TN 1 (07-04)

DI 45001.347 Notice — R-HI/R-SMI Award When RRB Jurisdiction for Medicare is Involved:

TO REQUEST THIS NOTICE:

Enter on SSA-5002: “Send notice 1102 with 3 fill-ins         ,         , and         .”

This refers to your claim for entitlement to Medicare benefits on the basis of a kidney condition. Your claim has been allowed. Based on your ( transplant ) ( regular dialysis treatments )**, you are eligible for hospital insurance beginning         and medical insurance beginning         . However, our records show that your hospital and medical insurance are handled by the Railroad Retirement Board (RRB). Since you already have Medicare under your Railroad claim number you should continue using that number. If the Medicare entitlement dates above based on your kidney condition are earlier than the dates on your current Medicare card, you will be issued a new card shortly which will show the earlier months of entitlement. The RRB will collect any additional medical insurance premiums due as a result of the earlier entitlement.

By law, Medicare coverage based on kidney disease ends with the last day of the 36th month after the month in which a transplant occurred or the last day of the 12th month after the month a regular course of dialysis ended, whichever is later. Since you already have Medicare, however, your coverage may continue based on the RRB determination of entitlement. If you end current dialysis treatments, receive a transplant, or start dialysis treatments after a transplant fails, please notify any Social Security office.

If you believe this determination is not correct, you may request that your case 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 your request through any Social Security office. If additional evidence is available, you should submit it with your request.

If you have any questions about your Medicare coverage, you should contact any Social Security office. If you visit an office, please take this notice with you.

*Do not enter a Social Security Claim number on this award notice.

**Choose appropriate basis for entitlement.