POMS Reference

This change was made on Jun 28, 2018. See latest version.
Text removed
Text added

NL 00720.180: HIB Health Insurance Benefits

changes
*
  • Effective Dates: 09/13/2017 - Present
  • Effective Dates: 06/28/2018 - Present
  • TN 8 (09-17)
  • TN 9 (06-18)
  • NL 00720.180 HIB Health Insurance Benefits
  • HIB002 TEMPORARY SUBSTITUTION OF NOTICE FOR HEALTH INSURANCE CARD (H23)
  • (Requested/Generated)
  • Caption: Information About Medicare
  • We will send  (1)  a Medicare card.  (2)  should take this card with  (3)  when  (4)   (5)  medical care. If  (6)   (7)  medical care before receiving the card and  (8)  coverage has already begun, use this letter as proof that  (9)  covered by Medicare.
  •  (1)  will get a Medicare card within 2 weeks.  (2)  show this card when  (3)  medical care. To learn more about what Medicare covers, visit Medicare.gov. If  (4)  questions about  (5)  Medicare coverage, call 1-800-MEDICARE (1-800-633-4227).
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: Ms. plus Beneficiary's Last Name
  • Choice 2: Mr. plus Beneficiary's Last Name
  • Choice 3: Beneficiary's First Name
  • Choice 4: Beneficiary's Name
  • Choice 1: You
  • Choice 5: you
  • Choice 2: Beneficiary's Name
  • Fill-in (2) - Systems Generated
  • Choice 1: She
  • Choice 1: You should
  • Choice 2: He
  • Choice 2: He should
  • Choice 3: You
  • Choice 3: She should
  • Fill-in (3) - Systems Generated
  • Choice 1: her
  • Choice 1: you need
  • Choice 2: him
  • Choice 2: he needs
  • Choice 3: you
  • Choice 3: she needs
  • Fill-in (4) - Systems Generated
  • Choice 1: she
  • Choice 1: you have
  • Choice 2: he
  • Choice 2: he has
  • Choice 3: you
  • Choice 3: she has
  • Fill-in (5) - Systems Generated
  • Choice 1: need
  • Choice 2: needs
  • Fill-in (6) - Systems Generated
  • Choice 1: she
  • Choice 2: he
  • Choice 3: you
  • Fill-in (7) - Systems Generated
  • Choice 1: need
  • Choice 2: needs
  • Fill-in (8) - Systems Generated
  • Choice 1: her
  • Choice 1: your
  • Choice 2: his
  • Choice 3: your
  • Fill-in (9) - Systems Generated
  • Choice 1: she is
  • Choice 2: he is
  • Choice 3: you are
  • Choice 3: her
  • HIB003 MEDICAL CLAIMANT ENROLLED BEFORE INITIAL ENROLLMENT PERIOD (H42)
  • (Requested)
  • Caption: Information About Medicare
  •  (1)  not entitled to  (2)  under Medicare because  (3)  application was filed too soon.  (4)  may apply again at any time during the period  (5)  through  (6)  .  (7)  must apply in the first three months of this period to make sure Medicare starts in the month  (8)   (9)  age 65.
  •  (1)  not entitled to  (2)  under Medicare because  (3)  application was filed too soon.  (4)  may apply again at any time during the period  (5)  through  (6)  .  (7)  must apply in the first three months of this period to make sure Medicare starts in the month  (8)   (9)  age 65.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: You are
  • Choice 2: She is
  • Choice 3: He is
  • Fill-in (2) - Systems Generated
  • Choice 1: medical insurance coverage
  • Fill-in (3) - Systems Generated
  • Choice 1: your
  • Choice 2: her
  • Choice 3: his
  • Fill-in (4) - Systems Generated
  • Choice 1: You
  • Choice 2: She
  • Choice 3: He
  • Fill-in (5) - Systems Generated
  • Choice 1: Month and Year
  • Fill-in (6) - Systems Generated
  • Choice 1: Month and Year
  • Fill-in (7) - Systems Generated
  • Choice 1: You
  • Choice 2: She
  • Choice 3: He
  • Fill-in (8) - Systems Generated
  • Choice 1: you
  • Choice 2: she
  • Choice 3: he
  • Fill-in (9) - Systems Generated
  • Choice 1: reach
  • Choice 2: reaches
  • HIB004 MEDICAL CLAIMANT ENROLLED AFTER IEP AND BEFORE GENERAL ENROLLMENT PERIOD (H43)
  • (Requested)
  • Caption: Information About Medicare
  •  (1)  not entitled to  (2)  under Medicare because  (3)  application was filed too late.  (4)  should have filed before  (5)  . However,  (6)  g 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.
  •  (1)  not entitled to  (2)  under Medicare because  (3)  application was filed too late.  (4)  should have filed before  (5)  . However,  (6)  g may apply for coverage again during the next general enrollment period. A general enrollment period takes place in January, February, and March of each year.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: You are
  • Choice 2: She is
  • Choice 3: He is
  • Fill-in (2) - Systems Generated
  • Choice 1: medical insurance coverage
  • Fill-in (3) - Systems Generated
  • Choice 1: your
  • Choice 2: her
  • Choice 3: his
  • Fill-in (4) - Systems Generated
  • Choice 1: You
  • Choice 2: She
  • Choice 3: He
  • Fill-in (5) - Systems Generated
  • Choice 1: Month and Year
  • Fill-in (6) - Systems Generated
  • Choice 1: you
  • Choice 2: she
  • Choice 3: he
  • HIB011 PREMIUM BILLING FOR HOSPITAL INSURANCE ONLY (H46)
  • (Requested)
  • Caption: Information About Medicare
  • The monthly premium for  (1)  hospital insurance is  (2)  . We will bill you each month for  (3)  g .
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: your
  • Choice 2: her
  • Choice 3: his
  • Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢
  • Choice 1: HPAC amount
  • Fill-in (3) - Requested As A One Position Alpha Character
  • Choice 1: (A) this premium
  • Choice 2: (B) the combined premium for hospital and medical insurance
  • Choice 3: (C) premiums
  • HIB015 CIVIL SERVICE BUY-IN (H31)
  • (Requested/Generated)
  • Caption: Information About Medicare
  • The Office of Personnel Management will deduct the medical insurance premiums from  (1)  annuity checks. They will let  (2)  g know when this will start.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: Beneficiary's Name possessive
  • Choice 2: your
  • Fill-in (2) - Systems Generated
  • Choice 1: him
  • Choice 2: her
  • Choice 3: you
  • HIB019 BENEFICIARY IS NOT ENTITLED TO MEDICARE PART A FOR FREE BUT ELIGIBLE TO BUY MEDICARE PART A (HOSPITAL INSURANCE) FOR A FEE
  • (Requested)
  • Caption: None
  •  (1)  cannot get Medicare Part A (hospital insurance) for free. However,  (2)  may be able to buy Medicare Part A for  (3)  a month. Please contact us for more information.
  •  (1)  cannot get Medicare Part A (hospital insurance) for free. However,  (2)  may be able to buy Medicare Part A for  (3)  a month. Please contact us for more information.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: You
  • Choice 2: Beneficiary's full name
  • Fill-in (2) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • Fill-in (3) - Systems Generated
  • Beneficiary's monthly cost for Part A
  • HIB021 DUAL ENTITLEMENT AUXILIARY/SURVIVOR AWARD AFTER PRIMARY - MEDICARE ENTITLEMENT PREVIOUSLY ESTABLISHED (H84)
  • (Requested)
  • Caption: Information About Medicare
  • This letter does not affect  (1)  Medicare benefits.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: your
  • Choice 1: his
  • Choice 1: her
  • HIB022 COVERAGE TRANSFERRED TO ANOTHER CLAIM NUMBER (H09)
  • (Requested/Generated)
  • Caption: Information About Medicare
  •  (1)  still be entitled to  (2)  insurance coverage from Medicare under the claim number we have shown above. We will send  (3)  a new Medicare card with this number on it.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: You will
  • Choice 2: He will
  • Choice 3: She will
  • Fill-in (2) - Requested As A One Position Alpha Character
  • Choice 1: (A) hospital
  • Choice 2: (B) hospital and medical
  • Fill-in (3) - Systems Generated
  • Choice 1: you
  • Choice 2: him
  • Choice 3: her
  • HIB033 HI COVERAGE - NO SMI ELECTED - PROVISIONAL BENEFITS CASE (P06)
  • (Requested)
  • Caption: Information About Medicare
  •  (1)  will have Medicare hospital insurance (Part A) coverage while  (2)  receiving these provisional benefits.  (3)  coverage will begin  (4)  .  (5)  hospital insurance (Part A) is free. If  (6)  provisional benefits end because  (7)  received 6 months of payments, then  (8)  Medicare coverage will end at the same time. If  (9)  provisional benefits end for any other reason, then  (10)  will get another letter telling  (11)  about  (12)  Medicare coverage.
  •  (1)  will have Medicare hospital insurance (Part A) coverage while  (2)  receiving these provisional benefits.  (3)  coverage will begin  (4)  .  (5)  hospital insurance (Part A) is free. If  (6)  provisional benefits end because  (7)  received 6 months of payments, then  (8)  Medicare coverage will end at the same time. If  (9)  provisional benefits end for any other reason, then  (10)  will get another letter telling  (11)  about  (12)  Medicare coverage.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: You
  • Choice 2: Beneficiary's name
  • Fill-in (2) - Systems Generated
  • Choice 1: you are
  • Choice 2: he is
  • Choice 3: she is
  • Fill-in (3) - Systems Generated
  • Choice 1: You
  • Choice 2: His
  • Choice 3: Her
  • Fill-in (4) - Systems Generated
  • Choice 1: Month CCYY (date Medicare coverage begins)
  • Fill-in (5) - Systems Generated
  • Choice 1: Your
  • Choice 2: His
  • Choice 3: Her
  • Fill-in (6) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (7) - Systems Generated
  • Choice 1: you have
  • Choice 2: he has
  • Choice 3: she has
  • Fill-in (8) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (9) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (10) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • Fill-in (11) - Systems Generated
  • Choice 1: you
  • Choice 2: him
  • Choice 3: her
  • Fill-in (12) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • HIB036 SMI COVERAGE ELECTED DURING PROVISIONAL PERIOD - PROVISIONAL BENEFITS CASE (P07)
  • (Requested)
  • Caption: Information About Medicare
  •  (1)  will have Medicare hospital insurance (Part A) and medical insurance (Part B) coverage while  (2)  receiving these provisional benefits.  (3)  coverage will begin  (4)  .  (5)  hospital insurance (Part A) is free.  (6)  medical insurance (Part B) premium will be deducted from the monthly payment. If  (7)  provisional benefits end because  (8)  received 6 months of payments, then  (9)  Medicare coverage will end at the same time. If  (10)  provisional benefits end for any other reason, then  (11)  will get another letter telling  (12)  about  (13)  g Medicare coverage.
