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 a course of dialysis is discontinued unless, before that point, a kidney transplant is received or regular dialysis is resumed. Since your course of dialysis was discontinued in   (month/year)   , your Medicare coverage ends with 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 again begin a course of diaylsis or if you receive a kidney transplant, please contact any social security office.

Enclosure: HCFA-10128

See the cautions in DI 45010.035 in assigning the following options. If the month of termination based on ESRD is the same or later than the first month of Medicare entitlement based on entitlement to an age 65 title II benefit or based on entitlement to a title II disability benefit, insert “based on kidney disease” after “Medicare coverage” in the 2nd sentence, first paragraph. Add the appropriate of the two alternatives below as the 3rd sentence:

1. “However, your Medicare coverage will continue based on your entitlement to disability benefits.”

2. “However, your Medicare coverage will continue based on your entitlement to an age 65 retirement benefit.”