CMS Pub. 100-24, ch. 5, § 5.6.2.2

The information below is required to successfully transmit a Medicare premium payments to

CMS via Fedwire:

Fedwire Field Name Information Needed

Amount:

(Format must be properly

punctuated with a dollar sign,

comma(s), and decimal point -

(e.g., $999,999.99).)

Enter payment amount.

Sending Bank Routing Number: Enter sending bank’s routing number

Receiver ABA Number: 021030004

Receiver ABA Short Name: TREAS NYC

Beneficiary Account Number:

(CMS Agency Location Code

(ALC))

875050080000

U.S. Agency Name: CMS

Originator: Input state name

Originator to Beneficiary

information:

• Enter the three-character agency code that CMS

assigned to the state

• Enter corresponding Medicare Program:

o if agency code starts with “S”,

corresponding Medicare Program is

Medicare Part A;

o if agency code is all numbers,

corresponding Medicare Program is

Medicare Part B

IMPORTANT: If the state combines the Medicare

Part A and Part B premiums into one payment, the

electronic funds transfer transmission must specify

the amount that applies to the Part A premium

liability and the amount that applies to the Part B

premium liability. If no designation appears, CMS

will apply the total premium payment to the Part B

premium payment which could result in an offset of

Fedwire Field Name Information Needed

the Part A premium liability amount.

Appendix 5.A - Medicare Part A Premium Amount

(Rev. 4, Issued: 08-21-20, Effective: 09-08-20, Implementation: 09-08-20)

Section 1818 of the Act specifies that the Secretary of Health and Human Services shall

determine the amount of the monthly Medicare Part A premium to be paid on behalf of each

individual who is entitled to Premium-Part A. See 42 CFR § 406.32(d). Surcharges for late

enrollment do not apply to the payment of Medicare Part A premiums on behalf of QMBs in Part

A buy-in states. A ten percent surcharge for late enrollment, if applicable, applies to Medicare

Part A premiums paid on behalf of QMBs in group payer states and on behalf of QDWIs in all

states as they must use the group payer arrangement to pay QDWI premiums. For a description

of the Part A premium surcharge, see chapter 1, section 1.1.

Monthly Medicare Part A Premium Amounts

Effective Date Part A Premium

Base Rate

10%

Surcharge

01/89 - 12/89 $156.00 $171.60

01/90 - 12/90 $175.00 $192.50

01/91 - 12/91 $177.00 $194.70

01/92 - 12/92 $192.00 $211.20

01/93 - 12/93 $221.00 $243.10

01/94 - 12/94 $245.00 $269.50

01/95 - 12/95 $261.00 $287.10

01/96 - 12/96 $289.00 $317.90

01/97 - 12/97 $311.00 $342.10

01/98 - 12/99 $309.00 $339.90

01/00 - 12/00 $301.00 $331.10

01/01 - 12/01 $300.00 $330.00

Effective Date Part A Premium

Base Rate

10%

Surcharge

01/02 - 12/02 $319.00 $350.90

01/03 - 12/03 $316.00 $347.60

01/04 - 12/04 $343.00 $377.30

01/05 - 12/05 $375.00 $412.50

01/06 - 12/06 $393.00 $432.30

01/07 - 12/07 $410.00 $451.00

01/08 - 12/08 $423.00 $465.30

01/09 - 12/09 $443.00 $487.30

01/10 - 12/10 $461.00 $507.10

01/11- 12/11 $450.00 $495.00

01/12 - 12/12 $451.00 $496.10

01/13 - 12/13 $441.00 $485.10

01/14 - 12/14 $426.00 $468.60

01/15 - 12/15 $407.00 $447.70

01/16 - 12/16 $411.00 $452.10

01/17 - 12/17 $413.00 $454.30

01/18 - 12/18 $422.00 $464.20

01/19 - 12/19 $437.00 $480.70

01/20 - 12/20 $458.00 $503.80

Section 1818(d) of the Act provides for reduced Medicare Part A premiums for individuals who

have at least 30 Social Security work credits.