  •  (1)  will have Medicare hospital insurance (Part A) and medical insurance (Part B) coverage while  (2)  receiving these provisional benefits.  (3)  coverage will begin  (4)  .  (5)  hospital insurance (Part A) is free.  (6)  medical insurance (Part B) premium will be deducted from the monthly payment. If  (7)  provisional benefits end because  (8)  received 6 months of payments, then  (9)  Medicare coverage will end at the same time. If  (10)  provisional benefits end for any other reason, then  (11)  will get another letter telling  (12)  about  (13)  g Medicare coverage.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: You
  • Choice 2: Beneficiary's Name
  • Fill-in (2) - Systems Generated
  • Choice 1: you are
  • Choice 2: he is
  • Choice 3: she is
  • Fill-in (3) - Systems Generated
  • Choice 1: Your
  • Choice 2: His
  • Choice 3: Her
  • Fill-in (4) - Systems Generated
  • Choice 1: Month CCYY (date Medicare coverage begins)
  • Fill-in (5) - Systems Generated
  • Choice 1: Your
  • Choice 2: His
  • Choice 3: Her
  • Fill-in (6) - Systems Generated
  • Choice 1: Your
  • Choice 2: His
  • Choice 3: Her
  • Fill-in (7) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (8) - Systems Generated
  • Choice 1: you have
  • Choice 2: he has
  • Choice 3: she has
  • Fill-in (9) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (10) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (11) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • Fill-in (12) - Systems Generated
  • Choice 1: you
  • Choice 2: him
  • Choice 3: her
  • Fill-in (13) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • HIB039 INITIAL PREMIUM BILLING BENEFITS SUSPENDED OR DEFERRED STATUS MATURING BEYOND CURRENT YEAR (H60)
  • (Requested/Generated)
  • Caption: Information About Medicare
  • We will charge a monthly premium for  (1)  medical insurance under Medicare. 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 payment is due.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: your
  • Choice 2: Beneficiary's Name possessive
  • HIB040 MEDICARE COVERAGE WILL CONTINUE BASED ON EXTENDED MEDICARE PROVISIONS - PROVISIONAL BENEFITS CASE (P08)
  • (Requested)
  • Caption: Information About Medicare
  •  (1)  Medicare coverage will continue while  (2)  receiving these provisional benefits.  (3)  hospital insurance (Part A) is free. If  (4)  medical insurance (Part B)  (5)  will no longer get a bill for the premium.  (6)  premium will be deducted from the monthly payment.  (7)  Medicare coverage may end if we deny  (8)  request for reinstatement.  (9)  will get another letter telling  (10)  if  (11)  Medicare coverage will end.
  •  (1)  Medicare coverage will continue while  (2)  receiving these provisional benefits.  (3)  hospital insurance (Part A) is free. If  (4)  medical insurance (Part B)  (5)  will no longer get a bill for the premium.  (6)  premium will be deducted from the monthly payment.  (7)  Medicare coverage may end if we deny  (8)  request for reinstatement.  (9)  will get another letter telling  (10)  if  (11)  Medicare coverage will end.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: Your
  • Choice 2: Beneficiary's Name
  • Fill-in (2) - Systems Generated
  • Choice 1: you are
  • Choice 2: he is
  • Choice 3: she is
  • Fill-in (3) - Systems Generated
  • Choice 1: Your
  • Choice 2: His
  • Choice 3: Her
  • Fill-in (4) - Systems Generated
  • Choice 1: you have
  • Choice 2: he has
  • Choice 3: she has
  • Fill-in (5) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • Fill-in (6) - Systems Generated
  • Choice 1: Your
  • Choice 2: His
  • Choice 3: Her
  • Fill-in (7) - Systems Generated
  • Choice 1: Your
  • Choice 2: His
  • Choice 3: Her
  • Fill-in (8) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (9) - Systems Generated
  • Choice 1: You
  • Choice 2: He
  • Choice 3: She
  • Fill-in (10) - Systems Generated
  • Choice 1: you
  • Choice 2: him
  • Choice 3: her
  • Fill-in (11) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • HIB041 HI TERMINATION DUE TO DIB CESSATION OR MARRIAGE OF DAC (H80)
  • (Requested/Generated)
  • Caption: Information About Medicare
  • Since  (1)   (2)  no longer entitled to monthly Social Security benefits, we are stopping  (3)  hospital insurance coverage under Medicare.  (4)  hospital insurance coverage ends on the last day of  (5)  .  (6)  g Medicare card will no longer be valid after coverage ends, so please tear it up.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: Beneficiary name
  • Choice 2: you
  • Fill-in (2) - Systems Generated
  • Choice 1: is
  • Choice 2: are
  • Fill-in (3) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (4) - Systems Generated
  • Choice 1: Your
  • Choice 2: His
  • Choice 3: Her
  • Fill-in (5) - Requested As A Date In Format Shown Below
  • Choice 1: MM/CCYY
  • Fill-in (6) - Systems Generated
  • Choice 1: Beneficiary's Name possessive
  • Choice 2: Your
  • HIB043 MEDICARE COVERAGE WILL CONTINUE BASED ON ESRD - PROVISIONAL BENEFITS CASE (P09)
  • (Requested)
  • Caption: Information About Medicare
  •  (1)  already entitled to  (2)  because  (3)  enrolled based on a kidney condition. If  (4)  medical insurance (Part B)  (5)  will no longer get a bill for the premium.  (6)  premium will be deducted from the monthly payment.
  •  (1)  already entitled to  (2)  because  (3)  enrolled based on a kidney condition. If  (4)  medical insurance (Part B)  (5)  will no longer get a bill for the premium.  (6)  premium will be deducted from the monthly payment.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: You are
  • Choice 2: Beneficiary's Name + is
  • Fill-in (2) - Requested As A One Position Alpha Character
  • Choice 1: (A) hospital insurance (Part A)
  • Choice 2: (B) hospital insurance (Part A) and medical insurance (Part B)
  • Fill-in (3) - Systems Generated
  • Choice 1: you are
  • Choice 2: he is
  • Choice 3: she is
  • Fill-in (4) - Systems Generated
  • Choice 1: you have
  • Choice 2: he has
  • Choice 3: she has
  • Fill-in (5) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • Fill-in (6) - Systems Generated
  • Choice 1: Your
  • Choice 2: His
  • Choice 3: Her
  • HIB045 MEDICARE CLOSED PERIOD - PROVISIONAL BENEFITS CASE (P10)
  • (Requested)
  • Caption: Information About Medicare
  •  (1)   (2)  coverage under Medicare from  (3)  through  (4)  . The Medicare coverage has ended because  (5)  no longer receiving provisional benefits.
  •  (1)   (2)  coverage under Medicare from  (3)  through  (4)  . The Medicare coverage has ended because  (5)  no longer receiving provisional benefits.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: You have
  • Choice 2: She has
  • Choice 3: He has
  • Fill-in (2) - Requested As A One Position Alpha Character
  • Choice 1: (A) hospital insurance (Part A)
  • Choice 2: (B) hospital insurance (Part A) and medical insurance (Part B)
  • Fill-in (3) - Systems Generated
  • Choice 1: MM/CCYY (date Medicare coverage begins)
  • Fill-in (4) - Systems Generated
  • Choice 1: MM/CCYY (date Medicare coverage begins)
  • Fill-in (5) - Systems Generated
  • Choice 1: you are
  • Choice 2: he is
  • Choice 3: she is
  • HIB052 SMI REFUSAL PROCEDURE (H24)
  • (Requested)
  • Caption: Information About Medicare
  • If you do not want medical insurance, please complete the enclosed card and return it to us in the envelope we have provided. You will need to do this by the date shown on the card. If you decide you do not want the insurance, we will return any premiums that you have paid.
  • Fill-in values:
  • None
  • HIB061 HMO ENROLLMENT CIVIL SERVICE INVOLVEMENT (H54)
  • (Requested)
  • Caption: Information About Medicare
  • The Office of Personnel Management will continue to deduct  (1)  medical insurance premiums from  (2)  annuity checks.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: Beneficiary Name, possessive
  • Choice 2: your
  • Fill-in (2) - Systems Generated
  • Choice 1: his
  • Choice 2: her
  • Choice 3: your
  • HIB092 HMO DISENROLLMENT. PRIVATE PREMIUM PAYMENT WILL CONTINUE. PENALTY INVOLVED. (H56)
  • (Requested)
  • Caption: Information About Medicare
  •  (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.
  •  (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) - Systems Generated
  • Choice 1: Beneficiary Name, possessive
  • Choice 2: Your
  • Fill-in (2) - Systems Generated
  • Choice 1: his
  • Choice 2: her
  • Choice 3: your
  • Choice 4: the
  • Fill-in (3) - Systems Generated
  • Choice 1: He
  • Choice 2: She
  • Choice 3: You
  • Choice 4: Beneficiary's Name
  • HIB093 HMO DISENROLLMENT. STATE WILL CONTINUE TO PAY PREMIUMS (H55)
  • (Requested)
  • Caption: Information About Medicare
  • Our records show that  (1)  will continue to pay the premiums for  (2)  Medicare  (3)  insurance coverage.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: the State
  • Choice 2: an organization
  • Fill-in (2) - Systems Generated
  • Choice 1: his
  • Choice 2: her
  • Choice 3: your
  • Fill-in (3) - Systems Generated
  • Choice 1: hospital and medical
  • Choice 2: medical
  • HIB095 CHANGE IN DATE OF ENTITLEMENT TO SMI (H13)
  • (Requested or Systems Generated)
  • Caption: Information About Medicare
  • We have changed the date of  (1)  entitlement to  (2)  insurance under Medicare.  (3)  new entitlement date is  (4)  . We will take any premiums due for the insurance out of  (5)  next payment.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: your
  • Choice 2: Beneficiary Name possessive
  • Fill-in (2) - Requested As A One Position Alpha Character
  • Choice 1: (A) hospital
  • Choice 2: (B) medical
  • Choice 3: (C) hospital and medical
  • Fill-in (3) - Systems Generated
  • Choice 1: Your
  • Choice 2: His
  • Choice 3: Her
  • Fill-in (4) - Requested As A Date In Format Shown Below
  • Choice 1: MM/CCYY
  • Fill-in (5) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • HIB139 HEALTH INSURANCE – PENALTY FOR LATE ENROLLMENT (H21-2)
  • (Requested/Generated)
  • Caption: Information About Medicare
  • This medical insurance premium includes a penalty because  (1)  enrolled later than  (2)  could have.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: you
  • Choice 2: Beneficiary's Name
  • Fill-in (2) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • HIB152 SMI DECLINED DURING IEP OR SMI DECLINED WHEN OFFERED THROUGH EQUITABLE RELIEF (H05)
  • (Requested/Generated)
  • Caption: Information About Medicare
  •  (1)   (2)  through  (3)  to enroll in Medicare Part B (medical insurance).
  •  (1)   (2)  through  (3)  to enroll in Medicare Part B (medical insurance).
  • People who have Part B pay a monthly premium. If  (4)  not sign up for Part B when  (5)  first eligible,  (6)  may have to pay a late enrollment penalty for as long as  (7)  Part B.  (8)  monthly premium may go up 10 percent for each full 12-month period that  (9)  could have had Part B coverage, but did not sign up for it. Usually  (10)  will not have to pay a late enrollment penalty if (  (11) ) up during a special enrollment period.
  • People who have Part B pay a monthly premium. If  (4)  not sign up for Part B when  (5)  first eligible,  (6)  may have to pay a late enrollment penalty for as long as  (7)  Part B.  (8)  monthly premium may go up 10 percent for each full 12-month period that  (9)  could have had Part B coverage, but did not sign up for it. Usually  (10)  will not have to pay a late enrollment penalty if (  (11)  ) up during a special enrollment period.
  • If  (12)  to sign up for Part B after  (13) ,  (14)  will usually have to wait until the general enrollment period. The general enrollment period takes place in January, February, and March of each year. If  (15)  up in the general enrollment period,  (16)  Part B coverage will start July 1 of the year  (17)  up.
