TN 1 (07-04)
DI 45001.342 Notice — R-HI/R-SMI Award Based on Transplant or Dialysis, Entitlement Dates are the
Same or Later Than Age 65 HI/SMI Coverage (Conversion Notice)
TO REQUEST THIS NOTICE:
Enter on SSA-5002: “Send
If the footnote applies (claimant already entitled
to age 65 HI only), include the special instructions 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 attainment of age 65, there will be no change in the effective dates
of your hospital insurance and supplementary medical insurance entitlement.
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 age 65 HI
only, delete the phrase “and supplementary medical insurance” which changes the last
sentence in the first paragraph to end after the phrase “hospital insurance.” Then add two new sentences
You now have medical insurance beginning (date). Your monthly medical insurance premium
is (amount) .