TN 13 (07-17)

GN 00206.020 Hospital Insurance (HI) and Withdrawal (WD)

A. Scope of the withdrawal of a Medicare application

An application for Medicare covers Part A Hospital Insurance (HI) and Part B Supplementary Medical Insurance (SMI) benefits. A claimant age 65 or over may withdraw an application for monthly RSI benefits without losing HI as per HI 00805.001A.2. However, claimants who withdraw an application for monthly disability benefits lose both HI and SMI.

At the time of filing, a claimant can decline the SMI benefit and receive a HI benefit only. If a claimant filed for both HI and SMI benefits and later wants to stop the SMI coverage, he or she can:

  • Withdraw the SMI benefit if the benefit has not gone into effect as per HI 00805.080 or;

  • Request the termination of SMI benefits as per HI 00820.045.

NOTE: Once the claimant has withdrawn his or her application for Part A, (either a Medicare –Only application or an application for RSI benefits that conferred Part A entitlement) we will terminate the Part A entitlement retroactive to the month in which entitlement originally began.

B. Background on how WD affects HI entitlement

1. Before January 1, 1981

A claimant age 65 or over had to be entitled to monthly Retirement or Survivors Insurance (RSI) benefits to qualify for HI benefits. Therefore, a claimant who withdrew his or her claim for monthly benefits lost HI entitlement and SMI if enrolled.

2. Effective January 1, 1981

The P.L. 96-473 modified the Social Security Act to provide that we deem a claimant age 65 or over who filed a claim for monthly RSI benefits and HI, to have filed separate claims for cash benefits and HI coverage (see Section 226(a)(2)). In addition, we can deem the claimant entitled to HI based on the date of the original application for monthly benefits, which he or she subsequently withdrew. This applies only to claimants who are age 65 or over. It does not apply to Disability (i.e. DIB or disability freeze) claimants, Childhood disability beneficiaries (CDB), disabled surviving spouses, or disabled surviving divorced spouses.

NOTE: If a disability claimant listed above attains age 65 and requests WD of his or her monthly benefit, we do not deem him or her to be enrolled in HI based on the date of the original application for monthly benefits. WD of the DIB application will nullify the HI entitlement. This is because a separate RIB application is not taken for DIB-RIB conversion cases.

C. Policy after January 1, 1981 for WD requests involving HI coverage

We base HI coverage on entitlement to monthly RSDI cash benefits. Therefore, a claimant who is entitled to monthly RSDI benefits cannot withdraw HI coverage and keep the cash benefits only. For information on a waiver of HI entitlement by an RSI beneficiary, see HI 00801.002. The claimant with HI entitlement may withdraw the:

  • RSI cash benefits only; or

  • Both RSI cash benefits and Medicare coverage (i.e. both Part A (HI) and Part B (SMI)); or

  • Medicare- only claim (i.e. claim for Part A (HI) and Part B (SMI)); or

  • End-stage Renal Disease (ESRD) Medicare application, see HI 00801.197A.1.

EXAMPLE:

In January 2013, a number holder (NH) (age 65) becomes entitled to retirement insurance benefits (RIB). In June 2013, the NH withdrew his application for cash benefits but kept his HI entitlement, which began in January 2013 at age 65 (no SMI was involved as he declined it).

D. Procedure for handling WD requests involving HI coverage

The conditions for approval of the WD request depend on the specific entitlement(s) the claimant wants to nullify. The claimant entitled to both monthly RIB benefits and HI must clearly state if the request includes HI entitlement.

1. RSI Claimant age 65 or older wants to keep HI and WD cash benefits

Claimants age 65 and older who are entitled to both RSI and HI can withdraw the RSI benefit and retain HI.

If the claimant wants to withdraw the claim for monthly benefits and keep HI coverage, follow instructions to request only the RSI benefit refund in GN 00206.014. There is no need to repay any HI benefits already paid on the claimant's behalf since the claimant is not withdrawing the claim for HI coverage.

2. DIB Claimant wants to keep HI and WD cash benefits

Claimants who withdraw an application for monthly disability benefits lose both HI and SMI benefits as the Medicare entitlement is based on the DIB award. If the claimant wants to withdraw the claim for DIB benefits and keep HI coverage, inform him or her that it is not possible and the WD of the DIB application will affect the Medicare entitlement. See HI 00820.001 Terminations and Withdrawals for detailed information about effect of withdrawal on HI.

3. Claimant wants to WD both cash benefits and HI coverage

If the claimant’s WD request includes withdrawing HI entitlement, the Field Office (FO) must follow instructions on GN 00206.014A. Once the Processing Center (PC) receives the WD request, the PC must contact the Center for Medicare and Medicaid Services (CMS) using the steps below before taking action on the WD request to determine whether they made HI payments on behalf of the claimant. The FO should not take a new claim until we receive verification from CMS and we approve the WD request.

Before approving the WD request, the PC must:

  1. Complete all entries on the top portion of a form SSA-L345 (Request for Verification of Hospital Insurance Payments).

  2. Use the email feature in the inform website to submit the request to CMS atL345east@cms.hhs.gov. The email must include the following information on the subject line:

    • NH’s state of residence,

    • NH’s name, and

    • NH’s Beneficiary Identification Code (BIC) for Medicare coverage. For example: “Subject: NY-John Doe-B6”

      IMPORTANT: Do not email the WD request or other associated material to CMS.

  3. Fax a copy of the SSA-L345 into the Non-Disability Repository for Evidentiary Documents (NDRed) and prepare a 15-day diary to follow up with CMS, if necessary.

  4. Send a follow up email request to CMS if you have not received a response when the 15-day diary matures. Write “Second request” in the subject line in addition the information included in the subject line on the initial request. Set another 15-day diary.

  5. Compute the claimant’s repayment amount using the response provided by CMS and add to the total repayment request as explained in GN 00206.014B.3.

4. Claimant pays owed HI and cash benefits

The claimant has up to 45 days from the date of the notice to refund the benefits paid. Therefore, the PC must obtain a second verification for the HI to ensure CMS did not provide additional services. Follow the instructions below when the claimant submits the HI and cash benefits amounts needed for the WD request:

  • Call the CMS representative listed on the SSA-L345 completed by CMS to verify that no additional HI expenses occurred. Prepare a 15-day diary to follow up with CMS, if needed.

  • Document the file with the CMS confirmation (no new HI expenses were made) and process the WD request following GN 00206.014B.4.

If CMS informs you that additional HI payments are needed, complete and email a new SSA-L345 request following instructions in GN 00206.020D.2.

E. References


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0200206020
GN 00206.020 - Hospital Insurance (HI) and Withdrawal (WD) - 08/11/2017
Batch run: 08/11/2017
Rev:08/11/2017