2011 Irmaa Medicare Part B Reimbursement Claim Submission Form printable pdf download

City of New York Health Benefits Program

IRMAA Medicare Part B Reimbursement Claim Instructions

A new federal law requires that some beneficiaries pay a higher premium for Medicare Part B coverage based on

their income . If you and/or your eligible dependent paid a Medicare Part B income-related monthly adjustment

amount (IRMAA) during CALENDAR YEAR 2011 - which means more than the standard Medicare Part B

monthly premium during 2011- you may be entitled to an additional reimbursement (surcharge for late

enrollment does not qualify as an amount that is eligible for additional reimbursement).

To claim the additional reimbursement you are required to document the eligible amount paid in excess of the

standard premium. Please submit the following documentation as requested below:

Required Documentation

You MUST submit BOTH items indicated below to receive a reimbursement.

(See other side for sample documentation forms)

Submit a copy of your and/or your eligible dependent’s Social Security Administration (SSA) statement

issued to you and/or your eligible dependent at the end of CALENDAR YEAR 2010 showing what the income-

related monthly adjustment amount will be in CALENDAR YEAR 2011.

AND

Submit a copy of your and/or your eligible dependent’s Form SSA-1099 sent to you by the SSA in January of

2012, as proof of the monthly Medicare Part B premium actually paid for CALENDAR YEAR 2011. If you

cannot provide a Form SSA-1099 because you did not receive Social Security benefits in 2011 you must provide

official documentation that you paid Medicare premiums in 2011 (a receipt from Social Security, cancelled

checks for Medicare premium payment, or similar official documentation).

YOU MUST INCLUDE THE RETIREE’S NAME AND FULL SOCIAL SECURITY NUMBER ON ANY

ELIGIBLE DEPENDENT’S DOCUMENTS.

If you need a replacement copy of your IRMAA notice you can obtain one from your local Social Security

office, which can be located on the following website: This

website can also be accessed to request a copy of the SSA-1099.

Submit copies of both of the documents listed above for each eligible person, along with a completed

Submission Form, to:

City of New York, Office of Labor Relations

Health Benefits Program

40 Rector Street, 3

Floor

New York, NY 10006

Attention: IRMAA

IRMAA reimbursements checks will be issued beginning in March 2013.

(Claims that do not include both documents for each eligible person and claims that include documents

for years other than the years specified above WILL NOT BE EVALUATED.)

2011 Irmaa Medicare Part B Reimbursement Claim Submission Form