TN 48 (11-22)

HI 01001.300 Field Office (FO) Action When Enrollee Protests Determination

When the enrollee or representative applies to the FO for relief, obtain a statement of the reasons why the premiums were not paid within the grace period. Accept a credible statement that is not contradicted by any available evidence or information.

Ordinarily, the enrollee can show a notice of termination that states when Supplementary Medical Insurance (SMI) coverage ended and how much the enrollee owes. If relief was requested timely, and the situation meets the criteria in HI 01001.295, ask the enrollee to pay all premiums due through the current month. If the enrollee is unable to do so immediately and wishes additional time to make the payment, give the enrollee a written notice that SMI coverage will be continued, provided that premiums (of specified amount) now overdue and unpaid are received by the FO no later than (date), and that unless these premiums are received. Also, indicate that no further action will be taken with regard to SMI enrollment.

Tell the enrollee when the next premium should be paid and explain that if a premium notice is not received by the time premium is due the enrollee must still submit the premium payment. The payment should be sent directly to the Medicare Premium Collection Center with all necessary identifying information (name, and Medicare number). Inform the enrollee that the premium must be paid timely, since the extension of the time will rarely be given twice.

In cases where it appears that relief might be granted, it will be necessary to review the direct billing record to ascertain the amount of overdue premiums, the date of termination, whether relief was requested timely, etc. The FO makes the determination as to whether relief may be granted and forwards the material to the program service center (PSC).

If the enrollee provides the remittance to the FO, send the remittance to the Medicare Premium Collection Center and the request with the material establishing the right to reinstatement (with a copy of the check annotated sent to Medicare Premium Collection Center) to the PSC. Add "Reinstatement of SMI enrollment in accordance with HI 01001.295" to the statement or report of contact transmitting the material. If the remittance is not received during the interview with the enrollee, hold the material in the FO until the remittance is received and then take appropriate action.

When the FO finds that the enrollee is not eligible for relief and the requested premiums have not been paid within the 30-day period, forward the enrollee's statement and the FO report to the PSC for action per HI 01001.305.