An individual who enrolls in Premium-HI for the Aged may withdraw enrollment application without incurring any premium liability by filing a written request for withdrawal at any time within 3 months after notice of HI coverage.

If a request for withdrawal if received more than 3 months after the notice, process as a voluntary request for termination.

When an individual requests withdrawal of Premium-HI enrollment, be sure that the individual realizes the consequences of the action by following the guidelines in HI 00805.080 and HI 00820.045 – HI 00820.075 for SMI withdrawal and termination requests. Also, make sure the individual is aware of the QMB provisions (see HI 00801.139) if requesting withdrawal because of inability to pay premiums.

If, after receiving a full explanation of the consequences of withdrawal, the individual still wishes to withdraw, obtain complete form CMS-1763 (Request for Termination of Premium Hospital Insurance and/or Supplementary Medical Insurance), clearly documenting reasons for making the request.