Form Cms-500 - Medicare Premium Bill - Sample Page 2

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To pay your bill online – Contact your bank for information on how to sign up for their Online Bill Pay Service and pay
your premiums directly from a bank account. For more information on paying your bill online, visit Medicare.gov, or call
1-800-MEDICARE (1-800-633-4227). Teletypewriter (TTY) users should call 1-877-486-2048.
If you use Medicare Easy Pay to pay your premiums, and the box on the front in the upper right says “This is not
a bill,” your premium payment will be deducted from your bank account around the 20th of the month. Keep this
statement for your records. By signing up for Medicare Easy Pay, you can have your Medicare premiums automatically
deducted from your checking or savings account each month. For information on how to sign up, visit Medicare.gov, or
call 1-800-MEDICARE.
Payments by check or money order – Make a check or money order payable to “CMS Medicare Insurance.” When
you pay by check, you authorize the Medicare Premium Collection Center (MPCC) to use the information from your
check to make a one-time electronic funds transfer from your bank account or to process the payment as a check
transaction. Your bank statement will show the transaction as “CMS Medicare.”
Payments by credit/debit card – Credit/debit card payments need a signature. Fill out the credit/debit card section in
the coupon on the front of the bill and sign it. Medicare can’t set up automatic monthly credit/debit card payments.
• If you have questions about your Part A or Part B bill amount or Part A or Part B insurance, call Social Security
at 1-800-772-1213, or write or visit any Social Security office. TTY users should call 1-800-325-0778.
• If you have questions about your IRMAA Part D bill amount, call 1-800-MEDICARE (1-800-633-4227). TTY users
should call 1-877-486-2048.
• If you need help paying your Medicare costs, call or visit your State Medical Assistance (Medicaid) office, and
ask for information on Medicare Savings Programs. You can also contact your State Health Insurance Assistance
Program (SHIP). To get the phone numbers for your state, visit Medicare.gov/contacts, or call 1-800-MEDICARE.
• For more information about this bill, visit Medicare.gov and type “CMS-500” in the Search box.
• CMS doesn’t discriminate in its programs and activities. To request this publication in an alternate format, please
call 1-800-MEDICARE or email AltFormatRequest@cms.hhs.gov. TTY users should call 1-877-486-2048.
What if I don’t pay my Part A or Part B premium? You’ll lose your coverage, and you must still pay the total premium
amount you owe. You can only reapply for Medicare during the General Enrollment Period from January 1 through
March 31 each year. If you reapply, your coverage will start on July 1 of that year, and you may have to pay a higher
monthly premium amount for Part A as well as a lifetime late enrollment penalty for Part B.
What’s IRMAA & why do I pay for it? This bill may include an Income-Related Monthly Adjustment Amount (IRMAA).
IRMAA is an extra amount you must pay for Part B and Part D coverage because you have a higher income. If you have
IRMAA Part D, you’re billed monthly and it’s included in this bill. Your Part D plan premium is different, and you must
pay the plan premiums to your Medicare drug plan. If you have IRMAA for Part B, it’s included in your Part B premium
amount. Your IRMAA can change each year. For more information about IRMAA, visit socialsecurity.gov.
What if I don’t pay my IRMAA Part D amount? You’ll lose your Part D coverage, even if it’s part of your Medicare
Advantage plan (like an HMO or PPO) or employer coverage. If you sign-up for Part D later, you’ll still have to pay any
IRMAA for Part D you owe, and you may have to pay a monthly penalty for as long as you have Part D coverage.
IF YOUR NAME OR ADDRESS HAS CHANGED (OR IS DIFFERENT FROM THE NAME OR ADDRESS SHOWN ON
THE FRONT OF THIS BILL), PRINT THE CORRECT INFORMATION BELOW:
Last Name
First Name
MI
Street Number
Street Name
Apartment Number
P.O. Box
State
City
Zip Code
–

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