  •  (18)  may also be able to sign up during a special enrollment period.  (19)  can do this if  (20)  one of the conditions listed below:
  • *  (21)  covered under a group health plan through  (22)  current work or  (23)  spouse's current work,
  •  (18)  may also be able to sign up during a special enrollment period.  (19)  can do this if  (20)  one of the conditions listed below:
  • *  (21)  covered under a group health plan through  (22)  current work or  (23)  spouse's current work,
  • *  (24)  covered under a large group health plan through  (25)  current work or any family member's current work.
  •  (26)  may sign up for medical insurance at any time  (27)  covered under the group health plan. However,  (28)  may wait and sign up during the 8-month period that begins when the work ends or  (29)  coverage under the plan ends, whichever occurs first.  (30)  may also sign up if the type of plan  (31)  changes.
  •  (26)  may sign up for medical insurance at any time  (27)  covered under the group health plan. However,  (28)  may wait and sign up during the 8-month period that begins when the work ends or  (29)  coverage under the plan ends, whichever occurs first.  (30)  may also sign up if the type of plan  (31)  changes.
  • NOTE: COBRA and Retiree health coverage do not count as health insurance based on current employment.
  • Deciding when to sign up for Part B may depend on how  (32)  health insurance works with Medicare. For example, a group health plan is usually not the primary insurance if the employer has less than 20 employees. In this case, it is important to have Medicare coverage, and you may want to sign up now.
  • If  (33)  help deciding what to do, please contact  (34)  employee benefits office or contact us.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: Beneficiary's full name
  • Choice 2: You
  • Fill-in (2) - Systems Generated
  • Choice 1: has
  • Choice 2: have
  • Fill-in (3) - Requested As A Date In Format Shown Below
  • Choice 1: Show HI-START plus 3 months MM/CCYY
  • Fill-in (4) - Systems Generated
  • Choice 1: you do
  • Choice 2: he does
  • Choice 3: she does
  • Fill-in (5) - Systems Generated
  • Choice 1: you are
  • Choice 2: he is
  • Choice 3: she is
  • Fill-in (6) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • Fill-in (7) - Systems Generated
  • Choice 1: you have
  • Choice 2: he has
  • Choice 3: she has
  • Fill-in (8) - Systems Generated
  • Choice 1: Your
  • Choice 2: His
  • Choice 3: Her
  • Fill-in (9) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • Fill-in (10) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • Fill-in (11) - Systems Generated
  • Choice 1: you sign
  • Choice 2: he signs
  • Choice 3: she signs
  • Fill-in (12) - Systems Generated
  • Choice 1: you want
  • Choice 2: he wants
  • Choice 3: she wants
  • Fill-in (13) - Systems Generated
  • Show HI-START plus 3 months MM/CCYY
  • Fill-in (14) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • Fill-in (15) - Systems Generated
  • Choice 1: you sign
  • Choice 2: he signs
  • Choice 3: she signs
  • Fill-in (16) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (17) - Systems Generated
  • Choice 1: you sign
  • Choice 2: he signs
  • Choice 3: she signs
  • Fill-in (18) - Systems Generated
  • Choice 1: Beneficiary's full name
  • Choice 2: You
  • Fill-in (19) - Systems Generated
  • Choice 1: You
  • Choice 2: He
  • Choice 3: She
  • Fill-in (20) - Systems Generated
  • Choice 1: you meet
  • Choice 2: he meets
  • Choice 3: she meets
  • Fill-in (21) - Systems Generated
  • Choice 1: You are
  • Choice 2: He is
  • Choice 3: She is
  • Fill-in (22) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill (23) Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (24) Systems Generated
  • Choice 1: You are
  • Choice 2: He is
  • Choice 3: She is
  • Fill-in (25) Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (26) Systems Generated
  • Choice 1: You
  • Choice 2: He
  • Choice 3: She
  • Fill-in (27) Systems Generated
  • Choice 1: you are
  • Choice 2: he is
  • Choice 3: she is
  • Fill-in (28) Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • Fill-in (29) Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (30) Systems Generated
  • Choice 1: You
  • Choice 2: He
  • Choice 3: She
  • Fill-in (31) Systems Generated
  • Choice 1: you have
  • Choice 2: he has
  • Choice 3: she has
  • Fill-in (32) Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (33) Systems Generated
  • Choice 1: you need
  • Choice 2: he needs
  • Choice 3: she needs
  • Fill-in (34) Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • HIB157 CHILDREN'S HEALTH INSURANCE PROGRAM (H18)
  • (Requested/Generated)
  • Caption: Health Insurance For Children
  • 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) - Systems Generated
  • Choice 1: www.insurekidsnow.gov
  • HIB170 MONTHLY BENEFITS TERMINATED - HI/SMI CONTINUES - LAF U (H90)
  • (Requested/Generated)
  • Caption: Information About Medicare
  • Even though  (1)  no longer receiving monthly checks,  (2)  will still have hospital and medical insurance coverage under Medicare. Please keep  (3)  Medicare card.
  • There is a monthly premium for  (4)  medical insurance. Because we are stopping monthly checks, we will bill  (5)  g every 3 months for the premiums.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: Beneficiary name is
  • Choice 2: you are
  • Fill-in (2) - Systems Generated
  • Choice 1: he
  • Choice 2: she
  • Choice 3: you
  • Fill-in (3) - Systems Generated
  • Choice 1: his
  • Choice 2: her
  • Choice 3: your
  • Fill-in (4) - Systems Generated
  • Choice 1: his
  • Choice 2: her
  • Choice 3: your
  • Fill-in (5) - Systems Generated
  • Choice 1: her
  • Choice 2: him
  • Choice 3: your
  • HIB171 CRD ENTITLEMENT MONTHLY BENEFITS TERMINATED HI/SMI CONTINUES STATE BUY-IN CONTINUES (H91)
  • (Requested/Generated)
  • Caption: Information About Medicare
  • Even though  (1)  no longer receiving monthly checks,  (2)  will still have hospital and medical insurance coverage under Medicare. Please keep  (3)  Medicare card. The State where  (4)  will continue to pay the premiums for  (5)  medical insurance coverage under Medicare.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: you are
  • Choice 2: Beneficiary's Name is
  • Fill-in (2) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • Fill-in (3) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (4) - Systems Generated
  • Choice 1: you live
  • Choice 2: he lives
  • Choice 3: she lives
  • Fill-in (5) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • HIB175 SMI PREMIUMS/ARREARAGE DEDUCTED FROM PMA ORCMA
  • (System Generated)
  • Caption: Information About Medicare
  • We are deducting past-due premiums from  (1)  check.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: Name possessive
  • Choice 2: your
  • HIB182 IRMAA – MEDICARE PART B PREMIUM BASED ON INCOME (HA9)
  • (Requested/Generated)
  • Caption: Information About Medicare
  • 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) - Systems Generated
  • Choice 1: your
  • Choice 2: Beneficiary's Name Possessive
  • Fill-in (2) - Systems Generated
  • Choice 1: you have
  • Choice 2: she has
  • Choice 3: he has
  • Fill-in (3) - Systems Generated
  • Choice 1: you
  • Choice 2: she
  • Choice 3: he
  • Fill-in (4) - Systems Generated
  • Choice 1: your
  • Choice 2: her
  • Choice 3: his
  • Fill-in (5) - Systems Generated
  • Choice 1: your
  • Choice 2: her
  • Choice 3: his
  • Fill-in (6) - Systems Generated
  • Choice 1: your
  • Choice 2: her
  • Choice 3: his
  • Fill-in (7) - Systems Generated
  • Choice 1: you pay your
  • Choice 2: he pays his
  • Choice 3: she pays her
  • HIB183 IRMAA – BENEFICIARY/PAYEE – PRIOR NOTICE RECEIVED EXPLAINING IRMAA (HB1)
  • (Requested/Generated)
  • Caption: Information About Medicare
  • We sent you another letter that explained how we determined the amount of  (1)  g premium.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • HIB184 ADVISES BENEFICIARY/PAYEE THAT WE WILL CONTINUE TO BILL FOR PART B PREMIUMS (HB4)
  • (Requested/Generated)
  • Caption: Information About Medicare
  • We will continue to bill  (1)  for  (2)  Medicare Part B premiums.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: him
  • Choice 2: her
  • Choice 3: you
  • Fill-in (2) - Systems Generated
  • Choice 1: his
  • Choice 2: her
  • Choice 3: your
  • HIB185 IRMAA – CMA ADJUSTED DUE TO CHANGE IN PART B PREMIUM AMOUNT (HB3)
  • (Requested/Generated)
  • Caption: Information About Medicare
  • 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) - Requested As A Date in Format Shown Below
  • Choice 1: Using the PCI, show the calendar date in which the COM check will be paid
  • MM/DD/CCYY
  • Choice 2: Using the PCI, show the calendar date in which the DPD check will be paid
  • MM/DD/CCYY
  • Fill-in (2) - Systems Generated
  • Choice 1: his
  • Choice 2: her
  • Choice 3: your
  • HIB186 ADVISES ATTAINER/NEW FILER THAT IRMAA MAY APPLY BASED ON INCOME LEVEL (HB5)
  • (Requested/Generated)
  • Caption: Information About Medicare
  • 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)  g . 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) - Requested As A Money Amount In Format $$$$$.¢¢
  • Choice 1: Amount
  • Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢
  • Choice 1: Amount
  • Fill-in (3) - Systems Generated
  • Choice 1: his
  • Choice 2: her
  • Choice 3: your
  • Fill-in (4) - Systems Generated
  • Choice 1: he has
  • Choice 2: she has
  • Choice 3: you have
  • Fill-in (5) - Requested As A Date in Format Shown Below
  • Choice 1: SMI start Date MM/CCYY
  • HIB187 MEDICAL PREMIUM DEDUCTIONS CONTINUE (G24)
  • (System Generated)
  • Caption: Information About Medicare
  • We will continue to deduct Medicare premiums from  (1)  monthly checks.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: your
  • Choice 2: Beneficiary's name possessive
  • HIB188 SMI REFUSAL (H01)
  • (Requested/Generated)
  • Caption: Your Benefits
  •  (1)  told us that  (2)  want medical insurance under Medicare. We will send  (3)  a new Medicare card in a few days. It will show that  (4)  g entitled to only hospital insurance.
  •  (1)  told us that  (2)  want medical insurance under Medicare. We will send  (3)  a new Medicare card in a few days. It will show that  (4)  g entitled to only hospital insurance.
  • We will stop taking premiums for medical insurance out of  (5)  checks. If we have taken out any premiums for months when  (6)  not entitled to medical insurance, we will return the money to  (7)  .
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: You
  • Choice 2: Beneficiary's Name
  • Fill-in (2) - Systems Generated
  • Choice 1: you do not
  • Choice 2: he does not
  • Choice 3: she does not
  • Fill-in (3) - Systems Generated
  • Choice 1: you
  • Choice 2: him
  • Choice 3: her
  • Fill-in (4) - Systems Generated
  • Choice 1: you are
  • Choice 2: he is
  • Choice 3: she is
  • Fill-in (5) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (6) - Systems Generated
  • Choice 1: you were
  • Choice 2: he was
  • Choice 3: she was
  • Fill-in (7) - Systems Generated
  • Choice 1: you
  • Choice 2: him
  • Choice 3: her
  • HIB189 RAILROAD JURISDICTION (H02)
  • (Requested/Generated)
  • Caption: Information About Medicare
  • The Railroad Retirement Board is handling  (1)  hospital and medical insurance under Medicare.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: you
  • Choice 2: Beneficiary's Name possessive
  • HIB190 REENTITLEMENT TO DIB - NEW 24 MONTH WAITING PERIOD NEEDED (H04)
  • (Requested)
  • Caption: Information About Medicare
  • Our records show that  (1)  had an earlier disability. The earlier disability is not the same as  (2)  disability now. Since the disabilities are different,  (3)  will need to wait 24 months for Medicare to begin. We will tell you in another letter when  (4)  can get Medicare.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: you
  • Choice 2: Beneficiary's Name
  • Fill-in (2) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (3) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • Fill-in (4) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • HIB191 HI AND SMI DATE OF ENTITLEMENT (H11)
  • (Requested/Generated)
  • Caption: Information About Medicare
  •  (1)  entitled to hospital and medical insurance under Medicare beginning  (2)  .
