3 |
hospital and medical |
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Fill-in (3) |
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Choice 1 |
his |
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Choice 2 |
her |
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Choice 3 |
your |
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Fill-in (4) |
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Choice 1 |
he |
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Choice 2 |
she |
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Choice 3 |
you |
HIB054 – HI AND/OR SMI PERIOD NOT PREVIOUSLY COVERED
If (1) had any expenses that (2) should be covered by Medicare (3) insurance, please contact your local Social Security office. The telephone number and address are shown below.
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Fill-in values: |
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|---|---|
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Fill-in (1) |
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Choice 1 |
BGN plus BLN the word “has” |
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Choice 2 |
Beneficiary First Name plus the word “has” |
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Choice 3 |
you have |
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Fill-in (2) |
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Choice 1 |
he believes |
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Choice 2 |
she believes |
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Choice 3 |
you believe |
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Fill-in (3) |
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Choice 1 |
hospital |
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Choice 2 |
medical |
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Choice 3 |
hospital and medical |
HIB060 – SUSPENSE FOR PRISON/MENTAL ADVISES OF SMI PREMIUMS
Generally, Medicare will not pay for hospital or medical items or services (1) while (2) (3). However, you may want to pay (4) Medicare medical insurance premiums for two reasons:
The premiums may be higher if you cancel the Medicare medical insurance now and reenroll after (5) released from (6).
(7) may not have medical insurance for a period of time after (8) released from (9). This is because (10) will have to wait until a general enrollment period to reenroll. A general enrollment period takes place in January, February and March of each year.
If you want to cancel (11) medical insurance, please let us know. If you decide to keep Medicare medical insurance, we will bill you for the premium. The first bill we send will be for all premiums now due. After that, each bill we send will be for a 3-month period and will be sent to you shortly before the payment is due.
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Fill-in values: |
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|---|---|
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Fill-in (1) |
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Choice 1 |
BGN plus BLN plus the word “receives” |
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Choice 2 |
you receive |
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Fill-in (2) |
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Choice 1 |
he is |
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Choice 2 |
she is |
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Choice 3 |
you are |
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Fill-in (3) |
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Choice 1 |
imprisoned |
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Choice 2 |
confined in an institution |
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Fill-in (4) |
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Choice 1 |
his |
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Choice 2 |
her |
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Choice 3 |
your |
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Fill-in (5) |
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Choice 1 |
he is |
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Choice 2 |
she is |
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Choice 3 |
you are |
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Fill-in (6) |
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Choice 1 |
prison |
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Choice 2 |
the institution |
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Fill-in (7) |
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Choice 1 |
BGN plus BLN |
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Choice 2 |
You |
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Fill-in (8) |
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Choice 1 |
he is |
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Choice 2 |
she is |
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Choice 3 |
you are |
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Fill-in (9) |
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Choice 1 |
prison |
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Choice 2 |
the institution |
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Fill-in (10) |
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Choice 1 |
he |
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Choice 2 |
she |
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Choice 3 |
you |
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Fill-in (11) |
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Choice 1 |
his |
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Choice 2 |
her |
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Choice 3 |
your |
HIB061 – SMI PREMIUM CONTINUES DEDUCTION FROM CS ANNUITY
The Office of Personnel Management will continue to deduct (1) medical insurance premiums from (2) annuity checks.
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Fill-in values: |
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|---|---|
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Fill-in (1) |
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Choice 1 |
Beneficiary Full Name (possessive) |
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Choice 2 |
your |
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Fill-in (2) |
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Choice 1 |
his |
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Choice 2 |
her |
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Choice 3 |
your |
HIB066 – HI/SMI PREMIUMS ALREADY PAID
Any (1) insurance premiums (2) already paid will be credited to (3) record.
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Fill-in values: |
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|---|---|
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Fill-in (1) |
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Choice 1 |
medical |
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Choice 2 |
hospital |
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Choice 3 |
hospital and medical |
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Fill-in (2) |
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Choice 1 |
BGN plus BLN plus “has” |
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Choice 2 |
BGN plus “has” |
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Choice 3 |
you have |
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Fill-in (3) |
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Choice 1 |
his |
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Choice 2 |
her |
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Choice 3 |
your |
HIB067 – SMI PREMIUM BILLING
We will send (1) first bill for the premiums within a month. Each bill after that will be for a 3-month period.
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Fill-in values: |
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|---|---|
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Fill-in (1) |
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Choice 1 |
his |
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Choice 2 |
her |
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Choice 3 |
your |
HIB068 – HI/SMI EQUITABLE RELIEF
If (1) these benefits earlier, (2) can choose (3) insurance benefits beginning (4). To start benefits earlier, within 60 days after the date of this notice (5) must tell us in writing that (6) (7) insurance benefits beginning (8). In addition, (9) must:
pay us (10) (this covers premiums due from (11) through (12)); or
(13)
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Fill-in values: |
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|---|---|
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Fill-in (1) |
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Choice 1 |
he wants |
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Choice 2 |
she wants |
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Choice 3 |
you want |
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Fill-in (2) |
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Choice 1 |
he |
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Choice 2 |
she |
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Choice 3 |
you |
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Fill-in (3) |
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Choice 1 |
hospital |
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Choice 2 |
medical |
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Choice 3 |
hospital and medical |
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Fill-in (4) |
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Choice 1 |
Show the HI-NONEQRELST date in MMCCYY |
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Choice 2 |
Show the SMI-NONEQRELST date in MMCCYY |
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Fill-in (5) |
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Choice 1 |
he |
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Choice 2 |
she |
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Choice 3 |
you |
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Fill-in (6) |
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Choice 1 |
he wants |
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Choice 2 |
she wants |
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Choice 3 |
you want |
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Fill-in (7) |
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Choice 1 |
hospital |
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Choice 2 |
medical |
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Choice 3 |
hospital and medical |
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Fill-in (8) |
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Choice 1 |
Show the HI-NONEQRELST date in MMCCYY |
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Choice 2 |
Show the SMI-NONEQRELST date in MMCCYY |
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Fill-in (9) |
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Choice 1 |
he |
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Choice 2 |
she |
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Choice 3 |
you |
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Fill-in (10) |
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Choice 1 |
Show the total amount for HI premiums calculated |
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Choice 2 |
Show the total amount for SMI premiums calculated |
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Choice 3 |
Show the combined total amount for HI and SMI premiums calculated |
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Fill-in (11) |
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Choice 1 |
Show the HI-NONEQRELST date in MMCCYY |
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Choice 2 |
Show the SMI-NONEQRELST date in MMCCYY |
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Fill-in (12) |
Show the COM month in MMCCYY |
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Fill-in (13) |
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|
Choice 1 |
tell us we can withhold this amount from the check. |
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Choice 2 |
tell us to bill you for this amount. |
HIB069 – HI/SMI TERMINATION FOR NON-PAYMENT OF PREMIUMS
(1) Medicare premium amount of (2) for (3) insurance was not paid within the time limit. Therefore, (4) (5) insurance coverage has stopped. (6) last month of coverage (7) (8). Benefits will not be paid for any (9) services (10) after (11) last month of coverage.
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Fill-in values: |
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|---|---|
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Fill-in (1) |
|
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Choice 1 |
BGN plus BLN (possessive) |
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Choice 2 |
Your |
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Fill-in (2) |
Show money amount for HI/SMI premiums due in 99999.99 |
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Fill-in (3) |
|
|
Choice 1 |
hospital |
|
Choice 2 |
medical |
|
Choice 3 |
hospital and medical |
|
Fill-in (4) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (5) |
|
|
Choice 1 |
hospital |
|
Choice 2 |
medical |
|
Choice 3 |
hospital and medical |
|
Fill-in (6) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (7) |
|
|
Choice 1 |
is |
|
Choice 2 |
was |
|
Fill-in (8) |
|
|
Choice 1 |
Show the HI TERM date minus 1 month in MMCCYY |
|
Choice 2 |
Show the SMI TERM date minus 1 month in MMCCYY |
|
Fill-in (9) |
|
|
Choice 1 |
hospital |
|
Choice 2 |
medical |
|
Choice 3 |
hospital and medical |
|
Fill-in (10) |
|
|
Choice 1 |
he receives |
|
Choice 2 |
she receives |
|
Choice 3 |
you receive |
|
Fill-in (11) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
HIB070 – PREMIUM HI DWI CONTINUES SMI TERMINATES NON-PAYMENT
This decision does not affect (1) (2) insurance coverage. (3) should continue to pay (4) insurance premiums to keep this coverage.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (2) |
|
|
Choice 1 |
medical |
|
Choice 2 |
hospital |
|
Fill-in (3) |
|
|
Choice 1 |
He |
|
Choice 2 |
She |
|
Choice 3 |
You |
|
Fill-in (4) |
|
|
Choice 1 |
medical |
|
Choice 2 |
hospital |
HIB071 – RRB JURIS STARTS AND COLLECTS MEDICARE PREMIUMS
The Social Security Administration is no longer responsible for deducting Medicare premiums from Social Security payments. The Railroad Retirement Board (RRB) is now responsible for collecting medical insurance premiums for all railroad beneficiaries and their families. This includes beneficiaries who are also entitled to Social Security benefits.
