TN 1 (07-04)
DI 45001.330 Equitable Relief in Initial ESRD Cases
A. Premium arrearage
(See HI 00801.251B.)
R-SMI coverage ordinarily begins with the first month of R-HI entitlement unless refused within 2 months after the month the individual received notification of the deemed SMI enrollment. R-HI beneficiaries will generally utilize very costly health care services from the beginning of their R-HI coverage and therefore, have little to gain by refusal of SMI since most dialysis expenses are covered by SMI rather than by HI. However, many individuals being awarded R-HI retroactively may have difficulty paying for the retroactive SMI coverage if confronted by a large premium arrearage. Accordingly, equitable relief provisions are applicable to premium arrearage situations of 6 or more months of retroactive R-SMI coverage. The beneficiary must be given a choice, since he or she or some treating centers may often be willing to pay the premium arrearage because of the far greater R-SMI benefits. Therefore, in cases involving premium arrearage of 6 months or more, R-SMI will begin prospectively unless the enrollee elects to pay all the premiums for SMI coverage beginning either with the earliest month of R-HI entitlement or if later, the month of filing. Item 7 on the application Form CMS-43 should be examined for completion and, if completed, SMI enrollment should be processed accordingly.
If item 7b. of the CMS-43 is not completed, contact the beneficiary for an answer to determine the SMI date to be awarded.
In cases of 6 or more months of premium arrearage without the individual's clear election, process per the instructions in DI 11052.000 with the following additional actions.
When completing Form HCFA-SSA-892-U3, be sure to check “Yes” to item 32 (Equitable Relief).
Begin the R-HI coverage from the earliest possible date. Begin the R-SMI coverage with the current operating month (COM) in which the enrollment is being processed. In EAM and MADCAP DOFA cases, COM is the month shown in item 41 of the SSA-892-U3.
The appropriate paragraph below should be included in the formal award notice. Use Form SSA-5002 to request paragraph inclusions. (Write out paragraph to be included (with fill-ins)):
R-HI entitlement is the same or later than the month of filing:
“You may, if you wish, have your medical insurance begin (MOE to HI) provided that within 30 days of this notice you submit a signed request for such earlier coverage and pay $ , which is the premium due for your coverage from through .”
“If you are receiving monthly social security benefits you can make that payment by simply authorizing the Social Security Administration to withhold the amount due from your monthly benefits.”
R-HI entitlement precedes the month of filing:
“You may, if you wish, have your medical insurance begin with (1) your month of entitlement to hospital insurance (date) , or (2) the month you filed your application (date) . If you want this earlier coverage, you should submit a signed request specifying the month you want your coverage to begin. The request must be submitted within 30 days of the date of this notice. Additionally, payment of the premium due must accompany your request. The premium due would be $ if you select (date) or $ if you select (date) , provided your request is submitted within 30 days. If you are receiving monthly social security benefits you can make that payment by simply authorizing the Social Security Administration to withhold the amount due from your monthly benefit.”
NOTE: For fill-in of the amounts due in paragraphs a. and b. above, the computations must be based on SMI monthly premium rates of $5.80 effective 7/73, $6.10 effective 8/73, $6.30 effective 9/73, $6.70 effective 7/74, $7.20 effective 7/76, $7.70 effective 7/77, $8.20 effective 7/78, $8.70 effective 7/79. $9.60 effective 7/80, $11.00 effective 7/81, $12.20 effective 7/82, $14.60 effective 1/84, $15.50 effective 1/85, $17.90 effective 1/87, and $24.80 effective 1/88.
If an individual is included in a State buy-in agreement, modify the paragraphs shown above to remove the references to payment of premiums for the appropriate period covered by the agreement. (HI 00801.257).
However, if the State buy-in agreement is effective with the first possible month of R-SMI entitlement and continues for all following months to COM, equitable relief is not an issue as the State will pay the premiums.
B. Other equitable relief situations in initial ESRD cases
Situations may occur which warrant individualized measures to grant equitable relief at the initial level; for instance, the erroneous sending of a notice to the individual that he/she has coverage which may in fact not have been established and to which he/she is not entitled (such as later evidence of dialysis ending during the qualifying period). In order to determine whether granting equitable relief is appropriate in the particular case, review the guidelines in HI 00805.170. Be especially aware of the provisions of HI 00805.170A. and HI 00805.170B. Document the reasons for relief on Form SSA-5002.