Basic (03-86)

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: HCFA-10128