Your claim to establish eligibility for health insurance coverage under title XVIII of the Social Security Act as a disabled individual has been approved. Your health insurance coverage begins in (1) . A Health Insurance Identification Card will be mailed to you shortly.

A monthly premium is required to keep medical insurance protection.

1. (1) 

   Those premiums will be withheld from your monthly benefits beginning (2) .

2. (2) 

   Since you are not receiving checks, you will be billed for the premiums due.

Although you have been found entitled to a disability-based benefit, it is for the purposes of health insurance coverage only. It has no effect on the benefit to which you are now entitled.

The enclosed booklet lists the events you must report to the Social Security Administration as a disabled individual.

If you believe that this determination is not correct, you may request that your claim 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 any such request through any Social Security office. If additional evidence is available, you should submit it with your request. Keep this notice as a permanent record with the Social Security Award Certificate you received previously.

If You Have Any Questions

3901C

Enclosures:

Envelope

SSA Pub. No. 73-10153

This notice is used when a beneficiary entitled to mother's or widow's benefits files to establish a disability for health insurance coverage purposes. The health insurance system will prepare and mail an HCFA-1966, Health Insurance Identification Card to the individual after receipt of the health insurance entitlement information from the MBR system. Coverage can be immediately or 1 or 2 months in the future, depending on the month of entitlement to HI.

• •

  Fill-in:

  1. (1) 

     the month and year the health insurance coverage begins (determined from the DOED).

      

• •

  Paragraph 3619C:

  1. (1) 

     month/year of scheduled review

• •

  If the beneficiary has refused SMI coverage, the second paragraph of the letter must be deleted. If the SMI is elected, leave the second paragraph in but modify it appropriately. That is, use the first sentence if SMI premiums are to be deducted from benefits (indicate the date of the first check from which premiums will be deducted); or if the beneficiary will be billed (is in suspense), use the second sentence and delete the first sentence.

• •

  Include 3619A in Medical Improvement Possible cases.

• •

  Include 3619B in Medical Improvement Not Expected cases.

• •

  Include 3619C in Medical Improvement Expected cases.

Refer to NL 00703.005E. for 3901C text.

Information for this notice will be shown on Form SSA-573. The name and address, if not given, can be taken from the latest Form SSA-3926-EP in file.

The benefit authorizer will request the second paragraph to be deleted, if the beneficiary has refused SMI coverage. If the beneficiary elects SMI coverage the benefit authorizer will request one of the following sentences:

1. (1) 

   Those premiums will be withheld from your monthly benefits beginning mo /da/yr. (The benefit authorizer will furnish the date.) or

2. (2) 

   Since you are not receiving checks, you will be billed for the premiums due.