HIB072 – RRB JURIS STARTS AND COLLECTS MEDICARE PREMIUMS
Since (1) (2) a railroad beneficiary, the RRB will start to withhold medical insurance premiums from (3) Railroad Retirement annuity. If (4) not currently receiving a Railroad Retirement annuity, the Social Security Administration will let the RRB know when (5) next premium is due. The RRB will send (6) a bill for premiums.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
BGN plus BLN |
|
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 |
he is |
|
Choice 2 |
she is |
|
Choice 3 |
you are |
|
Fill-in (5) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (6) |
|
|
Choice 1 |
him |
|
Choice 2 |
her |
|
Choice 3 |
you |
HIB073 – RRB SENDS NEW MEDICARE CARD
(1) protection under Medicare will continue without any change in coverage.
The RRB will send (2) a new Medicare card. Until then, (3) may use (4) old card.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
BGN plus BLN (possessive) |
|
Choice 2 |
Your |
|
Fill-in (2) |
|
|
Choice 1 |
him |
|
Choice 2 |
her |
|
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 |
HIB074 – NEW MEDICARE CARD
We will send (1) a new health insurance card. It will show that (2) entitled to (3) insurance.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
BGN plus BLN (not possessive) |
|
Choice 2 |
BGN (not possessive) |
|
Choice 3 |
you |
|
Fill-in (2) |
|
|
Choice 1 |
he is |
|
Choice 2 |
she is |
|
Choice 3 |
you are |
|
Fill-in (3) |
|
|
Choice 1 |
hospital |
|
Choice 2 |
medical |
|
Choice 3 |
hospital and medical |
HIB075 – EQUITABLE RELIEF/HARDSHIP
If (1) benefits beginning (2) but (3) it hard to pay the premium amount in a lump sum, ask us about other ways to pay the money.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
he wants |
|
Choice 2 |
she wants |
|
Choice 3 |
you want |
|
Fill-in (2) |
|
|
Choice 1 |
Show the HI NONEQRELST date in MMCCYY |
|
Choice 2 |
Show the SMI NONEQRELST date in MMCCYY |
|
Fill-in (3) |
|
|
Choice 1 |
find |
|
Choice 2 |
finds |
HIB076 – HI/SMI TERMINATION INFORMATIONAL
If (1) not sign up for Part B when (2) first eligible, (3) may have to pay a late enrollment penalty for as long as (4) Part B. (5) monthly premium may go up 10 percent for each full 12-month period that (6) could have had Part B coverage, but did not sign up for it. Usually, (7) will not have to pay a late enrollment penalty if (8) up during a special enrollment period.
If (9) to sign up for (10) later, (11) will usually have to wait until the general enrollment period. The general enrollment period takes place in January, February, and March of each year. If (12) up in the general enrollment period, (13) Part B coverage will start July 1 of the year (14) up.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
you do |
|
Choice 2 |
he does |
|
Choice 3 |
she does |
|
Fill-in (2) |
|
|
Choice 1 |
you are |
|
Choice 2 |
he is |
|
Choice 3 |
she is |
|
Fill-in (3) |
|
|
Choice 1 |
you |
|
Choice 2 |
he |
|
Choice 3 |
she |
|
Fill-in (4) |
|
|
Choice 1 |
you have |
|
Choice 2 |
he has |
|
Choice 3 |
she has |
|
Fill-in (5) |
|
|
Choice 1 |
Your |
|
Choice 2 |
His |
|
Choice 3 |
Her |
|
Fill-in (6) |
|
|
Choice 1 |
you |
|
Choice 2 |
he |
|
Choice 3 |
she |
|
Fill-in (7) |
|
|
Choice 1 |
you |
|
Choice 2 |
he |
|
Choice 3 |
she |
|
Fill-in (8) |
|
|
Choice 1 |
you sign |
|
Choice 2 |
he signs |
|
Choice 3 |
she signs |
|
Fill-in (9) |
|
|
Choice 1 |
you want |
|
Choice 2 |
BGN plus BLN plus “wants” |
|
Fill-in (10) |
|
|
Choice 1 |
Part A |
|
Choice 2 |
Part B |
|
Choice 3 |
Part A and Part B |
|
Fill-in (11) |
|
|
Choice 1 |
you |
|
Choice 2 |
he |
|
Choice 3 |
she |
|
Fill-in (12) |
|
|
Choice 1 |
you sign |
|
Choice 2 |
he signs |
|
Choice 3 |
she signs |
|
Fill-in (13) |
|
|
Choice 1 |
your |
|
Choice 2 |
his |
|
Choice 3 |
her |
|
Fill-in (14) |
|
|
Choice 1 |
you sign |
|
Choice 2 |
he signs |
|
Choice 3 |
she signs |
HIB077 – SMI TERMINATION INFORMATIONAL
People who have Medicare Part B (medical insurance) pay a monthly premium. If (1) not sign up for Part B when (2) first eligible, (3) may have to pay a late enrollment penalty for as long as (4) Part B. (5) monthly premium may go up 10 percent for each full 12-month period that (6) could have had Part B coverage, but did not sign up for it. Usually, (7) will not have to pay a late enrollment penalty if (8) up during a special enrollment period.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
you do |
|
Choice 2 |
he does |
|
Choice 3 |
she does |
|
Fill-in (2) |
|
|
Choice 1 |
you are |
|
Choice 2 |
he is |
|
Choice 3 |
she is |
|
Fill-in (3) |
|
|
Choice 1 |
you |
|
Choice 2 |
he |
|
Choice 3 |
she |
|
Fill-in (4) |
|
|
Choice 1 |
you have |
|
Choice 2 |
he has |
|
Choice 3 |
she has |
|
Fill-in (5) |
|
|
Choice 1 |
Your |
|
Choice 2 |
His |
|
Choice 3 |
Her |
|
Fill-in (6) |
|
|
Choice 1 |
you |
|
Choice 2 |
he |
|
Choice 3 |
she |
|
Fill-in (7) |
|
|
Choice 1 |
you |
|
Choice 2 |
he |
|
Choice 3 |
she |
|
Fill-in (8) |
|
|
Choice 1 |
you sign |
|
Choice 2 |
he signs |
|
Choice 3 |
she signs |
HIB078 – HI TERMINATION INFORMATIONAL
(1) monthly premium for hospital insurance may be 10 percent higher when (2).
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
His |
|
Choice 2 |
Her |
|
Choice 3 |
Your |
|
Fill-in (2) |
|
|
Choice 1 |
he re-enrolls |
|
Choice 2 |
she re-enrolls |
|
Choice 3 |
you re-enroll |
HIB079 – VOLUNTARY TERMINATION FOR PREMIUM HI OR SMI
Because (10) canceling (2) (3) insurance coverage, (4) no longer entitled to (5) insurance coverage. (6) hospital and medical insurance coverage ends on the last day of (7).
