September 16, 2004

(Recipient name)
(Recipient address)
(Rec. City/State/Zip)

CHANGE IN MEDICAID BENEFITS

Effective September 30, 2004, your coverage as a Qualifying Individual (QI-1) is being discontinued because federal law is ending this coverage.  The Medicaid benefit you were eligible for paid your Medicare Part B premium.  

Your eligibility as a Qualifying Individual indicates that you had monthly income of at least $1068 for an individual, or $1426 for a couple.  If your income has changed, and is below these amounts, you may be eligible for other programs and should contact me for more information.

The Medicaid program will no longer pay your Medicare premium, so the premium will automatically be subtracted from your social security benefits.  Because it will take about two months to begin deducting the premium from your social security benefit, there will be no deduction actually withheld in October and November 2004.  The premiums for October, November, and December 2004 will be deducted from your December 2004 check.  You may want to plan ahead for these deductions.

This action is based on Section 1902(a)(10)(E)(iv) of the Social Security Act.

Because this benefit terminated solely due to federal law, affected individuals will not be granted an opportunity for a hearing.  In the event that Congress extends this coverage beyond September 30, 2004, your eligibility will also be extended and you will be notified of that extension.  

If you have questions regarding this action, please contact me.

(Eligibility worker name)
(County Social Service Office)
(County phone #)