  •  (1)  entitled to hospital and medical insurance under Medicare beginning  (2)  .
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: You are
  • Choice 2: Beneficiary's Name is
  • Fill-in (2) - Requested As A Date In Format Shown Below
  • Choice 1: MM/CCYY
  • HIB192 SUSPENSION OF 24 MONTH WAITING PERIOD - BENE DIAGNOSED WITH ALS (H16)
  • (Requested)
  • Caption: Information About Medicare
  • Because of a change in the law people receiving disability benefits because of Amyotrophic Lateral Sclerosis (ALS) no longer have to wait 24 months for Medicare coverage. We have therefore changed  (1)  entitlement dates to hospital insurance (Part A) and medical insurance (Part B) to  (2)  .
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: your
  • Choice 2: Beneficiary's Name possessive
  • Fill-in (2) - Requested As A Date In Format Shown Below
  • Choice 1: MM/DD/CCYY
  • HIB193 SMI PREMIUM AMOUNTS AND EFFECTIVE DATES (H21)
  • (Requested/Generated)
  • Caption: Information About Medicare
  • We charge a monthly premium for  (1)  medical insurance. The rates are shown below:
  • Beginning Date Amount
  •  (2)   (3) 
  •  (2)   (3) 
  • NOTE: To allow multiple repetitions of the date and premium rates in Fill-ins 2 and 3, HIB259 is automatically generated.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: your
  • Choice 2: Beneficiary's Name possessive
  • Fill-in (2) - Requested As A Date In Format Shown Below
  • Choice 1: MM/CCYY
  • Fill-in (3) - Requested As A Money Amount In Format $$$$$.¢¢
  • Choice 1: Amount of SMI premium
  • HIB194 STATE BUY-IN (H30)
  • (Requested/Generated)
  • Caption: Information About Medicare
  • The State where  (1)  will pay the premiums for  (2)  Medicare coverage beginning  (3)  .  (4)  may receive a refund for some of the premiums  (5)  may have paid, if the State is responsible for paying them.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: you live
  • Choice 2: Beneficiary's Name lives
  • Fill-in (2) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (3) - Requested As A Date In Format Shown Below
  • Choice 1: MM/CCYY
  • Fill-in (4) - Systems Generated
  • Choice 1: You
  • Choice 2: He
  • Choice 3: She
  • Fill-in (5) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • HIB195 PRIVATE GROUP BUY-IN (H32)
  • (Requested/Generated)
  • Caption: Information About Medicare
  • Beginning  (1)  , we will send the bills for  (2)  medical insurance premiums to the organization which  (3)  selected. Although we will send the bills to them,  (4)  will still be responsible for making sure that  (5)  premiums are paid. If the organization decides that it will no longer pay the premiums, we will start sending the premium bills to  (6)  again.
  •  (7)  may receive a refund for some of the premiums  (8)  g may have paid, if the organization is responsible for paying them.
  •  (7)  may receive a refund for some of the premiums  (8)  g may have paid, if the organization is responsible for paying them.
  • Fill-in values:
  • Fill-in (1) - Requested As A Date In Format Shown Below
  • Choice 1: MM/CCYY
  • Fill-in (2) - Systems Generated
  • Choice 1: your
  • Choice 2: Beneficiary's Name possessive
  • Fill-in (3) - Systems Generated
  • Choice 1: you have
  • Choice 2: he has
  • Choice 3: she has
  • Fill-in (4) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • Fill-in (5) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (6) - Systems Generated
  • Choice 1: you
  • Choice 2: him
  • Choice 3: her
  • Fill-in (7) - Systems Generated
  • Choice 1: You
  • Choice 2: He
  • Choice 3: She
  • Fill-in (8) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • HIB196 TERMINATION OF PRIVATE GROUP BUY-IN (H40)
  • (Requested/Generated)
  • Caption: Information About Medicare
  • An organization has been paying  (1)  medical insurance premiums while  (2)  not receiving checks. Since we have started to pay  (3)  checks each month, we will take the premiums out of  (4)  checks beginning  (5)  .
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: your
  • Choice 2: Beneficiary's Name possessive
  • Fill-in (2) - Systems Generated
  • Choice 1: you were
  • Choice 2: he was
  • Choice 3: she was
  • Fill-in (3) - Systems Generated
  • Choice 1: you
  • Choice 2: him
  • Choice 3: her
  • Fill-in (4) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (5) - Requested As A Date In Format Shown Below
  • Choice 1: MM/CCYY
  • HIB197 TERMINATION OF CIVIL SERVICE BUY-IN (H41)
  • (Requested/Generated)
  • Caption: Information About Medicare
  •  (1)  medical insurance premiums were taken out of  (2)  civil service annuity. Since we have started to pay  (3)  checks each month, we will take the premiums out of  (4)  Social Security checks beginning  (5)  .
  •  (1)  medical insurance premiums were taken out of  (2)  civil service annuity. Since we have started to pay  (3)  checks each month, we will take the premiums out of  (4)  Social Security checks beginning  (5)  .
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: Your
  • Choice 2: Beneficiary's Name possessive
  • Fill-in (2) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (3) - Systems Generated
  • Choice 1: you
  • Choice 2: him
  • Choice 3: her
  • Fill-in (4) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (5) - Requested As A Date In Format Shown Below
  • Choice 1: MM/CCYY
  • HIB198 OPENING PARAGRAPH - AUXILIARY MQGE APPLICANT ON NUMBER HOLDER'S WAGE RECORD (H44)
  • (Requested)
  • Caption: None
  • This notice refers to  (1)  claim for  (2)  based on  (3)  Government employment.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: your
  • Choice 2: Beneficiary's Name possessive
  • Fill-in (2) - Requested As A One Position Alpha Character
  • Choice 1: (A) Medicare
  • Choice 2: (B) Medicare as a disabled individual
  • Fill-in (3) - Systems Generated
  • Choice 1: Number Holder's name (possessive)
  • HIB199 BILLING FOR BOTH HI AND SMI PREMIUMS (H45)
  • (Requested)
  • Caption: Information About Medicare
  • The monthly premium for  (1)  medical insurance is  (2)  . The monthly premium for  (3)  hospital insurance is  (4)  . We will bill  (5)  each month for the combined premium for hospital and medical insurance.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: your
  • Choice 2: Beneficiary's Name possessive
  • Fill-in (2) - Systems Generated
  • Choice 1: Amount of SMI premium
  • Fill-in (3) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (4) - Systems Generated
  • Choice 1: Amount of HI premium
  • Fill-in (5) - Systems Generated
  • Choice 1: you
  • Choice 2: him
  • Choice 3: her
  • HIB200 FULLY INSURED FOR MEDICARE AT AGE 65 (H47)
  • (Requested)
  • Caption: Information About Medicare
  • Based on  (1)  earnings and on the date of birth,  (2)  g worked long enough under Social Security to qualify for Medicare coverage at age 65.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: your
  • Choice 2: Beneficiary's Name, possessive
  • Fill-in (2) - Systems Generated
  • Choice 1: you have
  • Choice 2: he has
  • Choice 3: she has
  • HIB212 HI START DATE PRIOR TO AGE 65 - HI AWARD ACTION TAKEN IN AGE 65 ATTAINMENT MONTH OR LATER (H48)
  • (Requested)
  • Caption: Information About Medicare
  • Now that  (1)  65 years old,  (2)  Medicare coverage is no longer based on  (3)  disability.  (4)  Medicare coverage does not change because  (5)  65. Work does not affect  (6)  Medicare eligibility. This is because work restrictions only apply to Medicare beneficiaries under age 65 and disabled. If  (7)  condition improves, and  (8)  to return to work, it is not necessary to notify Social Security.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: you are
  • Choice 2: Beneficiary's Name is
  • Fill-in (2) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (3) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (4) - Systems Generated
  • Choice 1: Your
  • Choice 2: Beneficiary's Name possessive
  • Fill-in (5) - Systems Generated
  • Choice 1: you are
  • Choice 2: he is
  • Choice 3: she is
  • Fill-in (6) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (7) - Systems Generated
  • Choice 1: your
  • Choice 2: Beneficiary's Name possessive
  • Fill-in (8) - Systems Generated
  • Choice 1: you decide
  • Choice 2: he decides
  • Choice 3: she decides
  • HIB213 TOTALIZATION MONTHLY BENEFITS AWARDED TO U.S. RESIDENT BETWEEN AGE 50 AND AGE 64 AND 9 MONTHS. (NO MEDICARE ENTITLEMENT ON ANOTHER SSN) (H50)
  • (Requested)
  • Caption: Information About Medicare
  • If  (1)  to be entitled to Medicare insurance when  (2)  age 65,  (3)  will need to apply for it. The separate application is necessary because  (4)  monthly benefits are based on a combination of U.S. and foreign Social Security credits. Please get in touch with us 3 months before  (5)  65 for more information about Medicare insurance.  (6)  may have to pay for this insurance.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: you wish
  • Choice 2: Beneficiary's Name wishes
  • Fill-in (2) - Systems Generated
  • Choice 1: you reach
  • Choice 2: he reaches
  • Choice 3: she reaches
  • Fill-in (3) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • Fill-in (4) - Systems Generated
  • Choice 1: your
  • Choice 2: Beneficiary's Name possessive
  • Fill-in (5) - Systems Generated
  • Choice 1: you become
  • Choice 2: he becomes
  • Choice 3: she becomes
  • Fill-in (6) - Systems Generated
  • Choice 1: You
  • Choice 2: He
  • Choice 3: She
  • HIB214 TOTALIZATION MONTHLY BENEFITS AWARDED TO U.S. RESIDENT AT LEAST AGE 64 AND 9 MONTHS OR ALREADY ENTITLED TO DIB BENEFITS FOR 24 MONTHS — WORKER (NO FREE HI ENTITLEMENT ON ANOTHER SSN) (H51)
  • (Requested)
  • Caption: Information About Medicare
  •  (1)  not entitled to free Medicare hospital insurance under the Social Security agreement. We can use only U.S. Social Security credits to entitle someone to this insurance. This is true even though we have used foreign credits to pay monthly benefits.
  •  (1)  not entitled to free Medicare hospital insurance under the Social Security agreement. We can use only U.S. Social Security credits to entitle someone to this insurance. This is true even though we have used foreign credits to pay monthly benefits.
  •  (2)  a total of  (3)  credits of work under the U.S. Social Security system to be entitled to free hospital insurance.  (4)   (5)  credits.  (6)   (7)  more credits to become entitled.
