NL 00720: Manual Adjustment, Credit and Award Process (MADCAP) Beneficiary Notice Print Program
TN 9 (06-18)
HIB002 TEMPORARY SUBSTITUTION OF NOTICE FOR HEALTH INSURANCE CARD (H23)
(Requested/Generated)
Caption: Information About 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: You
Choice 2: Beneficiary's Name
Fill-in (2) - Systems Generated
Choice 1: You should
Choice 2: He should
Choice 3: She should
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 have
Choice 2: he has
Choice 3: she has
Fill-in (5) - Systems Generated
Choice 1: your
Choice 2: his
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.
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.
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.
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
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.
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.
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.
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.
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.
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.
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).
People who have Part B pay a monthly premium. If (4) not sign up for Part B when (5) first eligible, (6) may have to pay a late enrollment penalty for as long as (7) Part B. (8) monthly premium may go up 10 percent for each full 12-month period that (9) could have had Part B coverage, but did not sign up for it. Usually (10) will not have to pay a late enrollment penalty if ( (11) ) up during a special enrollment period.
If (12) to sign up for Part B after (13) , (14) will usually have to wait until the general enrollment period. The general enrollment period takes place in January, February, and March of each year. If (15) up in the general enrollment period, (16) Part B coverage will start July 1 of the year (17) up.
(18) may also be able to sign up during a special enrollment period. (19) can do this if (20) one of the conditions listed below:
(21) covered under a group health plan through (22) current work or (23) spouse's current work,
(24) covered under a large group health plan through (25) current work or any family member's current work.
(26) may sign up for medical insurance at any time (27) covered under the group health plan. However, (28) may wait and sign up during the 8-month period that begins when the work ends or (29) coverage under the plan ends, whichever occurs first. (30) may also sign up if the type of plan (31) changes.
NOTE: COBRA and Retiree health coverage do not count as health insurance based on current employment.
Deciding when to sign up for Part B may depend on how (32) health insurance works with Medicare. For example, a group health plan is usually not the primary insurance if the employer has less than 20 employees. In this case, it is important to have Medicare coverage, and you may want to sign up now.
If (33) help deciding what to do, please contact (34) employee benefits office or contact us.
Fill-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.
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) .
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)
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.
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) .
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.
(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.
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 $$$$$.¢¢
Choice 1: Amount of premiums
HIB221 PREMIUM ADJUSTMENT DUE TO CURRENT SMI ENTITLEMENT AND PRIOR PERIOD OF SMI ENTITLEMENT (H65)
(Requested/Generated)
Caption: Information About Medicare
We will (1) the payment (2) will receive shortly after (3) by (4) because of medical insurance premiums. When we figured the amount of (5) payment, we took into account all the medical insurance premiums which were previously paid or still due. We will deduct medical insurance premiums 1 month in advance.
Fill-in values:
Fill-in (1) - Requested As A One Position Alpha Character
Choice 1: (A) reduce
Choice 2: (B) increase
Fill-in (2) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (3) - Requested As A Date In Format Shown Below
Choice 1: MM/DD/CCYY
Fill-in (4) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Amount (PDA)
Fill-in (5) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
HIB223 SUBSEQUENT PREMIUM AND PINQ RECORD ADJUSTMENT (H66)
(System Generated)
Caption: Information About Medicare
We will (1) the payment (2) will receive after (3) by (4) because of medical insurance premiums which were (5) .
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: increase
Choice 2: reduce
Fill-in (2) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (3) - Systems Generated
Choice 1: MM/DD/CCYY
Fill-in (4) - Systems Generated
Choice 1: Amount (PDA)
Fill-in (5) - Requested As A One Position Alpha Character
Choice A: already paid
Choice B: owed
HIB224 PREMIUM AND PINQ RECORD ADJUSTMENT DUE TO RESUMPTION OF BENEFITS (H67)
(Requested/Generated)
Caption: Information About Medicare
We are (1) (2) next payment by (3) because of the medical insurance premiums (4) . After that we will take premiums out of (5) regular checks each month.
Fill-in values:
Fill-in (1) - Requested As A One Position Alpha Character
Choice 1: (A) reducing
Choice 2: (B) increasing
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: Beneficiary's Name possessive
Fill-in (3) - Requested As A Money Amount in Format $$$$$.¢¢
Choice 1: Amount
Fill-in (4) - Requested As A One Position Alpha Character
Choice 1: (A) you owe
Choice 2: (B) he owes
Choice 3: (C) she owes
Choice 4: (D) already paid
Fill-in (5) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
HIB228 SMI PREMIUM CHANGED TO VARIABLE RATE DUE TO DELAYED DECEMBER COM PROCESSING (H72)
(Requested)
Caption: Information About Medicare
We have determined that the premium amount of (1) , which (2) now being charged, should be reduced to (3) effective with January of this year. This reduction in (4) premium is being made because the increase in (5) premium as of January 1st resulted in a decrease in (6) monthly Social Security check. The law permits us to reduce the Part B premium amount as necessary (but not below the amount (7) paid in December of last year) if the yearly change in the premium would cause the Social Security checks (8) this year to be lower than the checks (9) last year.
Fill-in values:
Fill-in (1) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: SMI premium rate
Fill-in (2) - Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (3) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: New variable SMI rate
Fill-in (4) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (5) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (6) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (7) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (8) - Systems Generated
Choice 1: you receive
Choice 2: he receives
Choice 3: she receives
Fill-in (9) - Systems Generated
Choice 1: you received
Choice 2: he received
Choice 3: she received
HIB229 REVIEW REQUESTED VARIABLE SMI PREMIUM APPLIES (H73)
(Requested)
Caption: Information About Medicare
As (1) requested, we reviewed the amount of the premium (2) each month for medical insurance. We've decided that (3) premium should have been (4) since January (5) . Because we've been charging (6) (7) , it caused (8) to get less money in (9) Social Security check. This is why we'll lower (10) premium.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (2) - Systems Generated
Choice 1: you pay
Choice 2: he pays
Choice 3: she pays
Fill-in (3) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (4) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Variable premium for SMI, plus surcharge amount
Fill-in (5) - Requested As A Date In Format Shown Below
Choice 1: CCYY
Fill-in (6) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (7) - Requested As A Money Amount In Format $$$$$.¢¢
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:
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.
(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 $$$$$.¢¢
Choice 1: Money amount
Fill-in (5) - Requested As A One Position Alpha Character
Choice 1: (A) still due
Choice 2: (B) already paid
HIB237 DISABILITY CESSATION PREMIUMS DUE FOR FUTURE MONTH(S) (H86)
(Requested/Generated)
Caption: Information About Medicare
Premiums for medical insurance under Medicare are paid 1 month in advance. Since you have only paid (1) premiums through (2) , you owe (3) to pay for the remaining premiums.
Please make your check or money order payable to the “Centers for Medicare & Medicaid Services”. Include (4) Medicare number on your check or money order. Send your payment to:
Centers for Medicare & Medicaid ServicesMedicare Premium Collection Center
PO BOX 790355
St. Louis, MO 63179-0355
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary's Name possessive
Choice 2: your
Fill-in (2) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (3) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Money amount
Fill-in (4) - Systems Generated
Choice 1: 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.
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.
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.
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)
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.
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