Medicare Healthcare Cost Assistance Benefits Request Form

Medicare Healthcare Cost Assistance Benefits Request Form

Each care provider in the household needs to complete their own request form.
For eligible care providers who have Medicare, Healthcare Cost Assistance benefits help with the costs of:
- Monthly premiums for Medicare Part B (up to $185/month in 2025)
- Monthly premiums for Medicare Part D, Supplement, or Advantage plans (up to $50/month in 2025)
- Out-of-pocket expenses, such as deductibles, copayments, coinsurance, and prescriptions for services covered by Medicare (up to $7,165 in 2025)
  Healthcare Cost Assistance amounts may change from year to year.
Use this form:
- To request Healthcare Cost Assistance (HCA) benefits for Medicare this calendar year.
- To request missed reimbursements for Medicare Part B, Medicare Part D, Supplement, and Advantage previous monthly premiums (up to 12 months back*).
* If you're eligible for HCA for Medicare for the current year and eligible for the previous year (up to 12 months back), you can submit the required documents for both years at the same time.

Every year, you request Healthcare Cost Assistance for Medicare by submitting these required documents:
- For Part B: your Social Security letter or Medicare Premium Bill
- For a Part D, Supplement, and/or Advantage plan: your premium bill
For more information, please go to our Medicare HCA benefit webpage.

Every year, use this form to upload the required documentation to request Healthcare Cost Assistance (HCA) benefits for Medicare.

Note: The Trusts only allow any reimbursement, or payment claims, up to 1 year from the date of service. If you're eligible for HCA for Medicare for the current year and eligible for the previous year (up to 12 months back), you can submit the required documents for both years at the same time.
Which Medicare premium(s) are you requesting HCA benefits for (you can select more than 1 option):*

For Part B: submit your Social Security letter or Medicare Premium BillFor a Part D, Supplement, and/or Advantage plan: submit your premium bill
Which premium(s) do you need reimbursements for:*

Medicare Part B PremiumMedicare Advantage Plan, Supplement Plan, or Part D (Rx) Plan Premium
Medicare Part B Premium

Reimbursement up to $185/month in 2025. Proof of Part B premium must be provided when you first become eligible and then yearly.

Please select the year and include the amount you are requesting reimbursement(s) for.

Note: Requests for reimbursement must be submitted to Carewell SEIU 503. The Trusts will only allow any reimbursement or payment claims up to 1 year from the date of service.
Medicare B: Click the "Add Claim" button below if you need to claim another year.*
Medicare Advantage Plan, Supplement Plan, or Part D (Rx) Plan Premium

Reimbursement up to $50/month in 2025. Proof of premium for a Medicare Advantage Plan, Supplement Plan, or Part D Plan must be provided when you first become eligible and then yearly.

Please select the year and include the amount you are requesting reimbursement(s) for.

Note: Requests for reimbursement must be submitted to Carewell SEIU 503. The Trusts will only allow any reimbursement or payment claims up to 1 year from the date of service.
Medicare Advantage, Supplement, Part D (Rx): Click the "Add Claim" button below if you need to claim another year.*
Directions on how to upload files

If you DO have the files online:
1. Click on “Browse Files” on this online form
2. Select the file(s) you would like to attach/upload

If you DON’T have the files online:
1. Use your phone to take a photo of any forms and documents that you need to send to us. Make sure to take a complete picture of the form and that your name is included. We can’t read or use blurry photos.
2. Click on “Browse Files” on this online form
3. Select the file(s) you would like to attach/upload
Attach/upload forms and/or documents:*

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I certify that the information provided on this form is true and that I have incurred the expenses described on this form solely relating to my own medical coverage and expenses. I also certify that I have not already received reimbursement from Carewell SEIU 503 or any other source for any of the above-listed amounts.

I understand that if I receive medical coverage through a Qualified Health Plan from the Health Insurance Marketplace, I need to cancel my Marketplace Qualified Health Plan the day my Medicare coverage becomes active. If I don’t, I may be charged for Marketplace plan premiums.

You can cancel your Marketplace plan by:
- Calling the Marketplace at 1-800-318-2596 and requesting the cancellation of your Marketplace plan or online at HealthCare.gov; or
- Getting assistance from the agents at Valley Insurance Professionals — call 1-844-503-7348 to schedule an appointment.
Signature*

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Today's Date*

MonthDayYear
Date
Today's Date*
Amount in dollars for Medicare Part B Premium
Amount in dollars for Medicare Advantage, Supplement, or Part D Plan
Amount in dollars for Medical Out-of-Pocket Expenses
Date*

MonthDayYear
Date
Upload files (proof of premium payment, explanation of benefits, pharmacy receipt) *

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