City of Boston Medicare Part B Refund Instructions
This document provides essential information regarding the City of Boston's Medicare Part B refund process for retirees and surviving spouses. It details the qualifying conditions for the refund, required documentation for submission, and important deadlines. Users can find options for their Medicare payments and instructions on completing the refund request.
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How do I fill this out?
To fill out this form, begin by determining your Medicare Part B premiums for 2020. Next, select the appropriate option based on your payment amount listed in the instructions. Finally, complete the enclosed Medicare Refund Request Form and ensure you include all required documentation.

How to fill out the City of Boston Medicare Part B Refund Instructions?
1
Verify the amount you paid for Medicare Part B premiums in 2020.
2
Choose the correct option based on your monthly payment.
3
Complete the Medicare Refund Request Form.
4
Include proof of payment for Medicare Part B.
5
Postmark the forms before the deadline.
Who needs the City of Boston Medicare Part B Refund Instructions?
1
Retirees of the City of Boston who paid Medicare Part B premiums.
2
Surviving spouses of deceased City employees needing reimbursement.
3
Individuals paying Income Related Monthly Adjustment Amount (IRMAA).
4
City employees seeking clarity on the refund process.
5
Persons needing the necessary documentation for proper submission.
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What are the instructions for submitting this form?
To submit your Medicare Part B Refund Request Form, ensure all sections have been filled out completely and accurately. Email your completed form and attachment to hbi@boston.gov, or fax it to 617-635-4584. You may also submit your forms physically to 1 City Hall Square, Room 807, Boston, MA 02201, ensuring it is postmarked by April 30, 2021.
What are the important dates for this form in 2024 and 2025?
Important dates for the Medicare Part B refund include April 30, 2021, as the deadline for form submission. Ensure you send all required documentation by this date for a timely refund in July 2021. Keep an eye on future updates regarding potential changes in dates or refund amounts.

What is the purpose of this form?
The primary purpose of this form is to facilitate the refund process for Medicare Part B premiums paid by retirees and surviving spouses of the City of Boston. This ensures that eligible individuals receive a reimbursement for their contributions towards Medicare Part B. Furthermore, it promotes clarity and efficiency in the refund process, aiding the City in effectively managing reimbursements.

Tell me about this form and its components and fields line-by-line.

- 1. Name: Your full name as it appears on Medicare documents.
- 2. Contact Information: Your email address and phone number for correspondence.
- 3. Medicare Premium Amount Paid: The total amount you paid for Medicare Part B premiums in 2020.
- 4. Documentation: Proof of payment that is attached to this form.
- 5. Signature: Your signature for validating the request.
What happens if I fail to submit this form?
If you fail to submit this form, you may miss out on receiving a refund for your Medicare Part B premiums. Without submission, your payment documentation will not be processed, leading to a lack of reimbursement. As a result, you will automatically receive 50% of the standard Medicare Part B premium without any adjustments.
- Missed Refund Opportunity: Non-submission will lead to a loss of potential refunds.
- No Documentation Processed: Your payment records will not be reviewed.
- Standard Reimbursement Only: You'll receive only a standard refund, missing any additional adjustments.
How do I know when to use this form?

- 1. Retiree Refund: For retirees seeking their Medicare premium refunds.
- 2. Surviving Spouse Refund: To assist surviving spouses in obtaining their Medicare payments back.
- 3. Documentation of Payments: To compile official documentation for all Medicare Part B payments.
- 4. Clarification on IRMAA: For clarification on higher adjustments in premium payments.
- 5. Ensuring Proper Submission: To ensure that you're following the right channels for reimbursements.
Frequently Asked Questions
How can I access the Medicare Refund Request Form?
You can access the form directly from the City of Boston's official website or through PrintFriendly.
What documents do I need to submit with my form?
You must submit proof of your Medicare Part B premium payments for 2020 alongside the refund request form.
What is the deadline for submitting the refund request?
The deadline for postmarking your forms is April 30th, 2021.
Can I edit the PDF before submitting?
Yes, you can edit the PDF on PrintFriendly to add necessary information before submitting.
How will I know if my form was received?
Contact the Health Benefits and Insurance office to confirm that your submission has been received.
What if I don't have my payment documentation?
You can contact Social Security to obtain a copy of your Benefit Statement for documentation.
Is there support if I have questions while filling this out?
Yes, you can reach out to the Health Benefits and Insurance office via email or phone for assistance.
What refund will I receive if I cannot provide IRMAA documentation?
You will automatically receive a refund of 50% of the standard Medicare Part B premium.
Can I share the completed PDF with someone else?
Yes, you can share your completed PDF directly through PrintFriendly.
Can I download the edited PDF to my device?
Absolutely! After editing, you can download the PDF to your device for your records.
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