BASIC (03-86)

The law provides that Medicare coverage, based on kidney disease, will end with the last day of the 12th month after the month in which a course of dialysis is ended unless, before that point, a transplant is received or regular dialysis is resumed. Since you discontinued dialysis in   (month /year)   , your Medicare entitlement should have ended the last day of   (month/year)   . Your hospital insurance coverage did end the last day of   (month/year)   . However, because the work needed to end your coverage was not done on time, the law permits your medical insurance coverage to remain in effect through the last day of   (month /year)   .

If you believe that 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.

Please read the enclosed leaflet for a full explanation of your right to question the determination made on your claim. If you should again begin a course of dialysis or receive a kidney transplant, please contact any social security office about filing a new claim for Medicare coverage.

Enclosure: HCFA-10128