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)
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
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