HI 00830.001 Granting Equitable Relief

The 1972 amendments to the Social Security Act granted the Administration the authority to provide certain forms of relief to individuals whose SMI or premium-HI enrollment or coverage rights have been prejudiced by the error, misrepresentation, action or inaction of an employee or agent of the Government. This relief may include, but is not limited to, providing special enrollment and/or coverage periods and appropriate adjustment of premium liability. There is total retroactivity in this legislation. That is, relief can be granted beginning with July 1, 1966. However, no active search for applicable inequitable situations will be made of past occurrences. Relief will be considered retroactively if a case is brought to our attention, but no effort should be made to search for them.

The Centers for Medicare & Medicaid Services (CMS) has the authority and the responsibility of providing the policy guidelines to be observed in applying this relief to SMI and premium-HI coverage. No one has the authority to grant relief for enrollment/disenrollment situations involving the free- HI coverage. However, as indicated later in this section, a back-door type of relief is possible where payment of health costs was made in good faith but are subsequently determined to be in error.

CMS has issued certain guidelines in HI 00805.130 that pertain to the extent of relief that can be applied by the PSC (with the cooperation of the DO"s) without any referral to Central Office. This relief comes in three forms.:

1. 1. 

   special enrollment periods or entitlement or termination dates; and

2. 2. 

   the retention of a period of coverage where the requirements for legal entitlement were never met; and the relief from the liability for the premiums due for specified periods of time.

This section is intended to augment the interpretation of the amendment found in HI 00805.000ff. It is important to note that more than one type of relief may be applicable to any one case but each must be individually determined by the appropriate office having jurisdiction over the type of relief being considered (this is explained in subsequent sections).

Because most situations requiring equitable relief considerations will be brought to our attention through correspondence from claimants, an explanation of the equitable relief provisions and instructions for granting relief have been incorporated in this section. However, it must be remembered that these same provisions also apply to any inequitable situations discovered during any routine folder examination or subsequent action taken on the claim.