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
BGN plus BLN plus the word “is” |
|
Choice 2 |
BGN plus the word “is” |
|
Choice 3 |
you are |
|
Fill-in (2) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (3) |
|
|
Choice 1 |
medical |
|
Choice 2 |
hospital |
|
Fill-in (4) |
|
|
Choice 1 |
he is |
|
Choice 2 |
she is |
|
Choice 3 |
you are |
|
Fill-in (5) |
|
|
Choice 1 |
hospital |
|
Choice 2 |
medical |
|
Fill-in (6) |
|
|
Choice 1 |
His |
|
Choice 2 |
Her |
|
Choice 3 |
Your |
|
Fill-in (7) |
Show the HI TERM date minus 1 month in MMCCYY format |
HIB080 – VOLUNTARY SMI TERMINATION CIVIL SERVICE INVOLVED
The Office of Personnel Management will no longer deduct the medical insurance premiums from (1) annuity checks. They will let (2) know when the deductions will stop.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
BGN plus BLN (possessive) |
|
Choice 2 |
BGN (possessive) |
|
Choice 3 |
your |
|
Fill-in (2) |
|
|
Choice 1 |
him |
|
Choice 2 |
her |
|
Choice 3 |
you |
HIB082 – HI AND/OR SMI VOLUNTARY TERMINATION
(1) asked that we stop (2) (3) insurance coverage under Medicare. This coverage ends the last day of (4).
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
BGN plus BLN |
|
Choice 2 |
You |
|
Fill-in (2) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (3) |
|
|
Choice 1 |
hospital |
|
Choice 2 |
medical |
|
Choice 3 |
hospital and medical |
|
Fill-in (4) |
|
|
Choice 1 |
Show the HI TERM date minus 1 month in MMCCYY format |
|
Choice 2 |
Show the SMI TERM date minus 1 month in MMCCYY format |
HIB083 – SPECIAL ENROLLMENT PERIOD DISABILITY
(1) may also be able to enroll during a special enrollment period. (2) can do this if (3) (4) one of the conditions listed below:
(5) covered under a group health plan through (6) current work or (7) spouse's current work, or
(8) covered under a large group health plan through (9) current work or any family member's current work.
(10) may enroll for Medicare (11) insurance at any time (12) covered under the group health plan. However, (13) may wait and enroll during the 8-month period that begins when the work ends or (14) coverage under the plan ends, whichever occurs first. (15) may also enroll if the type of plan (16) changes.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
BGN plus BLN (not possessive) |
|
Choice 2 |
BGN (not possessive) |
|
Choice 3 |
You |
|
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 |
meets |
|
Choice 2 |
meet |
|
Fill-in (5) |
|
|
Choice 1 |
He is |
|
Choice 2 |
She is |
|
Choice 3 |
You are |
|
Fill-in (6) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (7) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (8) |
|
|
Choice 1 |
He is |
|
Choice 2 |
She is |
|
Choice 3 |
You are |
|
Fill-in (9) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (10) |
|
|
Choice 1 |
He |
|
Choice 2 |
She |
|
Choice 3 |
You |
|
Fill-in (11) |
|
|
Choice 1 |
hospital |
|
Choice 2 |
medical |
|
Choice 3 |
hospital and medical |
|
Fill-in (12) |
|
|
Choice 1 |
he is |
|
Choice 2 |
she is |
|
Choice 3 |
you are |
|
Fill-in (13) |
|
|
Choice 1 |
he |
|
Choice 2 |
she |
|
Choice 3 |
you |
|
Fill-in (14) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (15) |
|
|
Choice 1 |
He |
|
Choice 2 |
She |
|
Choice 3 |
You |
|
Fill-in (16) |
|
|
Choice 1 |
he has |
|
Choice 2 |
she has |
|
Choice 3 |
you have |
HIB084 – SPECIAL ENROLLMENT PERIOD AGED
(1) may also be able to enroll during a special enrollment period. (2) can do this if (3) all of the conditions listed below:
(4) health insurance coverage is under an employer's plan because (5) or (6) spouse is working, and
(7) had health insurance coverage under that plan since (8) became age 65.
(9) may enroll for Medicare (10) insurance at any time (11) covered under the group health plan. However, (12) may wait and enroll during the 8-month period that begins when the work ends or (13) coverage under the plan ends, whichever occurs first.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
BGN plus BLN (not possessive) |
|
Choice 2 |
BGN (not possessive) |
|
Choice 3 |
You |
|
Fill-in (2) |
|
|
Choice 1 |
He |
|
Choice 2 |
She |
|
Choice 3 |
You |
|
Fill-in (3) |
|
|
Choice 1 |
he meets |
|
Choice 2 |
she meets |
|
Choice 3 |
you meet |
|
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) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (7) |
|
|
Choice 1 |
He has |
|
Choice 2 |
She has |
|
Choice 3 |
You have |
|
Fill-in (8) |
|
|
Choice 1 |
he |
|
Choice 2 |
she |
|
Choice 3 |
you |
|
Fill-in (9) |
|
|
Choice 1 |
He |
|
Choice 2 |
She |
|
Choice 3 |
You |
|
Fill-in (10) |
|
|
Choice 1 |
hospital |
|
Choice 2 |
medical |
|
Choice 3 |
hospital and medical |
|
Fill-in (11) |
|
|
Choice 1 |
he is |
|
Choice 2 |
she is |
|
Choice 3 |
you are |
|
Fill-in (12) |
|
|
Choice 1 |
he |
|
Choice 2 |
she |
|
Choice 3 |
you |
|
Fill-in (13) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
HIB085 – VOLUNTARY SMI TERMINATION CURRENT PAY
We will stop taking premiums for medical insurance out of (1) checks.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
BGN plus BLN (possessive) |
|
Choice 2 |
BGN (possessive) |
|
Choice 3 |
your |
HIB086 – VOLUNTARY HI/SMI TERMINATION PREMIUMS DUE
(1) (2) (3) in premiums through (4). Please make (5) check or money order payable to the "Centers for Medicare & Medicaid Services" and mail it to us in the enclosed envelope. Include (6) Medicare number on (7) check or money order.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
BGN plus BLN (not possessive) |
|
Choice 2 |
You |
|
Fill-in (2) |
|
|
Choice 1 |
owes |
|
Choice 2 |
owe |
|
Fill-in (3) |
Show total past due amount in $999,999.99 format |
|
Fill-in (4) |
Show the HI/SMI termination date minus 1 month in the format May 1999 |
|
Fill-in (5) |
|
|
Choice 1 |
your |
|
Choice 2 |
his |
|
Choice 3 |
her |
|
Fill-in (6) |
|
|
Choice 1 |
your |
|
Choice 2 |
his |
|
Choice 3 |
her |
|
Fill-in (7) |
|
|
Choice 1 |
your |
|
Choice 2 |
his |
|
Choice 3 |
her |
HIB087 – VOLUNTARY SMI TERMINATION HI CONTINUES
(1) hospital insurance coverage will continue.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
BGN plus BLN (possessive) |
|
Choice 2 |
BGN (possessive) |
|
Choice 3 |
your |
HIB088 – HI/SMI FOREIGN ADDRESS
Normally, Medicare will only pay for (1) services which (2) (3) in the United States. Since (4) living outside the U.S., Medicare will not pay for (5) services unless (6) to the U.S. for services.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
hospital |
|
Choice 2 |
medical |
|
Choice 3 |
hospital and medical |
|
Fill-in (2) |
|
|
Choice 1 |
BGN plus BLN (not possessive) |
|
Choice 2 |
BGN (not possessive) |
|
Choice 3 |
you |
|
Fill-in (3) |
|
|
Choice 1 |
receives |
|
Choice 2 |
