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How to decline medicare part a Form: What You Should Know

For questions, please contact: Medical Director for Medicare Hospital an/or Medicare will cancel your Medicare Part B benefits if: you are 65 or older and your annual income is 20,170 or less, for you and your spouse. The filing fee for this form is 120 plus the filing and payment fee for Form CMS-1763. The application fee for this form is 24. There are two ways you would submit this request: 1. You and your spouse would each have to complete a 20 application 2. You and your spouse each would submit a 24 Application To request this form, complete this form. You will need to have the form in hand before you can fill it out. Keep this form until your enrollment in Medicare or Part B is complete! How much would you have to pay to have Medicare Part B paid for you after your 65? The calculation is very complicated. It depends on your age when you first received Medicare in your 50s. For instance, let's suppose your age at the start of your Medicare plan was 62 when you received Medicare. Let's further suppose that your income at that time was 30,000 For you and your spouse the following would be your numbers: 50% — monthly payments (1,100) The monthly payment is the sum of your monthly Part B premium and your Medicare benefits. For you and your spouse: Income is 30,000 Age is 62 Your monthly income amount is 1,100 per month This would be your monthly Part B payment amount! Therefore, we get: 1,100 2 = 2,700 Your Part B payment would be 2,700 per month, or 5,900 per year. What are the consequences of your age not meeting both of the above? The only difference from the above calculation is that your annual Part B payment would be 7,350. This still is lower than your Medicare premium. So your Part A premium would be 5,900 per year, and your Medicare Part B payments would not be 7,350. In this situation your Part A premium is your Part B payment. Let's suppose your income was 33,000 for you and your spouse.

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