  •  (2)  a total of  (3)  credits of work under the U.S. Social Security system to be entitled to free hospital insurance.  (4)   (5)  credits.  (6)   (7)  more credits to become entitled.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: You are
  • Choice 2: Beneficiary's Name is
  • Fill-in (2) - Systems Generated
  • Choice 1: You need
  • Choice 2: He needs
  • Choice 3: She needs
  • Fill-in (3) – Requested As A Number
  • Choice 1: Number of quarters needed to be insured for HI
  • Fill-in (4) - Systems Generated
  • Choice 1: You have
  • Choice 2: He has
  • Choice 3: She has
  • Fill-in (5) – Requested As A Number
  • Choice 1: Number of quarters earned
  • Fill-in (6) - Systems Generated
  • Choice 1: You need
  • Choice 2: He needs
  • Choice 3: She needs
  • Fill-in (7) – Requested As A Number
  • Choice 1: Number of quarters needed
  • HIB215 HI AND SMI TERMINATION DUE TO DIB CESSATION AFTER 25TH MONTH (H82)
  • (Requested/Generated)
  • Caption: Information About Medicare
  • 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) - Systems Generated
  • Choice 1: he is
  • Choice 2: she is
  • Choice 3: you are
  • Fill-in (2) - Systems Generated
  • Choice 1: his
  • Choice 2: her
  • Choice 3: your
  • Fill-in (3) - Requested As A One Position Alpha Character
  • Choice 1: (A) hospital
  • Choice 2: (B) hospital and medical
  • Fill-in (4) - Systems Generated
  • Choice 1: His
  • Choice 2: Her
  • Choice 3: Your
  • Fill-in (5) - Requested As A One Position Alpha Character
  • Choice 1: (A) hospital
  • Choice 2: (B) hospital and medical
  • Fill-in (6) - Requested As A Date In Format Shown Below
  • Choice 1: MM/CCYY
  • Fill-in (7) - Systems Generated
  • Choice 1: his
  • Choice 2: her
  • Choice 3: your
  • HIB216 TOTALIZATION MONTHLY BENEFIT AWARDED TO U.S. RESIDENT AT LEAST AGE 64 AND 9 MONTHS OR ENTITLED TO DISABILITY BENEFITS FOR 24 MONTHS AUXILIARY OR SURVIVOR (NO FREE HI ENTITLEMENT ON ANOTHER SSN) (H52)
  • (Requested)
  • Caption: Information About Medicare
  •  (1)  not entitled to free Medicare hospital insurance under the Social Security agreement. We can use only U.S. Social Security credits to entitle someone to this insurance. This is true even though we have used foreign credits to pay monthly benefits.
  •  (1)  not entitled to free Medicare hospital insurance under the Social Security agreement. We can use only U.S. Social Security credits to entitle someone to this insurance. This is true even though we have used foreign credits to pay monthly benefits.
  • For  (2)  to be entitled to free hospital insurance,  (3)  needed to have earned  (4)  credits of work under the U.S. system. However, only  (5)  g credits were earned.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: You are
  • Choice 2: Beneficiary's Name is
  • Fill-in (2) - Systems Generated
  • Choice 1: you
  • Choice 2: him
  • Choice 3: her
  • Fill-in (3) - Requested As A Language
  • Choice 1: Name of worker
  • Fill-in (4) – Requested A Number
  • Choice 1: Number of quarters needed to be insured for HI
  • Fill-in (5) - Requested As A Number
  • Choice 1: Number of quarters earned
  • HIB217 INITIAL PREMIUM BILLING DUE TO ONE-CHECK-ONLY ADJUSTMENT PLUS SUSPENSION (H61)
  • (Requested/Generated)
  • Caption: Information About Medicare
  • We are taking medical insurance premiums out of the check  (1)  will receive. We will bill  (2)  every 3 months for future premiums, and will send  (3)  the bill shortly before payment is due.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • Fill-in (2) - Systems Generated
  • Choice 1: you
  • Choice 2: him
  • Choice 3: her
  • Fill-in (3) - Systems Generated
  • Choice 1: you
  • Choice 2: him
  • Choice 3: her
  • HIB218 FINAL PREMIUM ADJUSTMENT DUE TO TERMINATION OF BENEFITS (CAN BE USED FOR CONVERSION FROM T TO A.) (H62)
  • (Requested/Generated)
  • Caption: Information About Medicare
  • When we figured the amount of  (1)  payment, we took into account all medical insurance premiums which were already paid or still due.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • HIB219 PREMIUM ADJUSTMENT DUE TO DEFERRED ACTION THAT WILL MATURE IN CURRENT YEAR (H63)
  • (Requested/Generated)
  • Caption: Information About Medicare
  • We will change  (1)  next check to account for medical insurance premiums that are due or already paid.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • HIB220 INITIAL PREMIUM ADJUSTMENT DUE TO SMI ENTITLEMENT (H64)
  • (Requested/Generated)
  • Caption: Information About Medicare
  • We are taking medical insurance premiums due through  (1)  out of the check  (2)  will receive around  (3)  . These premiums total  (4)  . We will deduct medical insurance premiums 1 month in advance.
  • Fill-in values:
  • Fill-in (1) - Requested As A Date In Format Shown Below
  • Choice 1: MM/CCYY
  • Fill-in (2) - Systems Generated
  • Choice 1: you
  • Choice 2: Beneficiary's Name
  • Fill-in (3) - Requested As A Date In Format Shown Below
  • Choice 1: MM/DD/CCYY
  • Fill-in (4) - Requested As A Money Amount In Format $$$$$.¢¢
  • Choice 1: Amount of premiums
  • HIB221 PREMIUM ADJUSTMENT DUE TO CURRENT SMI ENTITLEMENT AND PRIOR PERIOD OF SMI ENTITLEMENT (H65)
  • (Requested/Generated)
  • Caption: Information About Medicare
  • We will  (1)  the payment  (2)  will receive shortly after  (3)  by  (4)  because of medical insurance premiums. When we figured the amount of  (5)  payment, we took into account all the medical insurance premiums which were previously paid or still due. We will deduct medical insurance premiums 1 month in advance.
  • Fill-in values:
  • Fill-in (1) - Requested As A One Position Alpha Character
  • Choice 1: (A) reduce
  • Choice 2: (B) increase
  • Fill-in (2) - Systems Generated
  • Choice 1: you
  • Choice 2: Beneficiary's Name
  • Fill-in (3) - Requested As A Date In Format Shown Below
  • Choice 1: MM/DD/CCYY
  • Fill-in (4) - Requested As A Money Amount In Format $$$$$.¢¢
  • Choice 1: Amount (PDA)
  • Fill-in (5) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • HIB223 SUBSEQUENT PREMIUM AND PINQ RECORD ADJUSTMENT (H66)
  • (System Generated)
  • Caption: Information About Medicare
  • We will  (1)  the payment  (2)  will receive after  (3)  by  (4)  because of medical insurance premiums which were  (5)  .
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: increase
  • Choice 2: reduce
  • Fill-in (2) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • Fill-in (3) - Systems Generated
  • Choice 1: MM/DD/CCYY
  • Fill-in (4) - Systems Generated
  • Choice 1: Amount (PDA)
  • Fill-in (5) - Requested As A One Position Alpha Character
  • Choice A: already paid
  • Choice B: owed
  • HIB224 PREMIUM AND PINQ RECORD ADJUSTMENT DUE TO RESUMPTION OF BENEFITS (H67)
  • (Requested/Generated)
  • Caption: Information About Medicare
  • We are  (1)   (2)  next payment by  (3)  because of the medical insurance premiums  (4)  . After that we will take premiums out of  (5)  regular checks each month.
  • Fill-in values:
  • Fill-in (1) - Requested As A One Position Alpha Character
  • Choice 1: (A) reducing
  • Choice 2: (B) increasing
  • Fill-in (2) - Systems Generated
  • Choice 1: your
  • Choice 2: Beneficiary's Name possessive
  • Fill-in (3) - Requested As A Money Amount in Format $$$$$.¢¢
  • Choice 1: Amount
  • Fill-in (4) - Requested As A One Position Alpha Character
  • Choice 1: (A) you owe
  • Choice 2: (B) he owes
  • Choice 3: (C) she owes
  • Choice 4: (D) already paid
  • Fill-in (5) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • HIB228 SMI PREMIUM CHANGED TO VARIABLE RATE DUE TO DELAYED DECEMBER COM PROCESSING (H72)
  • (Requested)
  • Caption: Information About Medicare
  • We have determined that the premium amount of  (1)  , which  (2)  now being charged, should be reduced to  (3)  effective with January of this year. This reduction in  (4)  premium is being made because the increase in  (5)  premium as of January 1st resulted in a decrease in  (6)  monthly Social Security check. The law permits us to reduce the Part B premium amount as necessary (but not below the amount  (7)  paid in December of last year) if the yearly change in the premium would cause the Social Security checks  (8)  this year to be lower than the checks  (9)  last year.
  • Fill-in values:
  • Fill-in (1) - Requested As A Money Amount In Format $$$$$.¢¢
  • Choice 1: SMI premium rate
  • Fill-in (2) - Systems Generated
  • Choice 1: you are
  • Choice 2: he is
  • Choice 3: she is
  • Fill-in (3) - Requested As A Money Amount In Format $$$$$.¢¢
  • Choice 1: New variable SMI rate
  • Fill-in (4) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (5) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (6) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (7) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • Fill-in (8) - Systems Generated
  • Choice 1: you receive
  • Choice 2: he receives
  • Choice 3: she receives
  • Fill-in (9) - Systems Generated
  • Choice 1: you received
  • Choice 2: he received
  • Choice 3: she received
  • HIB229 REVIEW REQUESTED VARIABLE SMI PREMIUM APPLIES (H73)
  • (Requested)
  • Caption: Information About Medicare
  • As  (1)  requested, we reviewed the amount of the premium  (2)  each month for medical insurance. We've decided that  (3)  premium should have been  (4)  since January  (5)  . Because we've been charging  (6)   (7)  , it caused  (8)  to get less money in  (9)  Social Security check. This is why we'll lower  (10)  premium.
  • As  (1)  requested, we reviewed the amount of the premium  (2)  each month for medical insurance. We've decided that  (3)  premium should have been  (4)  since January  (5) . Because we've been charging  (6)   (7)  , it caused  (8)  to get less money in  (9)  Social Security check. This is why we'll lower  (10)  premium.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: you
  • Choice 2: Beneficiary's Name
  • Fill-in (2) - Systems Generated
  • Choice 1: you pay
  • Choice 2: he pays
  • Choice 3: she pays
  • Fill-in (3) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (4) - Requested As A Money Amount In Format $$$$$.¢¢
  • Choice 1: Variable premium for SMI, plus surcharge amount
  • Fill-in (5) - Requested As A Date In Format Shown Below
  • Choice 1: CCYY
  • Fill-in (6) - Systems Generated
  • Choice 1: you
  • Choice 2: him
  • Choice 3: her
  • Fill-in (7) - Requested As A Money Amount In Format $$$$$.¢¢
  • Choice 1: Current base premium for SMI, plus surcharge, if applicable
  • Fill-in (8) - Systems Generated
  • Choice 1: you
  • Choice 2: him
  • Choice 3: her
  • Fill-in (9) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (10) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • HIB231 ERRONEOUS SMI TERMINATION EQUITABLE RELIEF GIVEN (H75)
  • (Requested)
  • Caption: Information About Medicare
  • We stopped  (1)  Medical insurance coverage under Medicare in  (2)  by mistake. We are sorry if our error caused  (3)  any inconvenience. We have corrected the mistake, and are starting  (4)  coverage again beginning  (5)  .
  • It might be to  (6)  advantage to start  (7)  medical coverage at an earlier date. We can start the coverage beginning  (8)  . However,  (9)  would have to pay the premiums for this insurance. The total amount of premiums from  (10)  through  (11)  is  (12)  .
