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.