Form Hr Ben 031A – Fill Out and Use This PDF

Medicare B Letter (Age 65) Supporting Form

HR-BEN-031a

Section 1 - Information and Instructions

The purpose of this form is to apply for a Medicare Part B Reimbursement. In order to obtain a reimbursement you must sign and date this

application. You must also submit with your application a copy of your Medicare card (the red, white and blue card) and a copy of your Form SSA-1099 issued by the Social Security Administration.

Once a retiree enrolls in Medicare Part B, attains age 65 or is disabled as defined by the Social Security Administration, the member may be entitled to a partial or full refund of their monthly Medicare Part B premiums based upon health plan in which they are enrolled.

1.To be eligible for Medicare Part B reimbursement a retiree must meet all of the following conditions:

A.Receiving a pension from NYCERS, MaBSTOA or MTA Bus.

B.Enrolled in a City or MTA New York City Transit or MTA Bus health plan.

C.Enrolled in Medicare Part B (medical insurance).

D.Paid Medicare premiums in the year in which applying for reimbursement.

E.Employee must not be receiving Medicare Part B reimbursement from another source.

2.To obtain reimbursement, review and make corrections as needed.

3.If your application is not signed and does not include your Medicare card and Form SSA-1099, it will be returned and may delay processing of your reimbursement.

4.Medicare Part B reimbursement ceases at the end of the month in which the retiree dies.

5.Please notify the MTA Business Service Center if you change your address.

6.Reimbursement will be mailed approximately 3 months from the receipt of your completed application.

7.You will receive a confirmation of your returned Medicare Part B reimbursement application.

Please fax a signed copy of the form to 212-852- 8700 or e-mail a signed copy of the form to bscservices@mtabsc.org .

If you have any questions, please contact MTA Business Service Center (BSC) at 646-376-0123 or bscservices@mtabsc.org .

Section 2 – Employee/RetireeInformation

Print Name

BSC ID

Last

First

M.I.

Suffix

Agency

BSC

B&T

CC

HQ Civilian

HQ Police

Department

(check one)

LI Bus

LIRR

MNR

MTA Bus

NYCT

Street Address

City

State

Zip Code

Phone (H)

Phone (W)

E-mail

Section 3 - Declaration

	I declare that the statements contained	in this application are to the best of my knowledge and belief, true and correct and that I have not knowingly
	and willfully made a false statement or given information which I know to be false.
	Your Date of Birth		Your Date of Retirement
	Your Date of Disability		Number of Months
	Your Health Insurance Provider
	Medicare “Part B” Date

Section 4 - Claiming a Spouse

If claiming a spouse, complete this section.

Spouse’s	Name	Spouse’s SSN
Spouse’s	Date of Birth	Medicare “Part B” Date
Spouse’s	Signature	Date

Section 5	- Authorization
I authorize	the Social Security Administration	to furnish to the MTA Business Service Center		any information relating to my enrollment under
Medicare. I agree to refund to the MTA any payment made to which I was not eligible.
Employee Signature			Date		SSN Last 4 Digits

Business ServiceCenter HR-BEN-031a

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