TN 1 (07-04)

DI 45001.346 Notice — R-HI/R-SMI Award Based on Dialysis, Age 65 SMI Beneficiary Did Not Have HI (Conversion Notice)

TO REQUEST THIS NOTICE:

Enter on SSA-5002: “Send notice 1086 with fill-in         .” 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 regular kidney treatment ends the last day of the 12th month after the month in which the individual last has dialysis treatment unless dialysis is resumed or a kidney transplant is received before that date.

Coverage based on kidney transplant continues through the last day of the 36th month after the month of the latest transplant. If coverage based on kidney disease should end for a person age 65 or older, that person could, of course, continue Medicare entitlement 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.

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 coverage.

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 R-SMI entitlement date is earlier than age 65-SMI, change the last sentence of paragraph 1 to read:

• •

  You now have hospital insurance beginning         . Your new entitlement date to medical insurance is         based on dialysis treatments. Premiums you previously paid will be credited to your record.