TN 66 (07-26)
HI 00815.204 Sample Email Format for SSO State Buy-in Problem Reporting (Email Request)
To: statebuy-in@cms.hhs.gov
From: {SSO Representative Email Address}
Subject: SSO REPORT OF STATE BUY-IN PROBLEM - [Beneficiary's state of residence]
Body:
Hello,
Ms. Doe contacted the field office regarding the status of her State Buy-In. She states
that she should be receiving assistance with Medicare premium payments. Her letter
is attached. I checked the CMS record for the current State Buy-In Accretion period;
there isn’t any current coverage information listed. Please advise if she is eligible
so that we can update our records. [Beneficiary name] [SSN or HICN] [Date of Birth
SSO Representative Contact
Information: • Name: [Representative Name] • Title: [Representative Title] • Contact Phone, if applicable: [Phone Number] • Contact
Email: [Email Address] Please review and advise on the appropriate resolution for this case.
Thank you, [SSO Representative Name]