Pay Me Back Claim Form - Medicare Reimbursement Account (Mra) Page 2
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3MRA Pay Me Back Claim Form Instructions
Section 1 – One Time Annual Request for Social Security Administration (SSA)
Deducted Premiums (Medicare Part B)
1. Complete this section if your Medicare Part B premium is deducted from your Social
Security check.
2. In the “Service Start Date” boxes, enter the first of the month in which you are eligible for
Medicare Part B for this year. In the “Service End Date” boxes, enter the last day of the
year. (If eligible for Medicare Part B on January 1, this will be January 1 to December 31.)
3. Enter the annual amount of your Medicare Part B payment (the monthly amount
multiplied by the number of months of coverage.)
4. Include a copy of your Social Security Cost of Living Adjustment (COLA) statement as
proof of your expense (typically mailed starting in November the year before it becomes
effective) or any other Medicare statement that clearly indicates your annual Medicare B
premiums. If your premium is not deducted from your Social Security check, please
complete Section 2 (Health Plan Premiums Not Deducted from Your Social Security
Check) on the claim form in order to be reimbursed.
5. We will reimburse you based on your annual premiums. Your monthly reimbursement
will not be more than the current balance in your account or the maximum benefit
available of $600.
Section 2 – Medicare Part B Healthcare Premiums Not Deducted from Your Social
Security Check
1. Complete this section if your Medicare Part B premiums are:
a. not deducted from your Social Security check, and
b. paid by you on an after-tax basis.
2. Make sure to provide documentation, such as the COLA statement, that shows the
premium you pay. After you have paid your Medicare Part B premium, you may use a
front and back copy of the cleared check, a bank statement or credit card statement that
shows the Medicare Part B premium payment.
3. The Service Start and End Dates should represent the period of coverage you paid for
and want reimbursed. These dates should match the COLA statement.
4. Keep your original receipts and make copies to fax or mail to WageWorks.
Note: Pre-tax deductions for premiums from your payroll or your pension plan are not
eligible for reimbursement.
WW-BCBS-FEP-MRA-RT-PMB-INST (Dec 2017)
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