Medicare Premium Reimbursement Claim Form

Medicare Premium Reimbursement Claim Form

Each care provider in the household needs to complete their own reimbursement form.
Use this form to get your Medicare monthly premiums reimbursed for Medicare Part B, Medicare Part D, Supplement, and Advantage plans.

This needs to be submitted to Carewell SEIU 503 when you first become eligible for Healthcare Cost Assistance and annually thereafter.

Include proof of premium payment for every month/year for which you are requesting reimbursements.

This form covers reimbursements for different Medicare coverage options:

Medicare Part B Premium:

Covers doctor and other healthcare provider's services and outpatient care. Part B also covers durable medical equipment, home healthcare, and some preventive services.

Medicare Advantage Plan, Supplement Plan, or Part D (Rx) Plan:

Covers prescriptions/drugs.
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 $174.70/month in 2024. Proof of Part B premium and effective date of coverage must be provided when you first become eligible and annually thereafter.

Please select the month and 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 Part B: Click the "Add Claim" button below if you need to claim another month/year.*
Medicare Advantage Plan, Supplement Plan, or Part D (Rx) Plan Premium

Reimbursement up to $50/month in 2024. Proof of premium for a Medicare Advantage Plan, Supplement Plan, or Part D Plan, and effective date of coverage, must be provided when you first become eligible and annually thereafter.

Please select the month and 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 month/year.*
Include proof of premium payment for every month/year for which you are requesting reimbursements.
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, or I may be charged for Marketplace plan premiums. We can help: call 1-844-503-7348 to schedule an appointment with our partner insurance agency, Valley Insurance Professionals, to cancel your Marketplace coverage.
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Today's Date*

MonthDayYear
Date
Today's Date*
Medicare Part B Premium

Up to $164.90/mo in 2023. Proof of Part B premium and effective date of coverage must be provided when you first become eligible.
Amount in dollars for Medicare Part B Premium
Medicare Advantage Plan, Supplement Plan or Part D or Rx Plan

Up to $50/mo in 2023. Proof of premium for a Medicare Advantage Plan, Supplement Plan or Part D Plan, and effective date of coverage, must be provided when you first become eligible and annually thereafter.
Amount in dollars for Medicare Advantage, Supplement, or Part D Plan
Medical Out-of-Pocket Expenses

Up to $6,900 per year in 2023. Explanation of Benefits from your insurance company or pharmacy receipt with prescription issued must be provided with every reimbursement request.
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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Include proof of premium payment for every month/year for which you are requesting reimbursements.
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Medicare Premium Reimbursement Claim Form

Medicare Part B Premium

Medicare Advantage Plan, Supplement Plan or Part D or Rx Plan

Medical Out-of-Pocket Expenses