receive |
|
Fill-in (4) |
|
|
Choice 1 |
he is |
|
Choice 2 |
she is |
|
Choice 3 |
you are |
|
Fill-in (5) |
|
|
Choice 1 |
hospital |
|
Choice 2 |
medical |
|
Choice 3 |
hospital and medical |
|
Fill-in (6) |
|
|
Choice 1 |
he returns |
|
Choice 2 |
she returns |
|
Choice 3 |
you return |
HIB089 – BENE AT FRA PROVISION PAYMENTS END HI/SMI ENDS
Since (1) no longer receiving provisional monthly Social Security benefits, we are stopping (2) (3) insurance coverage. This coverage ends the last day of (4). Please destroy (5) Medicare card after coverage ends.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
BGN plus BLN plus the word “is” |
|
Choice 2 |
you are |
|
Fill-in (2) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (3) |
|
|
Choice 1 |
hospital |
|
Choice 2 |
hospital and medical |
|
Fill-in (4) |
Show HI-TERM date in MMCCYY format |
|
Fill-in (5) |
|
|
Choice 1 |
BGN plus BLN (possessive) |
|
Choice 2 |
your |
HIB090 – TERMINATION ALL MEDICARE COVERAGE
(1) Medicare card will not be valid when (2) (3) coverage ends. Please destroy (4) card after (5) coverage ends.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
BGN plus BLN (possessive) |
|
Choice 2 |
Your |
|
Fill-in (2) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (3) |
|
|
Choice 1 |
Medicare Part A (hospital insurance) and Part B (medical insurance) |
|
Choice 2 |
Medicare Part B (medical insurance) |
|
Fill-in (4) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (5) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
HIB092 – STATE/LOCAL GOVT CONTINUES TO PAY SMI PREMIUM
(1) State or local government retirement system will continue to pay (2) Medicare medical insurance late enrollment premium penalty. (3) must continue to pay the basic Medicare medical insurance premium.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
BGN plus BLN (possessive) |
|
Choice 2 |
Your |
|
Fill-in (2) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (3) |
|
|
Choice 1 |
He |
|
Choice 2 |
She |
|
Choice 3 |
You |
HIB093 – STATE OR GROUP CONTINUES TO PAY SMI PREMIUMS
Our records show that (1) will continue to pay the premiums for (2) Medicare (3) insurance coverage.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
the State |
|
Choice 2 |
an organization |
|
Fill-in (2) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (3) |
|
|
Choice 1 |
hospital and medical |
|
Choice 2 |
medical |
HIB101 – MEDICARE STATE BUY-IN
(1) (2) will pay (3) Medicare (4) insurance premium beginning (5). (6)
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
Leave blank |
|
Choice 2 |
The State of |
|
Fill-in (2) |
show state corresponding to the HITP-CODE or the SMTP-CODE |
|
Fill-in (3) |
|
|
Choice 1 |
BGN plus BLN (possessive) |
|
Choice 2 |
your |
|
Fill-in (4) |
|
|
Choice 1 |
hospital |
|
Choice 2 |
medical |
|
Choice 3 |
hospital and medical |
|
Fill-in (5) |
TP START date in MMCCYY format |
|
Fill-in (6) |
|
|
Choice 1 |
This also means that he is entitled to this Medicare coverage for an earlier period than shown on his current Medicare card. |
|
Choice 2 |
This also means that she is entitled to this Medicare coverage for an earlier period than shown on her current Medicare card. |
|
Choice 3 |
This also means that you are entitled to this Medicare coverage for an earlier period than shown on your current Medicare card. |
|
Choice 4 |
NULL |
HIB102 – STATE BUY-OUT
(1) (2) will no longer pay (3) Medicare (4) insurance premiums after (5). (6) must pay the premiums beginning (7).
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
Leave blank |
|
Choice 2 |
The State of |
|
Fill-in (2) |
show state corresponding to the HITP-CODE or the SMTP-CODE |
|
Fill-in (3) |
|
|
Choice 1 |
BGN plus BLN (possessive) |
|
Choice 2 |
your |
|
Fill-in (4) |
|
|
Choice 1 |
hospital |
|
Choice 2 |
medical |
|
Choice 3 |
hospital and medical |
|
Fill-in (5) |
Show the TP STOP date in MMCCYY format |
|
Fill-in (6) |
|
|
Choice 1 |
He |
|
Choice 2 |
She |
|
Choice 3 |
You |
|
Fill-in (7) |
Show the TP STOP date plus 1 month in MMCCYY format |
HIB103 – LIMITED BUY-IN AND BUY-OUT
(1) (2) paid (3) Medicare (4) insurance premium for (5).
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
Leave blank |
|
Choice 2 |
The State of |
|
Fill-in (2) |
Show state corresponding to the HITP-CODE or the SMTP-CODE |
|
Fill-in (3) |
|
|
Choice 1 |
BGN plus BLN (possessive) |
|
Choice 2 |
your |
|
Fill-in (4) |
|
|
Choice 1 |
hospital |
|
Choice 2 |
medical |
|
Choice 3 |
hospital and medical |
|
Fill-in (5) |
|
|
Choice 1 |
MMCCYY |
|
Choice 2 |
MMCCYY and MMCCYY |
|
Choice 3 |
MMCCYY through MMCCYY |
HIB104 – LIMITED ST BUY-IN/BUY-OUT NO CHANGE IN COVERAGE
This does not change our records, which show that (1) Medicare (2) insurance coverage.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
he currently has |
|
Choice 2 |
she currently has |
|
Choice 3 |
you currently have |
|
Choice 4 |
he does not currently have |
|
Choice 5 |
she does not currently have |
|
Choice 6 |
you do not currently have |
|
Fill-in (2) |
|
|
Choice 1 |
hospital |
|
Choice 2 |
medical |
|
Choice 3 |
hospital and medical |
HIB105 – RETRO BUYIN/BUYOUT PAST DUE PREMIUMS
Our records also show that (1) premiums through (2).
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
he still owes |
|
Choice 2 |
she still owes |
|
Choice 3 |
you still owe |
|
Fill-in (2) |
MMCCYY |
HIB106 – STATE BUYIN FOR SMI PREMIUM PENALTY ONLY
We must charge a premium penalty on (1) Medicare medical insurance because (2) enrolled later than (3) could have. (4) State or local government retirement system will pay (5) medical insurance late enrollment premium penalty beginning (6). However, (7) must pay the basic Medicare medical insurance premium.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
BGN plus 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) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (6) |
MM/YYYY |
|
Fill-in (7) |
|
|
Choice 1 |
he |
|
Choice 2 |
she |
|
Choice 3 |
you |
HIB107 – STATE STOPS PAYING SMI PREMIUM PENALTY
(1) State or local government retirement system will no longer pay (2) Medicare medical insurance late enrollment premium penalty after (3). (4) must pay the basic premium and the penalty beginning (5).
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
BGN plus BLN (possessive) |
|
Choice 2 |
Your |
|
Fill-in (2) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (4) |
show date in MMCCYY format |
|
Fill-in (5) |
|
|
Choice 1 |
He |
|
Choice 2 |
She |
|
Choice 3 |
You |
|
Fill-in (6) |
show date in MMCCYY format |
HIB108 – GROUP PAYER BUY-OUT
The organization that was paying (1) Medicare (2) insurance premium will no longer pay it after (3). (4) must pay the premium beginning (5).
