TN 59 (02-23)

HI 00801.197 Withdrawal of Application

A. Policy

1. Application may be withdrawn

An ESRD application may be withdrawn at any time after it is filed, even if entitlement has begun. Any Part A benefits paid to, or on behalf of, the claimant must be repaid to the Medicare program before the withdrawal is approved. The form SSA-L345 (Verification of Hospital Insurance Payments) should be completed and sent to CMS, see instructions GN 00206.020.

However, where the withdrawal and refiling are occurring at the same time and the beneficiary elects R-HI to begin again with the first month for which Part A benefits were paid, there would be no overpayment of benefits and no need for repayment. For an example of this situation, see HI 00801.197B.2.

2. Reason for withdrawing

Usually (but not exclusively), withdrawal of R-HI occurs when Medicare is the secondary payer of benefits (see HI 00801.247 for a discussion of the circumstances under which Medicare is the secondary payer for R-HI beneficiaries) and the individual discovers after R-HI and R-SMI have gone into effect that the employer plan will pay all expenses. Withdrawal of the R-HI application terminates R-SMI.

Whether or not R-SMI was elected on the original application for R-HI, on refiling for R-HI, as explained in HI 00801.197.A.5., a new initial enrollment period (IEP) for R-SMI occurs. This means that, upon reenrollment in Medicare, the enrollee will not have wait for a GEP to enroll for SMI and there will be no premium surcharge for late enrollment.

3. Ending dates for R-HI and R-SMI

When the application is withdrawn, R-HI terminates retroactive to the first month of R-HI entitlement. If R-SMI is currently in effect (i.e., had been elected and not previously terminated), R-SMI terminates at the end of the month in which the individual is notified that their R-HI withdrawal request is approved. R-SMI premiums paid for the period of entitlement are not refundable.

4. Refiling for R-HI

A subsequent R-HI application is treated as an initial application with retroactivity of entitlement limited to 12 months. R-HI retroactivity can also be restricted to any of the 12 months prior to the month of filing. The restriction on retroactivity of R-HI affects the new month of R-SMI entitlement.

5. Filing or refiling for R-SMI

R-SMI entitlement (whether it was previously in effect or if this is the initial filing for R-SMI) based on a refiled application for R-HI may be elected as of the month of R-HI entitlement. The individual has a new IEP for SMI based on the month of R-HI entitlement.

If there is a premium arrearage of 6 months or more, R-SMI may be elected as of the month of filing, or the month of processing, as explained in HI 00801.251. There is no premium surcharge for late enrollment if R-SMI is elected in this new IEP. If a premium surcharge had been payable during the past enrollment that was terminated, it does not carry over to this new period of R-SMI.

If a withdrawal of R-HI and a refiling for R-HI occur at the same time, R-SMI is not terminated, unless specifically requested. If a specific request is made, document the file to show that the adverse effect of terminating R-SMI has been explained. The effective date of R-SMI termination is the end of the month after the month termination is requested.

B. Examples

1. Withdrawal

In 8/99, Don withdraws ESRD application. Entitled to R-HI and R-SMI since 4/1/99, when had a kidney transplant. However, Don learned that group health plan had been paying all expenses and that Medicare not needed at this time. CMS reviewed the utilization records and advised SSA that no Part A benefits were paid on Don's behalf. Notification of approval of R-HI withdrawal takes place in 9/99 and R-SMI terminates effective 9/30/99.

In 5/02, Don refiles for R-HI and R-SMI. Restricts the retroactivity of R-HI application to 2/02 (the first month for which Medicare would be the primary payer of benefits under the 30-month Medicare secondary payer provisions, see HI 00801.247 B., and R-SMI is awarded with that month as well.

2. Simultaneous withdrawal and refiling

Georgia is entitled to R-HI and R-SMI effective 1/1/99, based on dialysis beginning in 10/98. In 8/00, withdraws ESRD application. Covered continuously by a group health plan since before dialysis began. Therefore, Medicare is secondary payer through 6/01. CMS reviews the utilization records and advises SSA that R-HI secondary benefits were paid only for services received in 2/00.

Georgia elects to re-file for R-HI on the same day withdraws the original application. Restricts the retroactivity of current R-HI application to 2/00. Has no Part A overpayment to repay as retroactive entitlement will cover the only month in which services were paid by Part A. Georgia does not elect R-SMI on new application. Therefore, R-SMI terminates with 8/31/00, since the withdrawal was approved in 8/00. However, files a GEP request for R-SMI in 3/01 and R-SMI begins again on 7/1/01, just in time for Medicare to pay primary benefits.

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HI 00801.197 - Withdrawal of Application - 02/08/2023
Batch run: 02/08/2023