  • If  (13)  coverage to start at the earlier date, please let us know within 60 days.  (14)  will need to tell us whether  (15)  to pay us directly for the premiums or have us take the money for the premiums out of  (16)  checks.
  • If  (17)  would like to have coverage beginning  (18)  , but it would be a hardship for  (19)  g to pay the premiums at one time, please let us know.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: your
  • Choice 2: Beneficiary's Name possessive
  • Fill-in (2) - Requested As A Date In Format Shown Below
  • Choice 1: MM/CCYY
  • Fill-in (3) - Systems Generated
  • Choice 1: you
  • Choice 2: him
  • Choice 3: her
  • Fill-in (4) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (5) - Requested As A Date In Format Shown Below
  • Choice 1: MM/CCYY
  • Fill-in (6) - Systems Generated
  • Choice 1: your
  • Choice 2: Beneficiary's Name, possessive
  • Fill-in (7) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (8) - Requested As A Date In Format Shown Below
  • Choice 1: MM/CCYY
  • Fill-in (9) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • Fill-in (10) - Requested As A Date In Format Shown Below
  • Choice 1: MM/CCYY
  • Fill-in (11) - Requested As A Date In Format Shown Below
  • Choice 1: MM/CCYY
  • Fill-in (12) - Requested As A Money Amount In Format $$$$$.¢¢
  • Choice 1: Premium amount due
  • Fill-in (13) - Systems Generated
  • Choice 1: you want
  • Choice 2: he wants
  • Choice 3: she wants
  • Fill-in (14) - Systems Generated
  • Choice 1: You
  • Choice 2: He
  • Choice 3: She
  • Fill-in (15) - Systems Generated
  • Choice 1: you want
  • Choice 2: he wants
  • Choice 3: she wants
  • Fill-in (16) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (17) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • Fill-in (18) - Requested As A Date In Format Shown Below
  • Choice 1: MM/CCYY
  • Fill-in (19) - Systems Generated
  • Choice 1: you
  • Choice 2: him
  • Choice 3: her
  • HIB232 PART B PREMIUM SURCHARGE ROLLBACK (H78)
  • (Requested)
  • Caption: Information About Medicare
  • We reduced the premium  (1)  paying for  (2)  medical insurance under Medicare. This is because of  (3)  health insurance coverage under an employer's health plan.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: you are
  • Choice 2: he is
  • Choice 3: she is
  • Fill-in (2) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (3) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • HIB233 PART B ENROLLEE BENEFITS SUSPENDED FOR WORK (H79)
  • (Requested)
  • Caption: Information About Medicare
  •  (1)  not getting benefits because  (2)  working, so  (3)  to know some special facts about Medicare.  (4)  to consider these facts if  (5)  working for an employer who has 20 or more employees:
  •  (1)  not getting benefits because  (2)  working, so  (3)  to know some special facts about Medicare.  (4)  to consider these facts if  (5)  working for an employer who has 20 or more employees:
  • * If  (6)  covered under  (7)  employer's group health plan, it will pay first for  (8)  g health care needs.
  • * Medicare will not pay any expenses that the group health plan pays for.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: You are
  • Choice 2: Beneficiary's Name is
  • Fill-in (2) - Systems Generated
  • Choice 1: you are
  • Choice 2: he is
  • Choice 3: she is
  • Fill-in (3) - Systems Generated
  • Choice 1: you need
  • Choice 2: he needs
  • Choice 3: she needs
  • Fill-in (4) - Systems Generated
  • Choice 1: You only need
  • Choice 2: He only needs
  • Choice 3: She only needs
  • Fill-in (5) - Systems Generated
  • Choice 1: you are
  • Choice 2: he is
  • Choice 3: she is
  • Fill-in (6) - Systems Generated
  • Choice 1: you are
  • Choice 2: he is
  • Choice 3: she is
  • Fill-in (7) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (8) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • HIB234 SMI WITHDRAWAL (H81)
  • (Requested/Generated)
  • Caption: Information About Medicare
  •  (1)  asked that we stop  (2)  medical insurance coverage under Medicare. This coverage ends the last day of  (3)  . If  (4)  g hospital insurance coverage, it will continue.
  •  (1)  asked that we stop  (2)  medical insurance coverage under Medicare. This coverage ends the last day of  (3)  . If  (4)  g hospital insurance coverage, it will continue.
  •  (5) 
  •  (5) 
  • If  (6)  in the future that  (7)  would like to have medical insurance coverage again, please get in touch with us.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: You
  • Choice 2: Beneficiary's Name
  • Fill-in (2) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (3) - Requested As A Date In Format Shown Below
  • Choice 1: MM/CCYY
  • Fill-in (4) - Systems Generated
  • Choice 1: you have
  • Choice 2: he has
  • Choice 3: she has
  • Fill-in (5) - Requested As A One Position Alpha Character
  • Choice 1: (A) We will stop taking premiums out of your Social Security checks. We will change your next payment to account for any premiums still due or any which you have already paid.
  • Choice 2: (B) Null
  • Fill-in (6) - Systems Generated
  • Choice 1: you decide
  • Choice 2: he decides
  • Choice 3: she decides
  • Fill-in (7) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • HIB235 INELIGIBLE FOR HI/SMI DIB CESSATION PRIOR TO 25TH MONTH (H83)
  • (System Generated)
  • Caption: Information About Medicare
  • Since  (1)  no longer entitled to monthly Social Security benefits,  (2)  will not be eligible for Medicare insurance. Please disregard any information we may have given  (3)  about Medicare.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: you are
  • Choice 2: Beneficiary's Name is
  • Fill-in (2) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • Fill-in (3) - Systems Generated
  • Choice 1: you
  • Choice 2: him
  • Choice 3: her
  • HIB236 PREMIUM ADJUSTMENT DUE TO SMI TERMINATION (H85)
  • (Requested/Generated)
  • Caption: Information About Medicare
  • Because we stopped  (1)  medical insurance, under Medicare, we will change the payment  (2)  will receive around  (3)  by  (4)  to account for premiums which were  (5)  g .
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: your
  • Choice 2: Beneficiary's Name possessive
  • Fill-in (2) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • Fill-in (3) - Requested As A Date In Format Shown Below
  • Choice 1: MM/DD/CCYY
  • Fill-in (4) - Requested As A Money Amount In Format $$$$$.¢¢
  • Choice 1: Money amount
  • Fill-in (5) - Requested As A One Position Alpha Character
  • Choice 1: (A) still due
  • Choice 2: (B) already paid
  • HIB237 DISABILITY CESSATION PREMIUMS DUE FOR FUTURE MONTH(S) (H86)
  • (Requested/Generated)
  • Caption: Information About Medicare
  • The premiums for medical insurance under Medicare are paid 1 month in advance. Since  (1)  premiums have been paid only through  (2)  ,  (3)  should send us  (4)  to pay for the remaining premiums.
  • Premiums for medical insurance under Medicare are paid 1 month in advance. Since you have only paid  (1)  premiums through  (2) , you owe  (3)  to pay for the remaining premiums.
  • Please make your check or money order payable to the Centers for Medicare & Medicaid Services. Include  (5)  claim number (shown above) on your check or money order. Send your payment to:
  • Centers for Medicare & Medicaid Services
  • Medicare Premium Collection Center
  • PO BOX 790355
  • St Louis, MO 63179-0355
  • Please make your check or money order payable to the Centers for Medicare & Medicaid Services. Include  (4)  Medicare number on your check or money order. Send your payment to:Centers for Medicare & Medicaid ServicesMedicare Premium Collection CenterPO BOX 790355St. Louis, MO 63179-0355
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: your
  • Choice 1: Beneficiary's Name possessive
  • Choice 2: Beneficiary's Name possessive
  • Choice 2: your
  • Fill-in (2) - Requested As A Date In Format Shown Below
  • Choice 1: MM/CCYY
  • Fill-in (3) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • Fill-in (4) - Requested As A Money Amount In Format $$$$$.¢¢
  • Fill-in (3) - Requested As A Money Amount In Format $$$$$.¢¢
  • Choice 1: Money amount
  • Fill-in (5) - Systems Generated
  • Fill-in (4) - Systems Generated
  • Choice 1: your
  • Choice 1: Beneficiary's Name possessive
  • Choice 2: Beneficiary's Name possessive
  • Choice 2: your
  • HIB238 INTRODUCTORY UTI FOR HEALTH PLAN PREMIUMS AND MEDICARE PRESCRIPTION DRUG PLAN COSTS (H88)
  • (Requested/Generated)
  • Caption: Information About Health Plan Premiums And Prescription Drug Plan Costs
  • As  (1)  requested, we will begin deducting  (2)  health plan premiums and Medicare prescription drug plan costs from  (3)  monthly benefit.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: Beneficiary's full name
  • Choice 2: you
  • Fill-in (2) - Systems Generated
  • Choice 1: his
  • Choice 2: her
  • Choice 3: your
  • Fill-in (3) - Systems Generated
  • Choice 1: his
  • Choice 2: her
  • Choice 3: your
  • HIB239 CRD ENTITLEMENT MONTHLY BENEFITS TERMINATED HI ENTITLEMENT CONTINUES (H92)
  • (Requested/Generated)
  • Caption: Information About Medicare
  • Even though  (1)  no longer receiving monthly checks,  (2)  will still have hospital insurance coverage under Medicare. Please keep  (3)  Medicare card.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: you are
  • Choice 2: Beneficiary's name is
  • Fill-in (2) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • Fill-in (3) - Systems Generated
  • Choice 1: your
  • Choice 2: Beneficiary's name, possessive
  • HIB240 ADDRESS CHANGED TO FOREIGN COUNTRY ENTITLED TO HI ONLY (H95)
  • (Requested)
  • Caption: Information About Medicare
  • In most cases, Medicare will only pay for hospital services which  (1)  in the United States. Since  (2)  living outside the U.S., Medicare will not pay for hospital services unless  (3)  to the U.S. for services.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: you receive
  • Choice 2: Beneficiary's Name receives
  • Fill-in (2) - Systems Generated
  • Choice 1: you are
  • Choice 2: he is
  • Choice 3: she is
  • Fill-in (3) - Systems Generated
  • Choice 1: you return
  • Choice 2: he returns
  • Choice 3: she returns
  • HIB241 FOREIGN ADDRESS GENERAL MEDICARE ELIGIBILITY (H96)
  • (Requested)
  • Caption: Information About Medicare
  • In most cases, Medicare will only pay for hospital and medical services which  (1)  in the United States.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: you receive
  • Choice 2: Beneficiary's Name receives
  • HIB242 AUXILIARY BENEFICIARY AGE 65 OR OVER TERMINATED T3, T8 OR T9 NEW HEALTH INSURANCE CARD SMI ONLY (H98)
  • (Requested/Generated)
  • Caption: Information About Medicare
  • Even though  (1)  no longer receiving monthly checks and  (2)  not have hospital insurance coverage under Medicare,  (3)  will still have medical insurance coverage. We will send  (4)  a new Medicare card, which will show that  (5)  medical insurance only.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: you are
  • Choice 2: Beneficiary's name is
  • Fill-in (2) - Systems Generated
  • Choice 1: do
  • Choice 2: does
  • Fill-in (3) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • Fill-in (4) - Systems Generated
  • Choice 1: you
  • Choice 2: him
  • Choice 3: her
  • Fill-in (5) - Systems Generated
  • Choice 1: you now have
  • Choice 2: he now has
  • Choice 3: she now has
  • HIB243 3RD PARTY BUY-IN FOR AUXILIARY BENEFICIARY AGE 65 OR OVER TERMINATED T3, T8 or T9 (H99)
  • (Requested/Generated)
  • Caption: Information About Medicare
  • We charge monthly premiums for  (1)  medical insurance under Medicare.  (2)  will continue to pay these premiums.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: your
  • Choice 2: Beneficiary's Name possessive
  • Fill-in (2) - Requested As A One Position Alpha Character
  • Choice 1: (A) The State where you live
  • Choice 2: (B) The organization you choose
  • HIB244 DIB CESSATION OVERPAYMENT AND PREMIUMS DUE FOR A FUTURE MONTH (H87)
  • (Requested/Generated)
  • Caption: Information About Medicare
  •  (1)  overpayment includes the Medicare medical insurance premiums of  (2)  which we took out of  (3)  checks during the time when  (4)  overpaid. Also,  (5)  not paid  (6)  premiums for  (7)  . For this reason, when  (8)  back  (9)  overpayment  (10)  should include  (11)  to pay for all premiums due.
