TN 1 (07-04)

DI 45001.344 Notice — R-HI/R-SMI Award Based on Dialysis to Premium HI/SMI Beneficiary, Entitlement Dates are the Same or Later Than Premium HI/SMI Coverage (Conversion Notice)

TO REQUEST THIS NOTICE:

Enter on SSA-5002: “Send notice 1084 with fill-in         .”

Your application to change the basis of your Medicare coverage has been approved. You are now entitled to Medicare on the basis of your kidney condition and the regular dialysis treatment you began in         . Since you were already entitled to Medicare based on the attainment of age 65, there will be no change in the effective dates of your hospital insurance and supplementary medical insurance entitlement. Medicare coverage based on kidney disease did not become available to persons age 65 or older until October 1978, even if the condition existed before October 1978.

Medicare coverage based on a regular kidney dialysis treatment ends the last day of the 12th month after the month in which the individual last has dialysis treatment unless dialysis ends as a result of a kidney transplant. Coverage based on a kidney transplant continues through the last day of the 36th month after the month of the latest transplant. If your coverage based on kidney disease should end you may, of course, be eligible to reenroll in your previous Medicare coverage on the basis of the age 65 provision. If you should receive a kidney transplant or no longer require regular dialysis treatment, please contact any Social Security office.

Although you must continue to pay premiums for your supplementary medical insurance, premiums are not charged for hospital insurance based on kidney disease. You will, therefore, be notified later of the change in your Medicare premium rates.

If you have any questions, please contact the people at any Social Security office by telephone or in person. If you visit the office, it would be helpful if you take this notice with you.