Island Park UFSD
2018 Medicare Part B and IRMAA
Reimbursement Claim Instructions
You are receiving this notice as a Medicare primary enrollee or dependent under the New York State Health Insurance Program (NYSHIP) who may have been subject to a Medicare Part B Income-Related Monthly
Adjustment Amount (IRMAA) in 2018.
Federal law mandates that some beneficiaries pay a higher premium for Medicare Part B coverage based on their income. This is not determined by the school district. If you and/or your eligible dependent paid a Medicare Part B income-related monthly adjustment amount (IRMAA) during CALENDAR YEAR 2018 - which means more than the standard Medicare Part B monthly premium during 2018 - you may be entitled to an additional reimbursement.
To claim your standard Medicare reimbursement and any additional surcharge you are required to document the eligible amount paid in premiums. Please submit the following documentation:
You MUST submit BOTH items indicated below to receive a reimbursement.
(See sample documentation forms that follow.)
Submit a copy of your and/or your eligible dependent’s Social Security Administration (SSA) letter issued to you and/or your eligible dependent at the end of CALENDAR YEAR 2018 showing what the income-related monthly adjustment amount will be in CALENDAR YEAR 2019.
Submit a copy of your and/or your eligible dependent’s Form SSA-1099 issued to you by the SSA in January of CALENDAR YEAR 2018, as proof of the monthly Medicare Part B premium actually paid for CALENDAR YEAR 2018. If you cannot provide a Form SSA-1099 because you did not receive Social Security benefits in 2018 you must provide official documentation that you paid Medicare premiums in 2018 (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 letter you can obtain one from your local Social Security office, which can be located on the following website: www.socialsecurity.gov/onlineservices. 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:
Island Park UFSD
99 Radcliff Road
Island Park, NY 11558
Attention: Barbara Niemira
2018 reimbursement will be issued in APRIL 2019.
(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.)
See Reimbursement Claim Submission Form PDF: Island Park 2018 medicare reimbursementJan2019.pdf