TN 14 (01-25)
DI 45001.103 Final Notice of Medicare Termination (Due to ESRD and Dialysis Cessations) When RRB
Jurisdiction is Involved
This is in reference to your entitlement to health insurance based on kidney disease.
The law provides that Medicare coverage based on kidney disease will end with the
last day of the 12th month after the month a course of dialysis is discontinued unless,
before that date, a kidney transplant is received or regular dialysis is resumed.
Since your course of dialysis was discontinued in (month/year) , your Medicare coverage based on kidney disease ends with the last day of (month/year) . However, our records indicate that your hospital and medical insurance are handled
by the Railroad Retirement Board. Your Medicare coverage will continue unless the
Railroad Retirement Board notifies you of termination.
If you believe this determination is not correct, you may request that your case be
reexamined. If you want this reconsideration, you must request it not later than 60
days from the date you receive this notice. You may make your request through any
social security office. Please read the enclosed leaflet for a full explanation of
your right to question the determination made on your claim. If you again begin a
course of dialysis or if you receive a kidney transplant, please contact any social
security office.
Enclosure: CMS-10128