HI 00820.904 Exhibit 4: Notice to R-HI Beneficiary About Termination Because of Transplant
AUDIENCE: OA, OS, CR, RR, FR, SR, TSC-SR, CA, CATA, CRTA, CDA, IES, RECONR, RECOVR, EE, EHS,
EIE, BA, BATA, CCDIPS, ER, LCC
This is in reference to your entitlement to health insurance based on kidney disease.
The law requires that Medicare health insurance based on kidney disease must end with
the last day of the 36th month following the month in which the person receives a
kidney transplant, unless before this date the patient receives another transplant
or begins a course of dialysis. Since you received a transplant in (month/year) your
Medicare will terminate on (date), unless you or your treatment center submits evidence
that you have begun a course of dialysis or received another kidney transplant.
If you have begun a course of dialysis or received another transplant, please have
your treatment center complete the enclosed form CMS-2728-U3 and return it promptly
(within 30 days) to the Social Security Administration in the envelope provided. If
there is any additional information or evidence you want us to consider please submit
it without delay. You may submit it in writing or orally, in person at your local
social security office, or by telephone to a social security representative.
You will receive formal notice about termination of your Medicare health insurance,
and will have an opportunity to file an appeal and to present further evidence at
that time, if you do not agree with that decision.
If you have any questions about this notice, wish to submit additional evidence or
have any difficulty in obtaining evidence regarding your transplant, please contact
your local social security office as soon as possible.