TN 1 (07-04)
DI 45001.341 Notice — R-HI/R-SMI Award Based on Transplant or Dialysis, Entitlement Dates are the Same or Later Than D-HI/D-SMI Coverage (Conversion Notice)
TO REQUEST THIS NOTICE:
Enter on SSA-5002: “Send notice 1081.”
If the footnote applies (claimant already entitled to D-HI only), include the special instruction (with fill-ins) to the typist on the SSA-5002.
This refers to your claim for entitlement to Medicare benefits on the basis of a kidney condition. The law provides Medicare coverage for people with this condition if it has been determined that a course of dialysis or a kidney transplant is the required treatment. Your claim has been allowed. However, since you are already entitled to Medicare based on your entitlement to monthly disability benefits, there will be no change in the effective date of your entitlement to hospital insurance and supplementary medical insurance.
Your Medicare entitlement will continue as long as you are entitled to disability benefits. If your disability benefits end, your coverage may continue based on kidney disease if at that time 12 months have not elapsed since the date dialysis ended, or 36 months have not elapsed since the date of the last transplant. Therefore, please notify any Social Security office of any significant change in your condition or treatment.
If you have any questions about your claim, you should contact any Social Security office. Most questions can be handled by telephone or mail. If you visit an office, however, please take this notice with you.
1 If the claimant is already entitled to D-HI only, change the last sentence in first paragraph to:
Since you are already entitled to Medicare based on your entitlement to monthly disability benefits, there will be no change in the effective date of your hospital insurance. However, you now have medical insurance beginning (date) . Your monthly medical insurance premium is (amount) .