Monthly Reduced Medicare Part A Premium Amounts

Effective Date Part A Premium

Reduced Rate

10%

Surcharge

01/94 - 12/94 $184.00 $202.40

01/95 - 12/95 $183.00 $201.30

01/96 - 12/96 $188.00 $206.80

01/97 - 12/97 $187.00 $205.70

01/98 - 12/99 $170.00 $187.00

01/00 - 12/00 $166.00 $182.60

01/01 - 12/01 $165.00 $181.50

01/02 - 12/02 $175.00 $192.50

01/03 - 12/03 $174.00 $191.40

01/04 - 12/04 $189.00 $207.90

01/05 - 12/05 $206.00 $226.60

01/06 - 12/06 $216.00 $237.60

01/07 - 12/07 $226.00 $248.00

01/08 - 12/08 $233.00 $256.30

01/09 - 12/09 $244.00 $268.40

01/10 - 12/10 $254.00 $279.40

01/11 - 12/11 $248.00 $272.80

01/12 - 12/12 $248.00 $272.80

01/13 - 12/13 $243.00 $267.30

01/14 - 12/14 $234.00 $257.40

01/15 - 12/15 $224.00 $246.40

01/16 - 12/16 $226.00 $246.40

Effective Date Part A Premium

Reduced Rate

10%

Surcharge

01/17 - 12/17 $227.00 $249.70

01/18 - 12/18 $232.00 $255.20

01/19 - 12/19 $240.00 $264.00

01/20 - 12/20 $252.00 $277.20

Appendix 5.B - Medicare Part B Premium Amount

(Rev. 4, Issued: 08-21-20, Effective: 09-08-20, Implementation: 09-08-20)

Section 1839 of the Act specifies that the Secretary of Health and Human Services shall

determine the amount of the standard monthly Medicare Part B premium to be paid by or on

behalf of each individual who is enrolled in Medicare Part B. From July 1966 through

December 1983, the premium period usually spanned July through the following June.

Beginning in January 1984, the premium period became January through December. Medicare

Part B premiums paid on behalf of individuals enrolled in Part B buy-in are not subject to a

surcharge for late enrollment. The following table reflects the premium amounts in effect since

the beginning of the Medicare program.

Monthly Medicare Part B Premium Rates

Effective Date Part B Premium

Base Rate

7/66 - 3/68 $3.00

4/68 - 6/70 $4.00

7/70 - 6/71 $5.30

7/71 - 6/72 $5.60

7/72 - 7/73 $5.80

8/73 - Only* $6.10

9/73 - 6/74 $6.30

7/74 - 6/76 $6.70

7/76 - 6/77 $7.20

7/77 - 6/78 $7.70

7/78 - 6/79 $8.20

7/79 - 6/80 $8.70

7/80 - 6/81 $9.60

7/81 - 6/82 $11.00

7/82 - 12/83 $12.20

1/84 - 12/84 $14.60

1/85 - 12/86 $15.50

1/87 - 12/87 $17.90

1/88 - 12/88 $24.80

1/89 - 12/89 $31.90

1/89 - 12/89** $27.90

1/90 - 12/90 $28.60

Effective Date Part B Premium

Base Rate

1/91 - 12/91*** $29.90

1/92 - 12/92 $31.80

1/93 - 12/93 $36.60

1/94 - 12/94 $41.10

1/95 - 12/95 $46.10

1/96 - 12/96 $42.50

1/97 - 12/97 $43.80

1/98 - 12/98 $43.80

1/99 - 12/99 $45.50

1/00 - 12/00 $45.50

1/01 - 12/01 $50.00

1/02 - 12/02 $54.00

1/03 - 12/03 $58.70

1/04 - 12/04 $66.60

1/05 - 12/05 $78.20

1/06 - 12/06 $88.50

1/07 - 12/07 $93.50

1/08 – 12/08 $96.40

1/09 – 12/09 $96.40

1/10 – 12/10 $110.50

1/11 – 12/11 $115.40

1/12 – 12/12 $99.90

1/13 – 12/13 $104.90

Effective Date Part B Premium

Base Rate

1/14 – 12/14 $104.90

1/15 – 12/15 $104.90

1/16 – 12/16 $121.80

1/17 – 12/17 $134.00

1/18 – 12/18 $134.00

1/19 – 12/19 $135.50

1/20 – 12/20 $144.60

*Due to Presidential price freeze

**Applicable to beneficiaries who have "Medicare Part B only" under a provision of the Medicare Catastrophic Coverage

Act (MCCA) and was applicable only during 1989.

***Section 103 of P.L. 100-360 set the Medicare Part B premium rate through 1995.

Appendix 5.C - Summary Accounting Statement

(Rev. 4, Issued: 08-21-20, Effective: 09-08-20, Implementation: 09-08-20)

Appendix 5.D - Listed Agency Billing (LAB) - Summary Sheet

(Rev. 4, Issued: 08-21-20, Effective: 09-08-20, Implementation: 09-08-20)

LAB LISTING FOR AGENCY CODE 000 (state name)

mm/03/yyyy

TOTAL ITEMS PROCESSED –

DEBIT CREDIT MISC.

ITEMS MONEY ITEMS MONEY ITEMS MONEY

CODE

11

CODE

14

CODE

20

CODE

41

CODE

15

CODE

21

CODE

43

CODE

16

CODE

22

CODE

45

CODE

17

CODE

23

TOTAL CODE

42

CODE

24

CODE

44

CODE

25

TOTAL CODE

26

CODE

27

CODE

28

CODE

29

CODE

30

CODE

49

CODE

86

CODE

87

TOTAL