TN 7 (07-95)

NL 00722.010 Form CMS-L1601-TR (Notice of Enrollment in Part A State Buy-in or Part A Group Payer)

A. POLICY

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 entitled.

This notice tells the beneficiary the date (month and year) that the State will begin to pay the Part A premium.

B. EXHIBIT — FORM CMS-L1601-TR

 

G-HCFA-L1601-TR

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To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900722010
NL 00722.010 - Form CMS-L1601-TR (Notice of Enrollment in Part A State Buy-in or Part A Group Payer) - 05/08/2008
Batch run: 01/27/2009
Rev:05/08/2008