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State-Wide Schools Cooperative Health Plan Medicare Part D-IRMAA Reimbursement Instructions

Federal law requires that some beneficiaries pay a higher premium for Medicare Part D coverage based on their income. Social Security determines the amount of premium beneficiaries will pay in 2016 based on their 2014 Federal tax return. If you and/or your eligible dependent paid a Medicare Part D-Income Related Monthly Adjustment Amount (IRMAA) during calendar year 2016 – which means more than the basic Medicare Part D monthly premium that SWSCHP paid on your behalf – you may be entitled to an additional reimbursement (surcharge for late enrollment does not qualify as an amount that is eligible for additional reimbursement).

To file a claim for the additional reimbursement you are required to document the eligible amount paid in excess of the basic plan premium that SWSCHP pays. Please submit the following documentation as requested below:

You must submit both items indicated below to receive a reimbursement
Submit a copy of your and /or your eligible dependent’s Social Security Administration (SSA) letter issued to you and/or your eligible dependent showing your Medicare D IRMAA for calendar year 2016.


Submit a copy of your and/or your eligible dependent’s Form SSA-1099 to be issued to you by SSA in January 2017, as proof of the monthly Medicare Part D premium actually paid in calendar year 2016. If you cannot provide a Form SSA-1099 because you did not receive Social Security benefits in 2016 you must provide official documentation showing the amount that you paid in Medicare D premiums in 2016. For example, your monthly statements from Social Security showing the premium payment due and last payment received or a receipt from Social Security. You must submit a copy of ALL of your 2016 statements for which you are requesting reimbursement.

Note: If your IRMAA was split between the two payments methods above, then you will need to submit proof of payment for each part in order to obtain your proper reimbursement.

Submit copies of the documents listed above for each eligible person, along with a completed Reimbursement Claim Submission Form To:

12 Metro Park Road, Suite 104
Colonie, NY 12205-1139
ATTENTION: IRMAA Reimbursement
If you need a replacement copy of IRMAA letter you can obtain one from your local Social Security office, which can be located on the following website: This website can
also be accessed to request a copy of the SSA-1099.

Many of our members have expressed concern about the statement in our last newsletter that SWSCHP will not provide Part D IRMAA Reimbursement for spousal expenses in 2017 or for any members in 2018. SWSCHP decided to undertake further study regarding that decision and on April 28th the SWSCHP Board decided to reinstate the previous reimbursement policy of reimbursing Part D IRMAA expenses for both members and their spouses. We apologize for any concerns you might have had regarding the policy described in the Winter 2017 Newsletter.

All requests for reimbursement of the 2016 Medicare D-IRMAA premium must
be received by June 30, 2017.
Contact SWSCHP at 1-888-779-7247 if you have
additional questions.

Young Adult Children Coverage
In-Network claims (services rendered by Participating BCBS provider) should be filed directly with the provider’s local BCBS (by your provider).
Out-of-Network Claims for Active and Retiree < 65 should be filed using the Alicare claim form below.
Determining UCR
Medicare Primary Claim Form
Medicare Part D Reimbursement

SWSCHP Accident Verification Form
International Claim Form

Contact a Care Navigator

Monday through Thursday: 8:00am - 8:00pm ET

Friday: 8:00am - 6:00pm ET

Saturday: 9:00am - 2:00pm ET

1-888 P-SWSCHP1-888 779-7247