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
BGN plus BLN (possessive) |
|
Choice 2 |
your |
|
Fill-in (2) |
|
|
Choice 1 |
hospital |
|
Choice 2 |
medical |
|
Choice 3 |
hospital and medical |
|
Fill-in (3) |
show date in MMCCYY format |
|
Fill-in (4) |
|
|
Choice 1 |
He |
|
Choice 2 |
She |
|
Choice 3 |
You |
|
Fill-in (5) |
Show date in MMCCYY format |
HIB109 – 3RD Party SMI PREMIUM DEDUCTED FROM MBA
We will deduct the (1) of (2) from (3) monthly payment. Later in this letter, we tell (4) what to do if (5) with this change in the amount of (6) monthly payment.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
Medicare medical insurance premium |
|
Fill-in (2) |
SMI premium amount in $9999.99 format |
|
Fill-in (3) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (4) |
|
|
Choice 1 |
him |
|
Choice 2 |
her |
|
Choice 3 |
you |
|
Fill-in (5) |
|
|
Choice 1 |
he disagrees |
|
Choice 2 |
she disagrees |
|
Choice 3 |
you disagree |
|
Fill-in (6) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
HIB110 – SMI PREMIUM DEDUCTED FROM MBA PAST DUE PREMIUMS
We will deduct the (1) of (2) from (3) monthly payment. We will also deduct the past due premiums, which total (4). Later in this letter, we tell (5) what to do if (6) with this change in the amount of (7) monthly payment.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
Medicare medical insurance premium |
|
Fill-in (2) |
SMI premium amount in $9999.99 format |
|
Fill-in (3) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (4) |
premium amount due in 99999.99 format |
|
Fill-in (5) |
|
|
Choice 1 |
him |
|
Choice 2 |
her |
|
Choice 3 |
you |
|
Fill-in (6) |
|
|
Choice 1 |
he disagrees |
|
Choice 2 |
she disagrees |
|
Choice 3 |
you disagree |
|
Fill-in (7) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
HIB111 – BUY-IN AND REFUND OF MEDICARE PREMIUMS
This is the money due (1) for the Medicare insurance premiums that (2) already paid.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
him |
|
Choice 2 |
her |
|
Choice 3 |
you |
|
Fill-in (2) |
|
|
Choice 1 |
he |
|
Choice 2 |
she |
|
Choice 3 |
you |
HIB112 – BUYIN PREMIUM NO LONGER DEDUCTED FROM MBA
We will no longer deduct the premium from (1) monthly payment. Later in this letter, we tell (2) what to do if (3) with this change in the amount of (4) monthly payment.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (2) |
|
|
Choice 1 |
you |
|
Fill-in (3) |
|
|
Choice 1 |
you disagree |
|
Fill-in (4) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
HIB113 – BUY-OUT NOT IN PAY STATUS PREMIUM BILLING
We will send (1) first bill for the (2) within a month. The monthly (3) (4). (5) Please contact us if (6) not receive the first bill within a month.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
BGN plus BLN (possessive) |
|
Choice 2 |
BGN (possessive) |
|
Choice 3 |
your |
|
Fill-in (2) |
|
|
Choice 1 |
Medicare hospital insurance premium |
|
Choice 2 |
Medicare medical insurance premium |
|
Choice 3 |
Medicare hospital and medical insurance premiums |
|
Fill-in (3) |
|
|
Choice 1 |
premium is |
|
Choice 2 |
premiums total |
|
Fill-in (4) |
money amount in format 999,999.99 |
|
Fill-in (5) |
|
|
Choice 1 |
After that, we will bill him each month for this premium. (Use in Medicare Part A and combined Part A and Part B billing.) |
|
Choice 2 |
After that, we will bill her each month for this premium. (Use in Medicare Part A and combined Part A and Part B billing.) |
|
Choice 3 |
After that, we will bill you each month for this premium. (Use in Medicare Part A and combined Part A and Part B billing.) |
|
Choice 4 |
Each bill after that will be for a 3-month period. (Use in Medicare Part B billing situations including those which include a premium penalty.) |
|
Fill-in (6) |
|
|
Choice 1 |
he does |
|
Choice 2 |
she does |
|
Choice 3 |
you do |
HIB114 – BENEFITS TERM PROFRA MEDICARE CONTINUES
(1) Medicare coverage will continue because (2) age 65 or older.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
BGN plus BLN (possessive) |
|
Choice 2 |
Your |
|
Fill-in (2) |
|
|
Choice 1 |
he is |
|
Choice 2 |
she is |
|
Choice 3 |
you are |
HIB115 – HI/SMI BUY-OUT
If (1) to cancel this insurance, please contact the local Social Security office at the telephone number and address shown below. Remember that the date (2) insurance coverage ends depends on when (3) it:
If (4) it within 30 days from the date of this notice, (5) coverage will end at the same time the State stopped paying the premiums.
If (6) it after 30 days but within six months of when the State stopped paying the premiums, coverage will stop at the end of the same month in which (7) us.
If (8) more than 6 months to contact us, coverage will stop at the end of the month after the month in which (9) us.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
BGN plus BLN plus “wants” |
|
Choice 2 |
you want |
|
Fill-in (2) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (3) |
|
|
Choice 1 |
he cancels |
|
Choice 2 |
she cancels |
|
Choice 3 |
you cancel |
|
Fill-in (4) |
|
|
Choice 1 |
he cancels |
|
Choice 2 |
she cancels |
|
Choice 3 |
you cancel |
|
Fill-in (5) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (6) |
|
|
Choice 1 |
he cancels |
|
Choice 2 |
she cancels |
|
Choice 3 |
you cancel |
|
Fill-in (7) |
|
|
Choice 1 |
he contacts |
|
Choice 2 |
she contacts |
|
Choice 3 |
you contact |
|
Fill-in (8) |
|
|
Choice 1 |
he waits |
|
Choice 2 |
she waits |
|
Choice 3 |
you wait |
|
Fill-in (9) |
|
|
Choice 1 |
he contacts |
|
Choice 2 |
she contacts |
|
Choice 3 |
you contact |
HIB119 – BILLING TO CONFIRM GROUP PAYER
(1) recently arranged for an organization to pay (2) Medicare (3) insurance premium. Although we will send the bills to this organization, (4) responsible for seeing that they are paid.
If this organization decides to stop paying (5) premium, we will again send the bills to (6).
If there is any other change in (7) Medicare premium, we will let (8) know.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
BGN plus BLN |
|
Choice 2 |
You |
|
Fill-in (2) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (3) |
|
|
Choice 1 |
hospital |
|
Choice 2 |
medical |
|
Choice 3 |
hospital and medical |
|
Fill-in (4) |
|
|
Choice 1 |
he is |
|
Choice 2 |
she is |
|
Choice 3 |
you are |
|
Fill-in (5) Choice 1 Choice 2 Choice 3 |
his her your |
|
Fill-in (6) |
|
|
Choice 1 |
him |
|
Choice 2 |
her |
|
Choice 3 |
you |
|
Fill-in (7) |
|
|
Choice 1 |
BGN plus BLN (possessive) |
|
Choice 2 |
your |
|
Fill-in (8) |
|
|
Choice 1 |
him |
|
Choice 2 |
her |
|
Choice 3 |
you |
HIB120 – BUY-OUT FOR HI AND SMI
(1) can cancel hospital insurance coverage and keep medical insurance coverage, or cancel both. However, (2) cannot keep hospital insurance coverage without medical insurance coverage. So if (3) medical insurance coverage, hospital insurance coverage will end at the same time.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
He |
|
Choice 2 |
She |
|
Choice 3 |
You |
|
Fill-in (2) |
|
|
Choice 1 |
he |
|
Choice 2 |
she |
|
Choice 3 |
you |
|
Fill-in (3) |
|
|
Choice 1 |
he cancels |
|
Choice 2 |
she cancels |
|
Choice 3 |
you cancel |
HIB131 – MEDICARE CONTINUES BASED ON AGE, DIB, OR ESRD
However, Medicare coverage will continue because (1) (2).
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
he is |
|
Choice 2 |
she is |
|
Choice 3 |
you are |
|
Choice 4 |
he has |
|
Choice 5 |
she has |
|
Choice 6 |
you have |
|
Fill-in (2) |
|
|
Choice 1 |
disabled |
|
Choice 2 |
over age 65 |
|
Choice 3 |
end stage renal disease |
HIB132 – ESRD TERMINATES AND RRB JURISDICTION
However, since the Railroad Retirement Board (RRB) handles (1) hospital and medical insurance (2) Medicare coverage will continue unless the RRB tells (3) they are stopping (4) coverage.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (2) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (3) |
|
|
Choice 1 |
him |
|
Choice 2 |
her |
|
Choice 3 |
you |
|
Fill-in (4) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
HIB133 – ESRD TERMINATION - SAME HI/SMI TERMINATION DATES
We are writing to tell (1) that Medicare coverage based on (2) kidney condition ends with the last day of (3).
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
BGN plus BLN (not possessive) |
|
Choice 2 |
you |
|
Fill-in (2) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (3) |
Show HI-TERM date minus 1 month in MMCCYY format |
HIB134 – ESRD TERM HI TERM DATE EARLIER THAN SMI TERM DATE
We are writing to tell (1) that (2) hospital insurance coverage ended on the last day of (3). (4) medical insurance coverage will end on the last day of (5).
