1199 SEIU Medicare Form: Eligibility, Requirements, and PDF Details

The 1199SEIU National Benefit Fund gives eligible retirees a way to recover part of their Medicare Part B premiums through the Statement of Claim for Medicare Part B Premium Reimbursement. Based at West 42nd Street in New York, the fund processes claims on a quarterly, semi-annual, or annual basis. Qualifying retirees and their spouses can receive up to 50% of the basic Medicare Part B premium cost.

Who Is Eligible for the 1199SEIU Medicare Reimbursement Benefit

Eligibility is defined by years of service and age at retirement, as outlined in the Summary Plan Description. You must be enrolled in Medicare Part B to qualify for this benefit. Retirees must meet the fund's minimum service requirements and have retired at the age specified in the plan. Spouses of eligible retirees are also covered and may claim 50% reimbursement on their own Medicare Part B premiums. For related benefit documentation, see the 1199SEIU benefit form available on FormsPal.

Documents Required to File a 1199SEIU Medicare Claim

Every claim requires Form SSA-1099 for each person included and for each claim year. First-time filers must attach a copy of the Medicare Part B ID card to their submission. Spouses filing for the first time also need to include their Medicare Part B ID card. Attaching all required documents to your Medicare reimbursement claim helps prevent delays in processing and ensures your payment arrives without complications.

Filing Deadlines and the Claim Period

Claims may cover the current benefit year and up to two prior years. Reimbursement is limited to past coverage through the month the claim is received by the fund. Future coverage cannot be claimed in advance. Retirees should file each year to ensure they receive the full reimbursement they are entitled to. Before submitting, also review whether you need to complete a standard Medicare Part B form as part of your enrollment or renewal process.

How to Submit Your Claim to the 1199SEIU National Benefit Fund

Complete the 1199SEIU Medicare form by providing all identifying information, checking the applicable claim period boxes (quarterly, semi-annual, or annual), and including the required SSA-1099 form. Mail or deliver the completed form along with all supporting documents to the 1199SEIU National Benefit Fund at West 42nd Street, New York. Retirees who need help with similar claims for other benefit types can also find the 1199SEIU optical reimbursement claim on FormsPal. After receiving your submission, the fund will process your claim and issue reimbursement for the covered months.

Claiming Reimbursement for a Spouse or Surviving Dependent

Spouses of 1199SEIU retirees who are enrolled in Medicare Part B may file their own claim for the 50% reimbursement benefit. Surviving spouses of deceased eligible retirees may also qualify to continue receiving the benefit, depending on the rules outlined in the Summary Plan Description. Each eligible person must file their own claim form along with their own SSA-1099 and Medicare Part B ID card. Retirees and dependents looking for supplemental Medicare coverage may also want to review the Medicare supplement form options available through FormsPal.

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: (

 

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Month

 

Day

Year

 

 

 

2.

Spouse’s full name:

 

 

 

 

 

 

 

 

 

 

Date of birth:

 

/

 

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Telephone: (

 

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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

How to Edit 1199 Seiu Medicare Form Online for Free

With the FormsPal online PDF editor, you can complete the 1199SEIU Medicare reimbursement form quickly and accurately. Our editor is updated regularly to provide the best experience for users. Follow these steps to fill in your claim:

Step 1: Access the PDF form by clicking the "Get Form" button at the top of this page.

Step 2: Use the PDF editor to enter text, make corrections, add required attachments, and sign the document electronically. Make sure all required fields are completed properly before moving to the next step.

1. Start by completing the first section of the form, which includes the following fields:

fund medicare reimbursement completion process detailed (part 1)

2. After finishing the first section, move to the second part and complete these 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 amount.

Filling in part 2 of fund medicare reimbursement

Take care when entering the months paid and year fields, as these are a common source of errors. Double-check that you have selected the correct claim period and included all required attachments.

Step 3: After reviewing your completed form, click "Done" to finish. Download the form or save it directly to your FormsPal account for easy access. Your data is private and is never shared or sold.

Frequently Asked Questions About the 1199SEIU Medicare Form

What is the 1199SEIU Medicare Part B Reimbursement Form used for?

The 1199SEIU Medicare Part B Reimbursement Form, also called the Statement of Claim for Medicare Part B Premium Reimbursement, is used by eligible 1199SEIU retirees to claim back a portion of their Medicare Part B premium costs. The 1199SEIU National Benefit Fund processes these claims and provides up to 50% reimbursement of the basic premium for qualifying retirees and their spouses.

How often can I submit a reimbursement claim?

Claims may be filed quarterly, semi-annually, or annually. Each submission covers past months through the date the claim is received by the fund. You can file claims covering the current year and up to two prior years, so it is important not to let old claims expire. Filing regularly ensures you receive the maximum reimbursement you are entitled to each year.

What documents do I need to include with my claim?

You need to include Form SSA-1099 for each person filing and for each claim year. First-time filers must also attach a copy of their Medicare Part B ID card. Related forms that may also be relevant to your benefits include the Medicare Part B Redetermination form and the 1199 notice and proof of claim for disability form, both available on FormsPal.

Can I fill out and submit the 1199SEIU Medicare form online?

Yes. Using the FormsPal online PDF editor, you can fill in all required fields of the 1199SEIU Medicare form directly in your browser. After completing the form, you can download a filled PDF and mail it to the 1199SEIU National Benefit Fund. The editor supports text entry, signature, and field completion without requiring any software installation.

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