INSTRUCTIONS (DO NOT fax these instructions with your claim)

Medicare Reimbursement Account (MRA)

Pay Me Back Claim Form

INSTRUCTIONS (DO NOT fax these instructions with your claim)

PLEASE READ THIS BEFORE SUBMITTING YOUR CLAIM FORM The Internal Revenue Service (IRS) requires you to provide documents to verify your reimbursement. Your documents must show that you paid for a Medicare Part B premium. At a minimum, the document(s) must show:

a) the date of coverage or expense b) the name of the person who incurred the expense c) the name of your insurance carrier (Blue Cross and Blue Shield Service Benefit Plan) d) the type of expense (Medicare Part B premiums) e) proof of premium payment

Tips for Completing the MRA Pay Me Back Claim Form 1. Print or write legibly. 2. Complete a separate form for your dependent or spouse. 3. Make sure you sign the form. If your Power of Attorney signs, please make sure he or

she signs the form in the following format "John Smith, Attorney in Fact for Jane Smith." Make sure the Power of Attorney is either on file or submitted with the first claim. 4. You should complete the account holder name section with your first and last n ame. 5. Submit copies of your Cost of Living Adjustment (COLA) Statements or other documents providing proof that you pay Medicare Part B premiums with your claim form. Keep the original documents for your records. If your claim is incomplete, you must resubmit the claim form and proof of Medicare Part B premium. Send legible copies of your documents.

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MRA Pay Me Back Claim Form Instructions

Section 1 ? One Time Annual Request for Social Security Administration (SSA) Deducted Premiums (Medicare Part B) 1. Complete this section if your Medicare Part B premium is deducted from your Social

Security check. 2. In the "Service Start Date" boxes, enter the first of the month in which you are eligible for

Medicare Part B for this year. In the "Service End Date" boxes, enter the last day of the year. (If eligible for Medicare Part B on January 1, this will be January 1 to December 31.) 3. Enter the annual amount of your Medicare Part B payment (the monthly amount multiplied by the number of months of coverage.) 4. Include a copy of your Social Security Cost of Living Adjustment (COLA) statement as proof of your expense (typically mailed starting in November the year before it becomes effective) or any other Medicare statement that clearly indicates your annual Medicare B premiums. If your premium is not deducted from your Social Security check, please complete Section 2 (Health Plan Premiums Not Deducted from Your Social Security Check) on the claim form in order to be reimbursed.

5. We will reimburse you based on your annual premiums. Your monthly reimbursement will not be more than the current balance in your account or the maximum benefit available of $600.

Section 2 ? Medicare Part B Healthcare Premiums Not Deducted from Your Social Security Check 1. Complete this section if your Medicare Part B premiums are:

a. not deducted from your Social Security check, and b. paid by you on an after-tax basis. 2. Make sure to provide documentation, such as the COLA statement, that shows the premium you pay. After you have paid your Medicare Part B premium, you may use a front and back copy of the cleared check, a bank statement or credit card statement that shows the Medicare Part B premium payment. 3. The Service Start and End Dates should represent the period of coverage you paid for and want reimbursed. These dates should match the COLA statement.

4. Keep your original receipts and make copies to fax or mail to WageWorks. Note: Pre-tax deductions for premiums from your payroll or your pension plan are not eligible for reimbursement.

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Medicare Reimbursement Account (MRA)

Pay Me Back Claim Form

TOLL-FREE FAX: (877) 353-9236

Or, mail to: Claims Administrator, PO Box 14053, Lexington, KY 40512

ACCOUNT HOLDER INFORMATION

DO NOT USE A FAX

COVER SHEET

to ensure speedy processing.

Last Name

ID Code* (Day of Birth

Birth Date

(DD) and last 2 digits of

(MM/DD)

SSN)

Email Address (complete only if new)

CERTIFICATION AND AUTHORIZATION

First Name

Blue Cross and Blue Shield Service Benefit Plan

Employer Name

Signature of Account Holder X

Date

I certify that the information on this form is accurate and complete. I am requesting reimbursement for Medicare part B premium expenses incurred by myself while I was a member of the Blue Cross and Blue Shield Service Benefit Plan. I have not/will not seek reimbursement of this expense from any other plan or party because I: 1) pay for the premiums through withholding, 2) have paid for the premiums out of pocket.

Use of this service indicates my acceptance of the WageWorks User Agreement at mra (available upon registration; enter username and password or click on First Time User).

CLAIMS FOR OUT-OF-POCKET EXPENSES

1. One-Time Annual Request for Social Security Administration (SSA) Deducted Premiums

(Medicare Part B)

Relationship to

Account Holder

$

Self

Service Start Date Service End Date Annual Out-of-Pocket

(MM/DD/YY)

(MM/DD/YY)

Cost

Account Holder's Name

2. Medicare Part B Health Plan Premiums Not Deducted from Your Social Security Check

Relationship to

Account Holder

$

Self

Service Start Date Service End Date Out-of-Pocket Cost

(MM/DD/YY)

(MM/DD/YY)

Account Holder's Name

* Your ID Code is a 4-digit combination of your day of birth and the last 2 digits of your SSN. For example, if you were born on the 8th day of the month and the last 2 digits of your SSN are 12, your ID Code would be 0812.

YOU MUST ATTACH A COPY OF APPROPRIATE PROOF OF PREMIUM PAYMENT FOR EACH AMOUNT ABOVE.

$

TOTAL THIS FORM

WW-BCBS-FEP-MRA-RT-PMB (Dec 2017)

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