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
BGN plus BLN (not possessive) |
|
Choice 2 |
you |
|
Fill-in (2) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (3) |
Show HI-TERM date minus 1 month in MMCCYY format |
|
Fill-in (4) |
|
|
Choice 1 |
His |
|
Choice 2 |
Her |
|
Choice 3 |
Your |
|
Fill-in (5) |
Show SMI-TERM date minus 1 month in MMCCYY format |
HIB135 – ESRD TERM HI TERM DATE EARLIER THAN SMI TERM DATE
Medicare coverage based on a kidney condition usually ends the last day of the (1) month after the month (2) unless before then (3) again:
(4) regular dialysis, or
(5) a kidney transplant
Since (6) in (7), (8) Medicare coverage should have ended the last day of (9). (10) hospital insurance did end on that date. But, because we didn't take action in time, we must continue (11) medical insurance coverage until the date shown above.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
12th |
|
Choice 2 |
36th |
|
Fill-in (2) |
|
|
Choice 1 |
he gets a transplant |
|
Choice 2 |
she gets a transplant |
|
Choice 3 |
you get a transplant |
|
Choice 4 |
regular dialysis stops |
|
Fill-in (3) |
|
|
Choice 1 |
he |
|
Choice 2 |
she |
|
Choice 3 |
you |
|
Fill-in (4) |
|
|
Choice 1 |
begins |
|
Choice 2 |
begin |
|
Fill-in (5) |
|
|
Choice 1 |
gets |
|
Choice 2 |
get |
|
Fill-in (6) |
|
|
Choice 1 |
he got a kidney transplant |
|
Choice 2 |
she got a kidney transplant |
|
Choice 3 |
you got a kidney transplant |
|
Choice 4 |
his dialysis stopped |
|
Choice 5 |
her dialysis stopped |
|
Choice 6 |
your dialysis stops |
|
Fill-in (7) |
|
|
Choice 1 |
Show KDNY-TRNSDATE date in MMCCYY format |
|
Choice 2 |
Show DLYS-STOP date in MMCCYY format |
|
Fill-in (8) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (9) |
Show HI-TERM date minus 1 month in format MMCCYY |
|
Fill-in (10) |
|
|
Choice 1 |
His |
|
Choice 2 |
Her |
|
Choice 3 |
Your |
|
Fill-in (11) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
HIB136 – TERMINATION OF ESRD COVERAGE
Let us know right away if (1) regular dialysis again or (2) a kidney transplant so (3) can file a new claim for Medicare coverage based on (4) kidney condition.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
he resumes |
|
Choice 2 |
she resumes |
|
Choice 3 |
you resume |
|
Fill-in (2) |
|
|
Choice 1 |
gets |
|
Choice 2 |
get |
|
Fill-in (3) |
|
|
Choice 1 |
he |
|
Choice 2 |
she |
|
Choice 3 |
you |
|
Fill-in (4) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
HIB137 – ESRD TERMINATES SAME HI/SMI TERMINATION DATES
Medicare coverage based on a kidney condition ends the last day of the (1) month after (2), unless before then (3):
a kidney transplant, or
resume regular dialysis.
Our records show that (4) (5) (6).
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
12th |
|
Choice 2 |
36th |
|
Fill-in (2) |
|
|
Choice 1 |
regular dialysis stops |
|
Choice 2 |
a kidney transplant |
|
Fill-in (3) |
|
|
Choice 1 |
he gets |
|
Choice 2 |
she gets |
|
Choice 3 |
you get |
|
Fill-in (4) |
|
|
Choice 1 |
he |
|
Choice 2 |
she |
|
Choice 3 |
you |
|
Fill-in (5) |
|
|
Choice 1 |
stopped regular dialysis |
|
Choice 2 |
received a kidney transplant |
|
Fill-in (6) |
|
|
Choice 1 |
Show DLYS-STOP date for the latest DLYS occurrence on the POST-MBR in format MMCCYY |
|
Choice 2 |
Show KDNY-TRNSDATE date for the latest KDNY occurrence on the POST-MBR in format MMCCYY |
HIB142 – CURRENT PAY TO SUSPENSE OR DEFERRED STATUS
We will continue to charge a monthly premium for (1) medical insurance under Medicare.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
BGN plus BLN (possessive) |
|
Choice 2 |
your |
HIB143 – SMI PENALTY RATE TO BASE RATE AT AGE 65
Under a special provision of the Social Security Act, now that (1) (2) for Medicare medical insurance based on (3) age, (4) monthly medical insurance premium amount has been reduced from (5) to (6).
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
BGN plus BLN (not possessive) |
|
Choice 2 |
you |
|
Fill-in (2) |
|
|
Choice 1 |
qualifies |
|
Choice 2 |
qualify |
|
Fill-in (3) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (4) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (5) |
Show the SMI premium penalty rate |
|
Fill-in (6) |
Show the SMI premium base rate |
HIB151 – LIMITED BUY-IN/BUY-OUT - COVERAGE CONTINUES
(1) must pay the premium beginning (2).
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
You |
|
Choice 2 |
He |
|
Choice 3 |
She |
|
Fill-in (2) |
MMCCYY |
HIB154 – EXPLANATION OF BENFITS WHEN MEDICARE IS THE SECONDARY PAYER WHEN THE BENEFICARY IS WORKING AND COVERED BY HIS OR HER EMPLOYER
(1) working for an employer who has 20 or more employees? (2) covered under this employer's group health plan? If so, the employer's plan will pay first for health care services. Medicare will pay secondary benefits when the employer's plan doesn't cover all of the expenses.
Contact your nearest Social Security office for more information about Part B Medicare special enrollment.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
The word 'Is' BGN plus BLN |
|
Choice 2 |
Are you |
|
Fill-in (2) |
|
|
Choice 1 |
Is he |
|
Choice 2 |
Is she |
|
Choice 3 |
Are you |
HIB157 – PIC C'S NOTICE WHEN CHILD < AGE 19 AND NO OPEN HI
If this notice is for a child under age 19 who is not covered by health insurance, there is a Children's Health Insurance Program that may help. To find out more, you can look on the Internet at (1) or call, toll free, 1-877-KIDS-NOW (1-877-543-7669). The number connects you to your state program.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
HIB160 – HI/SMI REVERSAL - NOT TIMELY BUT IN GEP
We received (1) cancellation of (2) earlier request that (3) Medicare (4) insurance coverage be terminated. Although this cancellation request was filed too late for the coverage to be reinstated without interruption, it was filed during a period in which (5) could reenroll. This difference is important because there are months for which (6) not have Medicare (7) insurance coverage.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
BGN plus 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 |
|
Fill-in (4) |
|
|
Choice 1 |
hospital |
|
Choice 2 |
medical |
|
Choice 3 |
hospital and medical |
|
Fill-in (5) |
|
|
Choice 1 |
he |
|
Choice 2 |
she |
|
Choice 3 |
you |
|
Fill-in (6) |
|
|
Choice 1 |
he does |
|
Choice 2 |
she does |
|
Choice 3 |
you do |
|
Fill-in (7) |
|
|
Choice 1 |
hospital |
|
Choice 2 |
medical |
|
Choice 3 |
hospital and medical |
HIB161 – HI/SMI REVERSAL NOT FILED TIMELY NOT IN GEP
We stopped (1) Medicare (2) insurance at (3) request. Then (4) decided that (5) still wanted it. (6) decided too late for us to start (7) Medicare (8) insurance again at this time.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
BGN plus BLN (possessive) |
|
Choice 2 |
your |
|
Fill-in (2) |
|
|
Choice 1 |
hospital |
|
Choice 2 |
medical |
|
Choice 3 |
hospital and medical |
|
Fill-in (3) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (4) |
|
|
Choice 1 |
he |
|
Choice 2 |
she |
|
Choice 3 |
you |
|
Fill-in (5) |
|
|
Choice 1 |
he |
|
Choice 2 |
she |
|
Choice 3 |
you |
|
Fill-in (6) |
|
|
Choice 1 |
He |
|
Choice 2 |
She |
|
Choice 3 |
You |
|
Fill-in (7) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (8) |
|
|
Choice 1 |
hospital |
|
Choice 2 |
medical |
|
Choice 3 |
hospital and medical |
HIB162 – REFUSAL OVER AUTOMATIC ENROLLMENT
(1) told us that (2) not want (3) insurance under Medicare.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
BGN plus BLN (not possessive) |
|
Choice 2 |
You |
|
Fill-in (2) |
|
|
Choice 1 |
he does |
|
Choice 2 |
she does |
|
Choice 3 |
you do |
|
Fill-in (3) |
|
|
Choice 1 |
hospital |
|
Choice 2 |
medical |
|
Choice 3 |
hospital and medical |
HIB163 – SMI REFUSAL CURRENT PAY REFUND OF PREMIUMS
(1) not have to pay a premium for any months (2) not entitled to Medicare Part B (medical insurance). If we took out premiums for any of these months, we will return the money to (3).
