1199 Seiu Medicare Form PDF Details

The 1199SEIU National Benefit Fund provides a significant avenue for eligible retirees to receive reimbursement for a portion of their Medicare Part B premiums through the Statement of Claim for Medicare Part B Premium Reimbursement. With its headquarters at West 42nd Street in New York, the fund offers a structured framework allowing claims to be filed on a quarterly, semi-annual, or annual basis, according to the needs of the retiree. It requires the submission of Form SSA-1099 for each person and each claim year to facilitate proper reimbursement. Specifically, eligible retirees, whose eligibility is defined by years of service and age at retirement as outlined in the Summary Plan Description, can claim 50% of the basic Medicare Part B premium for themselves and their spouse. For those filing a claim for the first time, presenting a copy of the Medicare Part B ID card alongside this form is mandatory. The policy stipulates that claims can be entertained for the current year and two years prior, emphasizing that reimbursement is strictly for past coverage up to the month the claim is received, negating any future claims. This process underscores the commitment of the 1199SEIU National Benefit Fund to support their members' healthcare needs post-retirement, ensuring they have access to necessary funds to cover essential Medicare Part B premiums.

QuestionAnswer
Form Name1199 Seiu Medicare Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other names1199, 1199 medicare reimbursement form, 1199 eyeglasses reimbursement form, 1199seiu reimbursement

Form Preview Example

1199SEIU National Benefit Fund

330฀West฀42nd฀Street,฀New฀York,฀NY฀10036-6977฀•฀www.1199SEIUBeneits.org฀ Tel฀(646)฀473-9200฀•฀Outside฀NYC฀Area฀Codes:฀(800)฀575-7771

Statement of Claim for Medicare Part B Premium Reimbursement

Filing Claims for Medicare Reimbursement

1.Claims may be filed on a quarterly, semi-annual or annual basis. To ensure proper reimbursement, please submit form SSA-1099 for each person for each claim year.

2.Eligible retirees* may submit a claim for 50% of the basic Medicare Part B premium for the retiree and spouse.

3.If this is your first time filing a claim for Medicare Part B premium reimbursement, you must include a copy of your Medicare Part B ID card with this form.

4.We will accept Medicare Part B premium claims for the current year and the two prior years.

*Eligibility is based on years of service and age at retirement. Check your Summary Plan Description for details.

Please print clearly in black or blue ink

1.

Member’s full name:

 

 

 

 

 

 

 

 

 

Date of birth:

 

/

 

/

 

Telephone: (

 

)

 

 

 

 

Month

 

Day

Year

 

 

 

2.

Spouse’s full name:

 

 

 

 

 

 

 

 

 

 

Date of birth:

 

/

 

/

 

Telephone: (

 

)

 

 

 

 

Month

 

Day

Year

 

 

 

3.

Address:

 

 

 

 

 

 

 

 

 

City:

Is this a new address?

4. Date of retirement:

 

/

 

Month

Yes

/

Day

State:

 

Zip code:

No

Year

5. Check one:

Single

Married

Widowed

Divorced

Legally separated

6. Your Member ID:

Member’s claim

Check box

Jan

Feb

Mar

Apr

May

June

July

Aug

Sept

Oct

Nov

Dec

for months paid

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Spouse’s claim

Year 20____

Check box

for months paid

Jan

Feb

Mar

Apr

May

June

July

Aug

Sept

Oct

Nov

Dec

Year 20____

Medicare Part B reimbursement will not be made for future time periods. Reimbursement will only be made up to and

including the month the claim is received.

7. Member’s signature X

 

Date:

I attest that the person(s) for whom reimbursement is being submitted has active Medicare Part B coverage and may be required to submit proof that the coverage is still in effect. Form will be returned if not signed.

Please complete and return to:

1199SEIU National Benefit Fund

3NBF18฀•฀5/13฀•฀1M

PO Box 2661

New York, NY 10108-2661

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1. First of all, once filling out the statement claim premium reimbursement, start with the page containing next blank fields:

fund medicare reimbursement completion process detailed (part 1)

2. After performing the last section, go on to the subsequent step and complete all required particulars in these blank fields - Spouses claim, Check box, for months paid, Jan, Feb Mar, Apr May, June, July, Aug, Sept, Oct, Nov, Dec, Year , and Medicare Part B reimbursement will.

Filling in part 2 of fund medicare reimbursement

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