2022 Lycoming Tioga MA Kit

Page 3 of 5 Paying your plan premiums You can pay your monthly plan premium (including any late enrollment penalty that you currently have or may owe) by mail, Electronic Funds Transfer (EFT), or credit card each month. You can also choose to pay your premium by having it automatically taken out of your Social Security or Railroad Retirement Board (RRB) benefit each month. If you have to pay a Part D-Income Related Monthly Adjustment Amount (Part D-IRMAA), you must pay this extra amount in addition to your plan premium. The amount is usually taken out of your Social Security benefit, or you may get a bill from Medicare (or the RRB). DON’T pay UPMC for Life the Part D-IRMAA. Please select a premium payment option. If you choose to pay your premium by Electronic Funds Transfer (EFT) or credit card, you will receive additional information about electronic premium payment options with your UPMC for Life plan confirmation of enrollment letter. If you don’t select a payment option, you will get a bill each month.  Get a bill .  Electronic Funds Transfer (EFT) from your bank account each month  Credit card   Automatic deduction from your monthly Social Security or Railroad Retirement Board (RRB) benefit check. I get monthly benefits from:  Social Security  RRB (The Social Security/RRB deduction may take two or more months to begin after Social Security or RRB approves the deduction. If the first deduction does not include all premiums due from your enrollment effective date, we will send you a letter letting you know the amount you owe UPMC for Life for any premiums not deducted by Social Security or RRB. If Social Security or RRB does not approve your request for automatic deduction, we will send you a paper bill for your monthly premiums.) PRIVACY ACT STATEMENT The Centers for Medicare & Medicaid Services (CMS) collects information from Medicare plans to track beneficiary enrollment in Medicare Advantage (MA) Plans, improve care, and for the payment of Medicare benefits. Sections 1851 and 1860D-1 of the Social Security Act and 42 CFR §§ 422.50 and 422.60 authorize the collection of this information. CMS may use, disclose and exchange enrollment data from Medicare beneficiaries as specified in the System of Records Notice (SORN) “Medicare Advantage Prescription Drug (MARx)”, System No. 09-70-0588. Your response to this form is voluntary. However, failure to respond may affect enrollment in the plan. Enrollment 125 1010101010101010101010 1100100001001000011001 1000100100001001000000 1010000100100001111111 1010010000100100001000 1000010010000000101011 1001000001010101101000 1001001000010101101101 1100001010101000110000 1100100001111011111011 1000100101110010101110 1010000101100110011101 1010010000001111000000 1000000001011011101011 1001011000100010011000 1001000100111110101101 1100001110111010101000 1100101010000010000011 1000100101011100110010 1010110100101011000001 1100011000100100001000 1111111111111111111111