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
You do |
|
Choice 2 |
BGN plus BLN plus does |
|
Fill-in (2) |
|
|
Choice 1 |
you were |
|
Choice 2 |
he was |
|
Choice 3 |
she was |
|
Fill-in (3) |
|
|
Choice 1 |
you |
|
Choice 2 |
him |
|
Choice 3 |
her |
HIB164 – SMI REFUSAL PREMIUM BILLING AND NO OPEN THIRD PARTY
Since our records were previously annotated to show that (1) enrolled for Medicare (2) insurance, a premium billing notice may have been prepared for mailing to (3). If (4) a billing notice, (5) should destroy it.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
he was |
|
Choice 2 |
she was |
|
Choice 3 |
you were |
|
Fill-in (2) |
|
|
Choice 1 |
hospital |
|
Choice 2 |
medical |
|
Choice 3 |
hospital and medical |
|
Fill-in (3) |
|
|
Choice 1 |
him |
|
Choice 2 |
her |
|
Choice 3 |
you |
|
Fill-in (4) |
|
|
Choice 1 |
he receives |
|
Choice 2 |
she receives |
|
Choice 3 |
you receive |
|
Fill-in (5) |
|
|
Choice 1 |
he |
|
Choice 2 |
she |
|
Choice 3 |
you |
HIB165 – REFUSAL/WITHDRAWAL STATE BUY-IN ESTABLISHED
Our records show that (1) State has agreed to pay the premiums for (2) Medicare (3) insurance coverage. Therefore, (4) will continue to be enrolled.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (2) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (3) |
|
|
Choice 1 |
hospital |
|
Choice 2 |
medical |
|
Choice 3 |
hospital and medical |
|
Fill-in (4) |
|
|
Choice 1 |
he |
|
Choice 2 |
she |
|
Choice 3 |
you |
HIB175 – SMI PREMIUMS/ARREARAGE DEDUCTED FROM PMA OR CMA
We are deducting past-due premiums from (1) check.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
Beneficiary's full name (possessive) |
|
Choice 2 |
your |
HIB176 – SMI PREMIUMS/ARREARAGE DEDUCTED FROM PMA OR CMA WHEN BENEFITS ARE RESUMED
Since benefits are again payable we will resume withholding (1) medical premiums due to date.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
BGN plus BLN (possessive) |
|
Choice 2 |
your |
HIB182 – IRMAA AMOUNT STARTS, IRMAA AMOUNT CHANGES OR IRMAA AMOUNT NO LONGER APPLIED TO SMI PREMIUM (PART B)
In an earlier letter, we told you that (1) Medicare Part B
(medical insurance) premium includes:
the standard Part B premium amount,
any surcharge that may apply for late enrollment or reenrollment, and
an income-related monthly adjustment amount (IRMAA).
If (2) prescription drug coverage, (3) also must pay a prescription drug coverage IRMAA. The IRMAA is in addition to (4) monthly premium. We base the IRMAA on (5) income. We deduct the IRMAA from (6) monthly Social Security benefits, regardless of how (7) premiums.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
your |
|
Choice 2 |
BGN plus BLN (possessive) |
|
Fill-in (2) |
|
|
Choice 1 |
you have |
|
Choice 2 |
she has |
|
Choice 3 |
he has |
|
Fill-in (3) |
|
|
Choice 1 |
you |
|
Choice 2 |
she |
|
Choice 3 |
he |
|
Fill-in (4) |
|
|
Choice 1 |
your |
|
Choice 2 |
her |
|
Choice 3 |
his |
|
Fill-in (5) |
|
|
Choice 1 |
your |
|
Choice 2 |
her |
|
Choice 3 |
his |
|
Fill-in (6) |
|
|
Choice 1 |
your |
|
Choice 2 |
her |
|
Choice 3 |
his |
|
Fill-in (7) |
|
|
Choice 1 |
you pay your |
|
Choice 2 |
he pays his |
|
Choice 3 |
she pays her |
HIB183 – USE WITH HIB182 WHEN IRMAA AFFECTS PART B RATE
We sent (1) another letter that explained how we determined the amount of (2) premium.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
him |
|
Choice 2 |
her |
|
Choice 3 |
you |
|
Fill-in (2) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
HIB184 – USE WITH HIB182 WHEN BENEFICIARY WILL CONTINUE TO BE BILLED FOR PART B SMI PREMIUMS
We will continue to bill (1) for (2) Medicare Part B premiums.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
him |
|
Choice 2 |
her |
|
Choice 3 |
you |
|
Fill-in (2) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
HIB185 – USE WHEN HIB182 IS GENERATED AS THE INTRODUCTORY UTI AND BENEFICIARY'S LAF IS CURRENT PAY OR DEFERRED
The amount you will receive around (1) was changed because of a change in (2) monthly Medicare Part B premium.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
using the PCI show the calendar date of the COM check |
|
Choice 2 |
using the PCI show the calendar date of the DPD check |
|
Fill-in (2) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
HIB186 – SMI MATURITY AND NO IRMAA DATA ON POST MBR
IMPORTANT: A Medicare law requires some higher income persons to pay higher premiums. The law applies to premiums for Medicare Part B (medical insurance) and prescription drug coverage. The law generally affects individuals with incomes higher than (1) and couples with incomes higher than (2). We will contact the Internal Revenue Service to get information about (3) income. If we decide that (4) to pay higher premiums, we will send a letter explaining our decision. The higher amount will be effective (5). For more information, please visit www.socialsecurity.gov on the Internet or call us toll-free at 1-800-772-1213 (TTY 1-800-325-0778).
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
Show the IRMAA level 1 yearly amount for singles |
|
Fill-in (2) |
Show the IRMAA level 1 yearly amount for couples |
|
Fill-in (3) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (4) |
|
|
Choice 1 |
he has |
|
Choice 2 |
she has |
|
Choice 3 |
you have |
|
Fill-in (5) |
show the SMI START date |
HIB215 – T2 BENEFITS TERMINATE HI/SMI TERMINATES
Since (1) no longer entitled to monthly Social Security benefits, we are stopping (2) (3) insurance coverage under Medicare. (4) (5) insurance coverage ends on the last day of (6). Please destroy (7) Medicare card after the coverage ends.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
he is |
|
Choice 2 |
she is |
|
Choice 3 |
you are |
|
Fill-in (2) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (3) |
|
|
Choice 1 |
hospital |
|
Choice 2 |
hospital and medical |
|
Fill-in (4) |
|
|
Choice 1 |
His |
|
Choice 2 |
Her |
|
Choice 3 |
Your |
|
Fill-in (5) |
|
|
Choice 1 |
hospital |
|
Choice 2 |
hospital and medical |
|
Fill-in (6) |
Show HI-TERM date in format MMCCYY |
|
Fill-in (7) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
HIB225 – HRFST LESSDO MBA LESS THAN SMI PREMIUM
(1) monthly medical insurance premium is (2). The monthly benefit that (3) should get is less than (4) medical insurance premiums. We are stopping (5) monthly benefits starting (6) to pay for part of this premium. After adjusting for (7) monthly benefits, we find that we must bill (8) for (9).
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
BGN plus BLN (possessive) |
|
Choice 2 |
Your |
|
Fill-in (2) |
Show the current SMI premium amount |
|
Fill-in (3) |
|
|
Choice 1 |
BGN plus BLN (not possessive) |
|
Choice 2 |
you |
|
Fill-in (4) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (5) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (6) |
Show the first EFD in HIST Data that corresponds to LESSDO |
|
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) |
Show money amount for the remaining premiums |
HIB226 – HRFST LESSDO MBA > SMI BUT LESS THAN A DOLLAR
We are stopping (1) monthly benefit starting (2). When we take (3) monthly medical insurance premium of (4) from (5) monthly benefit, the amount left is less than a dollar. At the end of the year, we will adjust (6) record and pay all money (7) due.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
BGN plus BLN (possessive) |
|
Choice 2 |
your |
|
Fill-in (2) |
Show the first EFD in HIST Data that corresponds to LESSDO |
|
Fill-in (3) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (4) |
Show current SMI premium amount |
|
Fill-in (5) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (6) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (7) |
|
|
Choice 1 |
he is |
|
Choice 2 |
she is |
|
Choice 3 |
you are |
HIB248 – PREMIUM HI REDUCTION WHEN 30 QUARTERS ATTAINED NO OPEN ENTITLEMENT TO PREMIUM HI
Currently, (1) not eligible for free Medicare hospital insurance. However, (2) may be eligible to buy hospital insurance for the reduced premium of (3) per month. You can get more information about this hospital insurance by contacting any Social Security office.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
BGN plus BLN plus the word “is” |
|
Choice 2 |
you are |
|
Fill-in (2) |
he / she / you |
|
Choice 1 |
he |
|
Choice 2 |
she |
|
Choice 3 |
you |
|
Fill-in (3) |
Show the premium HI amount that pertains to the HIRE-30QTR date in HIRE data in the format $$$$¢¢ |
HIB249 – OFFER RELIEF FOR SMI PREMIUMS (VSMI RATES)
If you want your medical insurance to start earlier, you can choose to have it start in (1). To start your medical insurance earlier, you must do the following things within 60 days after the date of this notice:
tell us in writing that you want medical insurance beginning (2);
AND
pay us (3) or tell us we can withhold this amount from your check. This amount covers the premiums due from (4) through (5).
