TN 1 (07-04)
DI 45001.345 Notice — R-HI/R-SMI Award Based on Transplant, Age 65 SMI Beneficiary Did Not Have
HI (Conversion Notice)
TO REQUEST THIS NOTICE:
Enter on SSA-5002: “Send
notice 1085 with 2 fill-ins and
.” If the footnote applies
(R-SMI date is earlier than age 65-SMI), include the special instruction
to the typist on the SSA-5002.
Your application to base your Medicare coverage on your kidney condition has been
approved. In addition to the medical insurance which you already have, you now have
hospital insurance coverage beginning .
Medicare coverage based on a kidney transplant ends the last day of the 36th month
after the month in which the transplant occurred unless by then a new transplant is
received or regular dialysis treatment is begun. Therefore, your coverage based on
your transplant will end the last day of , although you may, of course, continue the medical insurance coverage on the basis
of having attained age 65. If you require a new transplant or dialysis treatment,
please contact any Social Security office.
Premiums are not charged for hospital insurance based on kidney disease, although
you will be charged premiums at the base rate for your continuing medical insurance
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.
1 If the R-SMI entitlement
date is earlier than age
65-SMI, change the last sentence (paragraph 1) to read:
You now have hospital insurance beginning . Your new entitlement date to medical insurance is based on transplant. Premiums you previously paid will be credited to your record.