TN 1 (07-04)
DI 45001.348 Notice — R-HI/R-SMI Award When RRB Jurisdiction Involved — LAF Code “E” Cases
TO REQUEST THIS NOTICE:
Enter on SSA-5002: “Send
notice 1105 with 3 fill-ins , ,
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 . The Railroad Retirement Board (RRB) will issue you a Medicare card under your Railroad
claim number. Premiums for your medical insurance will be deducted from your RRB benefit.
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.