U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES OMB Approval Not Required Acknowledgment of Request for Premium Hospital Insurance Termination From: Department of Health and Human Services Centers for Medicare & Medicaid Services Date: Claim Number: You recently asked us to stop your Medicare Part A (hospital insurance) protection. On the basis of your request, this coverage will stop on (mm/dd/yyyy). You are responsible for all premiums due through the end of that month. If you change your mind and decide you want to keep your Part A insurance, you can do so by completing the form below. Take it or mail it to any Social Security office before the date your coverage will stop and your protection will continue without interruption. The decision to keep or drop this protection is one that only you can make. However, to assist you with making this important decision, we urge you to carefully consider the following information. What Does Medicare Part A Cover? Medicare Part A insurance helps pay for most of the services you receive when you are a patient in the hospital, including a semi-private room, meals, general nursing and other hospital services and supplies (this includes care in critical access hospitals and inpatient mental health care). Medicare Part A can also pay for inpatient care in a skilled nursing facility, hospice care and some home health care. (Over) I would like to keep my Medicare Part A insurance coverage. PRINT NAME Social Security Number (Signature by mark must be witnessed below) Date SIGN HERE Your Mailing Address Telephone Number City State Zip Code Signature of Witness (necessary if you sign by mark) Address of Witness FORM CMS-L458 (02/03) American LegalNet, Inc. www.USCourtForms.com DESTROY PRIOR EDITIONS How else can I protect myself against medical expenses if I drop Medicare Part A? You may not be able to get the same amount of protection that you now have with Medicare Part A insurance. If you are considering the purchase of private insurance, you should discuss this with your insurance representative before you drop Part A. For people over 65 who are eligible for Medicare, most private companies offer coverage only to add to their Medicare Part A insurance. If your income is very low, you may qualify for Medicaid which helps pay for medical and health care costs, including the Part A premium, for those who are eligible. Contact your State medical assistance office for more information. Can I join a Medicare managed care plan if I drop Medicare Part A? You must have both Medicare Part A and Part B to join a Medicare managed care plan. If you are already enrolled in a Medicare managed care plan and you drop Part A, your coverage in the plan may end. How can I get Medicare Part A again if I decide I want it? You can get Part A again by signing up during January, February, or March of any year for coverage which begins the following July. But your monthly premium may be higher than if you had not dropped the insurance. Do I have special re-enrollment rights if I am covered under a group health plan? If you or your spouse are working and have group health plan coverage through your or your spouse's employer or union, you may be eligible for a special enrollment period. If you are disabled and working (or you have group health plan coverage from a working family member), the special enrollment period rules also apply. You may re-enroll in Part A: · Anytime you or your spouse (or family member if you are disabled) are working and still covered under the group health plan, or · During the 8 months following the month when the employer or union group health plan coverage ends or when the employment ends, whichever happens first. Where can I get more information? If you have any questions or need more information, contact any Social Security office. You may also call Social Security's toll-free number, 1-800-772-1213. If you visit an office, take this letter with you. American LegalNet, Inc. www.USCourtForms.com