  •  (1)  overpayment includes the Medicare medical insurance premiums of  (2)  which we took out of  (3)  checks during the time when  (4)  overpaid. Also,  (5)  not paid  (6)  premiums for  (7)  . For this reason, when  (8)  back  (9)  overpayment  (10)  should include  (11)  to pay for all premiums due.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: Your
  • Choice 2: Beneficiary's Name possessive
  • Fill-in (2) - Requested As A Money Amount in Format $$$$$.¢¢
  • Choice 1: Amount
  • Fill-in (3) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (4) - Systems Generated
  • Choice 1: you were
  • Choice 2: he was
  • Choice 3: she was
  • Fill-in (5) - Systems Generated
  • Choice 1: you have
  • Choice 2: he has
  • Choice 3: she has
  • Fill-in (6) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (7) - Requested As A Date In Format Shown Below
  • Choice 1: MMCCYY
  • Fill-in (8) - Systems Generated
  • Choice 1: you pay
  • Choice 2: he pays
  • Choice 3: she pays
  • Fill-in (9) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (10) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • Fill-in (11) - Requested As A Money Amount in Format $$$$$.¢¢
  • Choice 1: Amount
  • HIB249 EQUITABLE RELIEF FOR V-SMI CASES ONLY (HC2)
  • (Requested/Generated)
  • Caption: Information About Medicare
  • If you want your medical insurance to start earlier, you can choose to have it start in  (1)  . To start your medical insurance earlier, you must do the following things within 60 days after the date of this notice:
  • * tell us in writing that you want medical insurance beginning  (2)  g ;
  • AND
  • * pay us  (3)  or tell us we can withhold this amount from your check. This amount covers the premiums due from  (4)  through  (5)  .
  • If you would find it hard to pay the premium amount you would owe in a lump sum, ask us about other ways to pay the premium.
  • If you choose to have your medical insurance start in  (6)  , your current monthly premium will be  (7)  . If you do not choose the earlier date, your monthly premium will be  (8)  .
  • Fill-in values:
  • Fill-in (1) - Requested As A Date In Format Shown Below
  • Choice 1: MM/CCYY
  • Fill-in (2) - Requested As A Date In Format Shown Below
  • Choice 1: MM/CCYY
  • Fill-in (3) - Requested As A Money Amount in Format $$$$$.¢¢
  • Choice 1: Amount
  • Fill-in (4) - Requested As A Date In Format Shown Below
  • Choice 1: MM/CCYY
  • Fill-in (5) - Requested As A Date In Format Shown Below
  • Choice 1: MM/CCYY
  • Fill-in (6) - Requested As A Date In Format Shown Below
  • Choice 1: MM/CCYY
  • Fill-in (7) - Requested As A Money Amount in Format $$$$$.¢¢
  • Choice 1: Amount
  • Fill-in (8) - Requested As A Money Amount in Format $$$$$.¢¢
  • Choice 1: Amount
  • HIB250 CHANGE IN RESIDENCE AFFECTS PREMIUM AMOUNT CATASTROPHIC LEGISLATION (H76)
  • (System Generated)
  • Caption: Information About Medicare
  • Beginning  (1)  we are changing  (2)  monthly Medicare premium rate to  (3)  because of  (4)  change in residence.
  • Fill-in values:
  • Fill-in (1) - Requested As A Date In Format Shown Below
  • Choice 1: MM/CCYY
  • Fill-in (2) - Systems Generated
  • Choice 1: your
  • Choice 2: Beneficiary's Name possessive
  • Fill-in (3) - Requested As A Money Amount In Format $$$$$.¢¢
  • Choice 1: Premium Amount
  • Fill-in (4) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • HIB251 WORK REINSTATEMENT NO SMI (H77)
  • (Requested)
  • Caption: Information About Medicare
  •  (1)  getting benefits because  (2)  stopped working, so  (3)  to know some special facts about Medicare.  (4)  to consider these facts if  (5)  covered under an employer group health plan while  (6)  working:
  • *  (7)  may enroll for medical insurance under Medicare up until 8 months after  (8)  working.
  •  (1)  getting benefits because  (2)  stopped working, so  (3)  to know some special facts about Medicare.  (4)  to consider these facts if  (5)  covered under an employer group health plan while  (6)  working:
  • *  (7)  may enroll for medical insurance under Medicare up until 8 months after  (8)  working.
  • * If  (9)  for medical insurance during the 8 months,  (10)  coverage will start sooner than if  (11)  until the regular enrollment time of January through March.
  • * Also,  (12)  may have to pay a premium penalty if  (13)  a full 12 months when  (14)  could have been, but  (15)  not, covered by Medicare. We do not count months of employer group health plan coverage when figuring the 12-month period.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: You are
  • Choice 2: Beneficiary name is
  • Fill-in (2) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • Fill-in (3) - Systems Generated
  • Choice 1: you need
  • Choice 2: he needs
  • Choice 3: she needs
  • Fill-in (4) - Systems Generated
  • Choice 1: You only need
  • Choice 2: He only needs
  • Choice 3: She only needs
  • Fill-in (5) - Systems Generated
  • Choice 1: you were
  • Choice 2: he was
  • Choice 3: she was
  • Fill-in (6) - Systems Generated
  • Choice 1: you were
  • Choice 2: he was
  • Choice 3: she was
  • Fill-in (7) - Systems Generated
  • Choice 1: You
  • Choice 2: He
  • Choice 3: She
  • Fill-in (8) - Systems Generated
  • Choice 1: you stop
  • Choice 2: he stops
  • Choice 3: she stops
  • Fill-in (9) - Systems Generated
  • Choice 1: you enroll
  • Choice 2: he enrolls
  • Choice 3: she enrolls
  • Fill-in (10) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (11) - Systems Generated
  • Choice 1: you wait
  • Choice 2: he waits
  • Choice 3: she waits
  • Fill-in (12) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • Fill-in (13) - Systems Generated
  • Choice 1: you have
  • Choice 2: he has
  • Choice 3: she has
  • Fill-in (14) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • Fill-in (15) - Systems Generated
  • Choice 1: were
  • Choice 2: was
  • HIB252 EQUITABLE RELIEF UNTIMELY PROCESSING (H49)
  • (Requested/Generated)
  • Caption: Information About Medicare
  • We did not give  (1)  earlier medical insurance because we did not process it timely. If  (2)  to have these benefits earlier,  (3)  can choose medical insurance benefits beginning  (4)  . If  (5)  this benefit to start earlier,  (6)  must do the following things within 60 days after the date of this notice:
  • * tell us in writing that  (7)  the medical insurance benefits beginning  (8)  ;
  • * pay us  (9)  (this covers the premiums due from  (10)  through  (11)  ); or,
  • * tell us we can withhold this amount from the check.
  • If  (12)  the benefits beginning  (13)  but  (14)  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) - Systems Generated
  • Choice 1: Beneficiary name
  • Choice 2: you
  • Fill-in (2) - Systems Generated
  • Choice 1: you want
  • Choice 2: he wants
  • Choice 3: she wants
  • Fill-in (3) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • Fill-in (4) - Requested As A Date In Format Shown Below
  • Choice 1: MM/CCYY
  • Fill-in (5) - Systems Generated
  • Choice 1: you want
  • Choice 2: he wants
  • Choice 3: she wants
  • Fill-in (6) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • Fill-in (7) - Systems Generated
  • Choice 1: you want
  • Choice 2: he wants
  • Choice 3: she wants
  • Fill-in (8) - Requested As A Date In Format Shown Below
  • Choice 1: MM/CCYY
  • Fill-in (9) - Requested As A Money Amount in Format $$$$$.¢¢
  • Choice 1: Total amount of medical insurance premiums
  • Fill-in (10) - Requested As A Date In Format Shown Below
  • Choice 1: MM/CCYY
  • Fill-in (11) - Requested As A Date In Format Shown Below
  • Choice 1: MM/CCYY
  • Fill-in (12) - Systems Generated
  • Choice 1: you want
  • Choice 2: he wants
  • Choice 3: she wants
  • Fill-in (13) - Requested As A Date In Format Shown Below
  • Choice 1: MM/CCYY
  • Fill-in (14) - Systems Generated
  • Choice 1: find
  • Choice 2: finds
  • HIB254 CHANGE IN DATE OF ENTITLEMENT TO HI AND SMI (H14)
  • (Requested/Generated)
  • Caption: Information About Medicare
  • We have changed the date of  (1)  entitlement to hospital and medical insurance under Medicare.  (2)  new entitlement date is  (3)  . We will take any premiums due for the insurance out of  (4)  g next check.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: your
  • Choice 2: Beneficiary's Name possessive
  • Fill-in (2) - Systems Generated
  • Choice 1: Your
  • Choice 2: His
  • Choice 3: Her
  • Fill-in (3) - Requested As A Date In Format Shown Below
  • Choice 1: MM/CCYY
  • Fill-in (4) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • HIB255 CHANGE IN DATE OF ENTITLEMENT TO HI (H15)
  • (Requested/Generated)
  • Caption: Information About Medicare
  • We have changed the date of  (1)  entitlement to hospital insurance under Medicare.  (2)  new entitlement date is  (3)  .
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: your
  • Choice 2: Beneficiary's Name possessive
  • Fill-in (2) - Systems Generated
  • Choice 1: Your
  • Choice 2: His
  • Choice 3: Her
  • Fill-in (3) - Requested As A Date In Format Shown Below
  • Choice 1: MM/CCYY
  • HIB256 FUTURE MEDICARE COVERAGE (H07)
  • (Requested/Generated)
  • Caption: Information About Medicare
  •  (1)  may be able to buy Medicare coverage in the future. If  (2)  a citizen of the United States,  (3)  can buy Medicare as soon as  (4)  to this country. If  (5)  not a citizen,  (6)  can buy Medicare only after  (7)  lived in the United States for five years in a row. These must be the five years right before  (8)  for Medicare. Also, as an alien  (9)  must be lawfully admitted for permanent residence.
