Nyship Form – Fill Out and Use This PDF

2011 MEDICARE PART B

INCOME RELATED ADJUSTMENT AMOUNT (IRMAA)

REIMBURSEMENT APPLICATION

Please complete this form ONLY if you and/or your dependent is subject to the 2011 Medicare Part B

Income Related Adjustment Amount (IRMAA). Submit this completed form and required documentation to:

NYS Department of Civil Service

Employee Benefits Division

Attn: IRMAA Accounting

Alfred E. Smith State Office Building

Albany, NY 12239

						ENROLLEE INFORMATION
Name: Last, First, MI											Social Security Number
			(Last)		(First)					(MI)
Enrollee Mailing Address											Daytime Telephone Number
Address								Apt.#			(with area code)
City				State			Zip Code

check here if this is a change of address

DEPENDENT INFORMATION

If you are applying for reimbursement for your dependent, you must complete the dependent information below.

DOCUMENTS REQUIRED FOR REIMBURSEMENT OF IRMAA

Enrollee (include both of the following)

1.copy of Social Security Administration (SSA) letter stating your 2011 Medicare Part B premium plus your income-related monthly adjustment amount

2.copy of Form SSA-1099 <OR> proof of direct payment (must provide proof of all payments for 2011) (for Railroad Retirement participants: copy of Form RRB-1099, Copy C)

Dependent (include both of the following)

1.copy of Social Security Administration (SSA) letter stating your 2011 Medicare Part B premium plus your income-related monthly adjustment amount

2.copy of Form SSA-1099 <OR> proof of direct payment (must provide proof of all payments for 2011) (for Railroad Retirement participants: copy of Form RRB-1099, Copy C)

By completing and signing this application, I certify that I was or my dependent was required to pay the Medicare Part B

Income Related Adjustment Amount and is not receiving reimbursement from another source.

Enrollee Signature:

Date:

Print Name:

IRMAA reimbursement for both the enrollee and dependent will be issued to the enrollee ONLY. In order for the Employee Benefits Division to speak with the dependent regarding the application for the Income Related Medicare Adjustment Amount (IRMAA), we must have a HIPAA Release Form (EBD-543) completed and signed by the enrollee.

If you need a replacement copy of your 2011 IRMAA notice, which was mailed to you in late 2010, contact your local Social Security office. The location of your local office can be found in your local telephone book or at: www.socialsecurity.gov/onlineservices. This website can also be accessed to request a replacement copy of the form SSA-1099.

You are encouraged to submit your request for NYSHIP reimbursement no later than May 31, 2012. Refunds will be sent as a separate check to your address of record. The refund process will take a minimum of 90-120 days from receipt of documentation.

Medicare Part B Premium Reimbursement From Another Source

Complete the following if you and/or your covered dependent receives full or partial Medicare Part B premium reimbursement from another source, such as your spouse’s former employer:

Enrollee/Dependent Name		Reimbursement Source		Amount or % (per month)

Personal Privacy Protection Law Notification: The information you provide on this form is requested for the principal purpose of authorizing the use and/or disclosure of protected health information pursuant to 45 CFR 164.508. Failure to provide the information may interfere with our ability to use or disclose protected health information necessary to administer NYSHIP and NYPERL. The information will be maintained by the Director of the Employee Benefits Division, Department of Civil Service, Albany, NY 12239. The information will be used in accordance with Public Officers Law section 96(1), also known as the Personal Privacy Protection Law. For information on the Personal Privacy Protection Law, call (518) 457-9375. If you have any questions regarding this form or your insurance coverage, please call (518) 457-5754 or 1-800-833-4344 between the hours of 9:00 a.m. and 3:00 p.m. Monday through Friday.

IRMAA 2011 APPL