If the beneficiary is requesting reinstatement and has “good cause” for reinstatement
as explained in HI 01001.360, obtain an SSA-795 (Statement of Claimant or Other Person) or any signed statement
from the claimant requesting “reinstatement” and an explanation of why the premiums
were not paid. The claimant must be able to repay all past-due premiums, plan to repay
them by installment, or have a third party who is willing to pay.
Document the “good cause” determination on an SSA-5002 (Report of Contact) and send
to PC7 via fax to the paperless server. Send a copy of the receipt you issued for
If the beneficiary cannot pay the retroactive premiums or cannot establish good cause,
he or she can re-file in the general enrollment period (GEP).
Do not develop a new ESRD application if the beneficiary has hospital insurance based
on ESRD (R-HI). The CMS-40B (Application for Enrollment in Medicare) is the appropriate
form to request Supplementary Medical Insurance based on ESRD (R-SMI) enrollment.
If the beneficiary has been covered by a Group Health plan, see DI 11052.001G and consider withdrawal of the ESRD application.
NOTE: Special enrollment period (SEP) provisions do not apply to ESRD beneficiaries, including
those dually entitled to Medicare based on ESRD and disability or age (ESRD/DIB, ESRD/RIB, ESRD/WIB).