BASIC (07-11)

HI 00803.080 Withdrawal of EHH Medicare Application

A. Policy for withdrawal from EHH Medicare

A beneficiary may withdraw an Environmental Health Hazards (EHH) Medicare application for any reason at any time after filing, even if entitlement has begun. Do not approve any request for withdrawal until the beneficiary has repaid any Hospital Insurance (HI) benefits to the Medicare program. Upon receipt of a request for withdrawal from EHH Medicare, the FO must:

  • complete form SSA-L345 (Request for Verification of Hospital Insurance Payments); and

  • send the SSA-L345 to CMS to find out if there are HI funds that the beneficiary must repay prior to withdrawal of the EHH Medicare application. For procedure when withdrawal request includes HI entitlement, see GN 00206.095B.1.c.

EXCEPTION: Where the beneficiary is entitled to HI based on age, disability or ESRD and that entitlement is prior to or effective with the month of EHH HI entitlement, there is no overpayment of HI benefits and no need for repayment.

1. When withdrawal of an EHH Medicare application may occur

Some examples of when withdrawal an EHH Medicare application may occur are:

  • Medicare is the secondary payer of benefits and the beneficiary discovers after HI and SMI are in effect that the employer plan will pay all expenses;

  • there is another insurance that is primary to Medicare or will pay all medical expenses; or

  • the beneficiary requires Part B coverage but does not meet the requirements for a special enrollment period (SEP).

2. Termination of HI and SMI upon withdrawal of EHH Medicare application

Upon withdrawal of the EHH Medicare application, EHH HI terminates retroactive to the first month of HI entitlement.

If the beneficiary files a withdrawal request within 60 days of the notification of EHH HI and SMI entitlement, EHH SMI terminates retroactive to the first month of SMI entitlement. If the beneficiary files a request for withdrawal after the 60-day period, EHH SMI terminates at the end of the month in which SSA notifies the beneficiary of approval of the request for withdrawal. SMI premiums paid for the period of entitlement are not refundable.

If the beneficiary is entitled to Medicare based on age, disability or ESRD, that coverage continues.

3. Refiling for HI (and SMI) after withdrawal

Treat a subsequent application for EHH Medicare as an initial application. The claimant has a new initial enrollment period (IEP) for SMI based on the month of HI entitlement. If the claimant does not refuse SMI, SMI is effective the month of HI entitlement without a premium surcharge for late enrollment.

B. Reference

GN 00206.095, Processing and Repayment in Withdrawal (WD) After Payment Effectuation Cases


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