TN 30 (03-96)

NL 00703.619 HI/SMI — Entitled To Mother's or Widow's Benefits —Coverage Based on Disability — Coverage Begins Within 2 Months After COM

Document Identifier for Word Processor: E3619

A. EXHIBIT LETTER

Your claim to establish eligibility for health insurance coverage under title XVIII of the Social Security Act as a disabled individual has been approved. Your health insurance coverage begins in (1) . A Health Insurance Identification Card will be mailed to you shortly.

A monthly premium is required to keep medical insurance protection.

  1. Those premiums will be withheld from your monthly benefits beginning (2) .

  2. Since you are not receiving checks, you will be billed for the premiums due.

Although you have been found entitled to a disability-based benefit, it is for the purposes of health insurance coverage only. It has no effect on the benefit to which you are now entitled.

3619AThe doctors and other trained personnel who decided that you are disabled believe that your health may improve. Therefore, we will review your case in about 3 years. We will send you a letter before we start the review. Based on that review, your Medicare will continue if you are still disabled, but will end if you are no longer disabled.
OR  
  
3619BDoctors and other trained personnel decided that you are disabled. And we realize that your health may not improve. But we must review all disability cases. Therefore, we will review your case in 5 to 7 years. We will send you a letter before we start the review. Based on that review, your Medicare will continue if you are still disabled, but will end if you are no longer disabled.
OR  
  
3619CThe doctors and other trained personnel who decided that you are disabled expect your health to improve. Therefore, we will review your case in (1) . We will send you a letter before we start the review. Based on that review, your Medicare will continue if you are still disabled, but will end if you are no longer disabled.

The enclosed booklet lists the events you must report to the Social Security Administration as a disabled individual.

If you believe that this determination is not correct, you may request that your claim 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 any such request through any Social Security office. If additional evidence is available, you should submit it with your request. Keep this notice as a permanent record with the Social Security Award Certificate you received previously.

 

If You Have Any Questions

3901C

Enclosures:

Envelope

SSA Pub. No. 73-10153

B. REQUESTING INSTRUCTIONS

This notice is used when a beneficiary entitled to mother's or widow's benefits files to establish a disability for health insurance coverage purposes. The health insurance system will prepare and mail an HCFA-1966, Health Insurance Identification Card to the individual after receipt of the health insurance entitlement information from the MBR system. Coverage can be immediately or 1 or 2 months in the future, depending on the month of entitlement to HI.

 

  • Fill-in:

    1. the month and year the health insurance coverage begins (determined from the DOED).

       

  • Paragraph 3619C:

    1. month/year of scheduled review

  • If the beneficiary has refused SMI coverage, the second paragraph of the letter must be deleted. If the SMI is elected, leave the second paragraph in but modify it appropriately. That is, use the first sentence if SMI premiums are to be deducted from benefits (indicate the date of the first check from which premiums will be deducted); or if the b