Effective Dates: 04/18/2016 - Present Previous | Next

TN 30 (03-96)

NL 00703.618 Beneficiary's Refusal of SMI Coverage Not Acceptable — State is Paying Premiums

Document Identifier for Word Processor: E3618

A. EXHIBIT LETTER

This is in reference to your notice to us that you do not want to be enrolled in the medical insurance part of Medicare.

Our records show that your State has agreed to pay the premiums for your medical insurance coverage. Therefore, you will continue to be enrolled. (1) .

If you have any questions in regard to Medicare, please get in touch with any Social Security office. Please have this letter with you if you call or visit an office. It will help us answer your questions.

B. REQUESTING INSTRUCTIONS

This notice is used to notify the beneficiary that his/her refusal of SMI coverage is not acceptable because a State is paying the premiums. If the individual has returned his/her HI card, it should be returned to the beneficiary.

 

  •  

    Fill-in:

(1) Choice 1 - “We will return to you the health insurance card showing that you have coverage under both the hospital insurance and medical insurance parts of Medicare.” (If the beneficiary returned the HI card.)
​ Choice 2 - NULL (If the beneficiary did not return the HI card.)

C. TYPING INSTRUCTIONS

Information for this letter will be shown on Form SSA-573. The name and address, if not given, can be taken from the latest Form SSA-3926-EP in file.

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900703618
NL 00703.618 - Beneficiary's Refusal of SMI Coverage Not Acceptable — State is Paying Premiums - 04/18/2016
Batch run: 04/22/2016
Rev:04/18/2016