TN 1 (07-04)

DI 45001.348 Notice — R-HI/R-SMI Award When RRB Jurisdiction Involved — LAF Code “E” Cases

TO REQUEST THIS NOTICE:

Enter on SSA-5002: “Send notice 1105 with 3 fill-ins         ,         , and         .”

This refers to your claim for entitlement to Medicare benefits on the basis of a kidney condition. Your claim has been allowed. Based on your ( transplant ) ( regular dialysis treatments )**, you are eligible for hospital insurance beginning         and medical insurance beginning         . The Railroad Retirement Board (RRB) will issue you a Medicare card under your Railroad claim number. Premiums for your medical insurance will be deducted from your RRB benefit.

By law, Medicare coverage based on kidney disease ends with the last day of the 36th month after the month in which a transplant occurred or the last day of the 12th month after the month a regular course of dialysis ended, whichever is later. Since you already have Medicare, however, your coverage may continue based on the RRB determination of entitlement. If you end current dialysis treatments, receive a transplant, or start dialysis treatments after a transplant fails, please notify any Social Security office.

If you believe this determination is not correct, you may request that your case be reexamined. If you want this reconsideration, you must request it not later than 60 days from the date you receive this notice. You may make your request through any Social Security office. If additional evidence is available, you should submit it with your request.

If you have any questions about your Medicare coverage, you should contact any Social Security office. If you visit an office, please take this notice with you.

*Do not enter a Social Security Claim number on this award notice.

**Choose appropriate basis for entitlement.