If you would find it hard to pay the premium amount you would owe in a lump sum, ask us about other ways to pay the premium.
If you choose to have your medical insurance start in (6), your current monthly premium will be (7). If you do not choose the earlier date, your monthly premium will be (8).
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
Show the SMI-NONEQRELST date |
|
Fill-in (2) |
Show the SMI-NONEQRELST date |
|
Fill-in (3) |
Show the total amount of the SMI premiums |
|
Fill-in (4) |
Show the SMI-NONEQRELST date |
|
Fill-in (5) |
Show the current operating month date |
|
Fill-in (6) |
Show the SMI-NONEQRELST date |
|
Fill-in (7) |
Show the current VSMI rate |
|
Fill-in (8) |
Show the current Part B premium rate |
HIB260 – PREMIUM RELIEF ESTABLISHED DUE TO IRMAA B AND/OR IRMAA D
As we told you in another letter, you owe more Medicare premiums because (1) income-related monthly adjustment amounts changed.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
BGN plus BLN (possessive) |
|
Choice 2 |
your |
HIB261 – PREMIUM RELIEF ESTABLISHED DUE TO IRMAA B
You owe (1) for Medicare Part B (medical insurance) premiums for (2) (3) (4).
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
Show the total amount of the SMI arrearages for IRMAA B in the format $$$$$$¢¢ |
|
Fill-in (2) |
Show the RLF-START date in the first occurrence of Premium Relief data in the format November 2009 |
|
Fill-in (3) |
|
|
Choice 1 |
null |
|
Choice 2 |
and |
|
Choice 3 |
through |
|
Fill-in (4) |
|
|
Choice 1 |
Null |
|
Choice 2 |
Show the RLF-STOP date in the last occurrence of Premium Relief data in the format November 2009 |
HIB262 – PREMIUM RELIEF ESTABLISHED DUE TO IRMAA D
You owe (1) for Medicare prescription drug coverage income-related monthly adjustment amounts for (2) (3) (4).
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
Show the total amount of IRMAA D equitable relief arrearages in the format $$$$$$¢¢ |
|
Fill-in (2) |
Show the RLF-START date in the first occurrence of Premium Relief data in the format November 2009 |
|
Fill-in (3) |
|
|
Choice 1 |
null |
|
Choice 2 |
and |
|
Choice 3 |
through |
|
Fill-in (4) |
|
|
Choice 1 |
Null |
|
Choice 2 |
Show the RLF-STOP date in the last occurrence of Premium Relief data in the format November 2009 |
HIB263 – PREMIUM RELIEF ESTABLISHED DUE TO IRMAA B AND ALSO IRMAA D
The total past-due Medicare amounts you owe are (1).
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
Show the sum of the total amount of the IRMAA B equitable relief arrearages plus the total amount of the IRMAA D equitable relief arrearages in the format $$$$$$¢¢ |
HIB264 – PREMIUM RELIEF ESTABLISHED - ALTERNATIVES TO FULL WITHHOLDING OF BENEFITS
If you would find it hard to pay the past-due Medicare amounts (1) at one time, please ask us about other ways to pay them. You may ask for waiver of these past-due Medicare amounts if paying them would be a severe financial hardship for you. If we do not hear from you within 30 days after the date of this letter, we will take the Medicare amounts (2) out of (3) monthly Social Security payments beginning (4).
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
he owes |
|
Choice 2 |
she owes |
|
Choice 3 |
you owe |
|
Fill-in (2) |
|
|
Choice 1 |
he owes |
|
Choice 2 |
she owes |
|
Choice 3 |
you owe |
|
Fill-in (3) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (4) |
Show the current operating month (COM) plus 2 months in the format July 2009 |
HIB265 – DEDUCTION OF CURRENT SMI PREMIUMS
We will deduct (1) current Medicare Part B (medical insurance) premium from (2) monthly Social Security payments beginning (3).
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
BGN plus BLN possessive |
|
Choice 2 |
your |
|
Fill-in (2) |
|
|
Choice 1 |
his |
|
Choice 2 |
her |
|
Choice 3 |
your |
|
Fill-in (3) |
Show the current operating month (COM) plus 2 months in the format July 2009 |
HIB266 – FULL WITHHOLDING OF PART B RELIEF PREMIUMS WHEN CURRENT SMI PREMIUMS ARE ALSO DEDUCTED
We will also deduct (1) for past-due Medicare Part B (medical insurance) premiums.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
Show the sum of the RCVBL-TOTAMT for current PART B only arrearages in the format $$$$$$¢¢ |
HIB267 – FULL WITHHOLDING OF IRMAA D RELIEF PREMIUMS WHEN CURRENT SMI PREMIUMS ARE BEING DEDUCTED
We will also deduct (1) for past-due Medicare prescription drug coverage income-related monthly adjustment amounts.
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
Show the sum of the RCVBL-TOTAMT for current IRMAA D only arrearages in the format $$$$$$¢¢ |
HIB268 – FULL WITHHOLDING OF IRMAA D RELIEF PREMIUMS WHEN NO CURRENT SMI PREMIUMS BEING DEDUCTED
We will deduct past-due Medicare prescription drug coverage income-related monthly adjustment amounts from your monthly Social Security payments beginning (1). The total amount we will deduct is (2).
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
Show the current operating month (COM) in the format July 2009 |
|
Fill-in (2) |
Show the sum of the IRMAA D arrearages in the format $$$$$$¢¢ |
HIB269 – FULL WITHHOLDING CONTINUES UNTIL PREMIUMS PAID IN FULL
We will withhold (1) monthly payments until you have paid all of the past-due Medicare amounts (2).
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
|
|
Choice 1 |
BGN plus BLN (possessive) |
|
Choice 2 |
your |
|
Fill-in (2) |
|
|
Choice 1 |
he owes |
|
Choice 2 |
she owes |
|
Choice 3 |
you owe |
HIB270 – FULL WITHHOLDING OF PART B RELIEF PREMIUMS WHEN NO CURRENT SMI PREMIUMS BEING DEDUCTED
We will deduct past-due Medicare Part B (medical insurance) premiums from your monthly Social Security payments beginning (1). The total amount we will deduct is (2).
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
Show the current operating month (COM) in the format July 2009 |
|
Fill-in (2) |
Show the sum of the IRMAA B arrearages in the format $$$$$$¢¢ |
HIB271 – PARTIAL RECOVERY OF PART B OR IRMAA D RELIEF PREMIUMS
We will deduct past-due Medicare Part B (medical insurance) premiums from your monthly Social Security payments beginning (1). The total amount we will deduct is (2).
|
Fill-in values: |
|
|---|---|
|
Fill-in (1) |
Add the RCVBL-PARTAMT for each occurrence and show this sum in the format $$$$$$¢¢ |
|
Fill-in (2) |
|
|
Choice 1 |
BGN plus BLN (possessive) |
|
Choice 2 |
your |
|
Fill-in (3) |
Show the current operating month (COM) in the format July 2009 |
|
Fill-in (4) |
Add the RCVBL-PARTAMT for each occurrence and show this sum in the format $$$$$$¢¢ |
HIB288 – SUBSEQUENT NOTICE WITH CMS BILLING STATEMENT AND INSTRUCTIONS FOR COMPLETING THE PAYMENT COUPON
We told you in another letter your Centers for Medicare & Medicaid Services (CMS) Billing Statement would be mailed in another envelope. At the end of this letter, you will find the CMS Billing Statement and instructions for completing the payment coupon.
HIB289 – (CMS) BILLING STATEMENT WILL BE MAILED IN ANOTHER ENVELOPE
Your Centers for Medicare & Medicaid Services (CMS) Billing Statement will be mailed in another envelope.