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.