The Office of Systems prints and releases this notice to a Qualified Medicare Beneficiary
(QMB) after the State:
accretes the beneficiary to Part A State Buy-in or a Part A Group Payer Account, and
assumes liability for the Part A premium.
The Buy-in action creates a Medicare Part A enrollment if the beneficiary is not already
This notice tells the beneficiary the date (month and year) that the State will begin
to pay the Part A premium.