  •  (1)  may be able to buy Medicare coverage in the future. If  (2)  a citizen of the United States,  (3)  can buy Medicare as soon as  (4)  to this country. If  (5)  not a citizen,  (6)  can buy Medicare only after  (7)  lived in the United States for five years in a row. These must be the five years right before  (8)  for Medicare. Also, as an alien  (9)  must be lawfully admitted for permanent residence.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: You
  • Choice 2: Beneficiary's name
  • Fill-in (2) - Systems Generated
  • Choice 1: you are
  • Choice 2: he is
  • Choice 3: she is
  • Fill-in (3) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • Fill-in (4) - Systems Generated
  • Choice 1: you return
  • Choice 2: he returns
  • Choice 3: she returns
  • Fill-in (5) - Systems Generated
  • Choice 1: you are
  • Choice 2: he is
  • Choice 3: she is
  • Fill-in (6) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • Fill-in (7) - Systems Generated
  • Choice 1: you have
  • Choice 2: he has
  • Choice 3: she has
  • Fill-in (8) - Systems Generated
  • Choice 1: you apply
  • Choice 2: he applies
  • Choice 3: she
  • Fill-in (9) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • HIB257 WHAT HOSPITAL INSURANCE WILL PAY (H27)
  • (Requested/Generated)
  • Caption: Information About Medicare
  • Hospital insurance will pay most hospital bills and certain post-hospital expenses. Medical insurance will help pay much of the medical expenses incurred for physicians and other medical services. This notice shows whether  (1)  entitled to hospital insurance only, medical insurance only, or both hospital and medical insurance. Benefits are payable if covered services were rendered on or after the entitlement date shown.  (2)  will receive by mail a health insurance card and a booklet explaining how to use the card, what services are covered, and the methods of claiming benefits for covered services. If  (3)  planning changes in any other hospital or medical insurance  (4)  , remember that Social Security health insurance coverage will be effective with the dates shown on this notice.
  • If  (5)  help with medical expenses before  (6)  health insurance coverage begins, or if  (7)  aid in meeting medical expenses not covered by  (8)  health insurance,  (9)  may want to get in touch with the nearest social services office to see whether  (10)  eligible under a program of medical assistance.
  • Notify any Social Security office immediately if  (11)   (12)  address so that  (13)  health insurance card and any claims or informational material may reach  (14)  promptly.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: you are
  • Choice 2: Beneficiary's name + is
  • Fill-in (2) - Systems Generated
  • Choice 1: You
  • Choice 2: He
  • Choice 3: She
  • Fill-in (3) - Systems Generated
  • Choice 1: you are
  • Choice 2: he is
  • Choice 3: she is
  • Fill-in (4) - Systems Generated
  • Choice 1: you now have
  • Choice 2: he now has
  • Choice 3: she now has
  • Fill-in (5) - Systems Generated
  • Choice 1: you need
  • Choice 2: he needs
  • Choice 3: she needs
  • Fill-in (6) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (7) - Systems Generated
  • Choice 1: you need
  • Choice 2: he needs
  • Choice 3: she needs
  • Fill-in (8) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (9) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • Fill-in (10) - Systems Generated
  • Choice 1: you are
  • Choice 2: he is
  • Choice 3: she is
  • Fill-in (11) - Systems Generated
  • Choice 1: you change
  • Choice 2: he changes
  • Choice 3: she changes
  • Fill-in (12) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (13) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (14) - Systems Generated
  • Choice 1: you
  • Choice 2: him
  • Choice 3: her
  • HIB258 OPENING INTRO WHEN BENEFICIARY IS ENTITLED TO MEDICARE BENEFITS UNDER TITLE XVIII
  • (Requested/Generated)
  • Caption: None
  • This certifies that  (1)  entitled under Title XVIII of the Social Security Act to the Medicare benefits shown, beginning with the date indicated.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: you are
  • Choice 2: Beneficiary's name + is
  • HIB259 SMI PREMIUM AMOUNTS AND EFFECTIVE DATES (H21 DETAIL LINE)
  • (Systems Generated)
  • Caption: Information About Medicare
  •  (1)   (2) 
  •  (1)   (2) 
  • NOTE: This UTI is automatically generated whenever HIB193 is requested/generated and there is more than one row of data to display in Fill-ins two and three under the headers in the chart.
  • Fill-in values:
  • Fill-in (1) - Systems Generated As A Date In Format Shown Below
  • Choice 1: MM/CCYY
  • Fill-in (2) - Systems Generated As A Money Amount In Format $$$$$.¢¢
  • Choice 1: Amount of SMI premium
  • HIB260 IRMAA
  • (System Generated)
  • Caption: Information About Medicare
  • As we told you in another letter, you owe more Medicare premiums because  (1)  income-related monthly adjustment amounts changed.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: Name possessive
  • Choice 2: your
  • HIB261 IRMAA
  • (System Generated)
  • Caption: Information About Medicare
  • You owe  (1)  for Medicare Part B (medical insurance) premiums for  (2)   (3)   (4)  .
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: Total Amount in $$$$$¢¢ format
  • Fill-in (2) - Systems Generated
  • Choice 1: MM/CCYY
  • Fill-in (3) - Systems Generated
  • Choice 1: null
  • Choice 2: and
  • Choice 3: through
  • Fill-in (4) - Systems Generated
  • Choice 1: null
  • Choice 2: MM/CCYY
  • HIB262 IRMAA D
  • (System Generated)
  • Caption: Information About Medicare
  • You owe  (1)  for Medicare prescription drug coverage income-related monthly adjustment amounts for  (2)   (3)   (4)  .
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: Total Amount in $$$$$¢¢ format
  • Fill-in (2) - Systems Generated
  • Choice 1: MM/CCYY
  • Fill-in (3) - Systems Generated
  • Choice 1: null
  • Choice 2: and
  • Choice 3: through
  • Fill-in (4) - Systems Generated
  • Choice 1: null
  • Choice 2: MM/CCYY
  • HIB263 IRMAA B and D
  • (System Generated)
  • Caption: Information About Medicare
  • The total past-due Medicare amounts you owe are  (1)  .
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: Total Amount in $$$$$¢¢ format
  • HIB264 IRMAA Waiver Request
  • (System Generated)
  • Caption: Information About Medicare
  • If you would find it hard to pay the past-due Medicare amounts  (1)  at one time, please ask us about other ways to pay them. You may ask for waiver of these past-due Medicare amounts if paying them would be a severe financial hardship for you. If we do not hear from you within 30 days after the date of this letter, we will take the Medicare amounts  (2)  out of  (3)  monthly Social Security payments beginning  (4)  .
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: he owes
  • Choice 2: she owes
  • Choice 3: you owe
  • Fill-in (2) - Systems Generated
  • Choice 1: he owes
  • Choice 2: she owes
  • Choice 3: you owe
  • Fill-in (3) - Systems Generated
  • Choice 1: his
  • Choice 2: her
  • Choice 3: your
  • Fill-in (4) - Systems Generated
  • Choice 1: MM/CCYY (COM + 2 months)
  • HIB265 IRMAA Deduction
  • (System Generated)
  • Caption: Information About Medicare
  • We will deduct  (1)  current Medicare Part B (medical insurance) premium from  (2)  monthly Social Security payments beginning  (3)  .
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: Name possessive
  • Choice 2: your
  • Fill-in (2) - Systems Generated
  • Choice 1: his
  • Choice 2: her
  • Choice 3: your
  • Fill-in (3) - Systems Generated
  • Choice 1: MM/CCYY (COM)
  • HIB266 IRMAA B Deduction
  • (System Generated)
  • Caption: Information About Medicare
  • We will also deduct  (1)  for past-due Medicare Part B (medical insurance) premiums.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: Amount in $$$$$¢¢ format
  • HIB267 IRMAA D Deduction
  • (System Generated)
  • Caption: Information About Medicare
  • We will also deduct  (1)  for past-due Medicare prescription drug coverage income-related monthly adjustment amounts.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: Amount in $$$$$¢¢ format
  • HIB268 IRMAA Partial Recovery
  • (System Generated)
  • Caption: Information About Medicare
  • We will deduct past-due Medicare prescription drug coverage income-related monthly adjustment amounts from your monthly Social Security payments beginning  (1)  . The total amount we will deduct is  (2)  .
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: MM/CCYY (COM)
  • Fill-in (2) - Systems Generated
  • Choice 1: Amount in $$$$$¢¢ format
  • HIB269 IRMAA Total Withholding
  • (System Generated)
  • Caption: Information About Medicare
  • We will withhold  (1)  monthly payments until you have paid all of the past-due Medicare amounts  (2)  .
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: Name possessive
  • Choice 2: your
  • Fill-in (2) - Systems Generated
  • Choice 1: he owes
  • Choice 2: she owes
  • Choice 3: you owe
  • HIB270 IRMAA PART B Arrearage
  • (System Generated)
  • Caption: Information About Medicare
  • We will deduct past due Medicare Part B (medical insurance) premiums from your monthly Social Security payments beginning  (1)  . The total amount we will deduct is  (2)  .
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: MM/CCYY (COM)
  • Fill-in (2) - Systems Generated
  • Choice 1: Amount in $$$$$.¢¢ format
  • HIB271 IRMAA D and/or B Installment Payment
  • (System Generated)
  • Caption: Information About Your Installment Payment
  • As you requested, we will withhold  (1)  from  (2)  monthly Social Security payments beginning  (3)  for past due Medicare amounts owed. We will withhold  (4)  each month until you have paid all of the past due Medicare amounts you owe.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: Amount in $$$$$.¢¢ format
  • Fill-in (2) - Systems Generated
  • Choice 1: Name possessive
  • Choice 2: your
  • Fill-in (3) - Systems Generated
  • Choice 1: MM/CCYY (COM)
  • Fill-in (4) - Systems Generated
  • Choice 1: Amount in $$$$$.¢¢ format
  • HIBR60 MEDICAL INSURANCE INFORMATION PRIMARY IS IMPRISONED OR CONFINED (H03)
  • (Requested)
  • Caption: Information About Medicare
  • Generally, Medicare will not pay for hospital or medical items or services  (1)  while  (2)   (3)  . However, you may want to pay  (4)  Medicare medical insurance premiums for two reasons:
  • * The premiums may be higher if you cancel the Medicare medical insurance now and re-enroll after  (5)  released from  (6)  .
  •  (7)  may not have medical insurance for a period of time after  (8)  released from  (9)  . This is because  (10)  will have to wait until a general enrollment period to re-enroll. A general enrollment period takes place in January, February and March of each year.
  •  (7)  may not have medical insurance for a period of time after  (8)  released from  (9)  . This is because  (10)  will have to wait until a general enrollment period to re-enroll. A general enrollment period takes place in January, February and March of each year.
  • * If you want to cancel  (11)  medical insurance, please let us know. If you decide to keep Medicare medical insurance, we will bill you for the premium. The first bill we send will be for a 3-month period and will be sent to you shortly before the payment is due.
  • Fill-in values:
  • Fill-in (1) - Systems Generated
  • Choice 1: you receive
  • Choice 2: Beneficiary's Name receives
  • Fill-in (2) - Systems Generated
  • Choice 1: you are
  • Choice 2: he is
  • Choice 3: she is
  • Fill-in (3) - Requested As A One Position Alpha Character
  • Choice 1: (A) imprisoned
  • Choice 2: (B) confined in a institution
  • Fill-in (4) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her
  • Fill-in (5) - Systems Generated
  • Choice 1: you are
  • Choice 2: he is
  • Choice 3: she is
  • Fill-in (6) - Systems Generated
  • Choice 1: prison
  • Choice 2: the institution
  • Fill-in (7) - Systems Generated
  • Choice 1: You
  • Choice 2: He
  • Choice 3: She
  • Fill-in (8) - Systems Generated
  • Choice 1: you are
  • Choice 2: he is
  • Choice 3: she is
  • Fill-in (9) - Systems Generated
  • Choice 1: prison
  • Choice 2: the institution
  • Fill-in (10) - Systems Generated
  • Choice 1: you
  • Choice 2: he
  • Choice 3: she
  • Fill-in (11) - Systems Generated
  • Choice 1: your
  • Choice 2: his
  • Choice 3: her