TN 28 (11-14)
HI 00805.055 Notice of Right to Refuse Deemed Enrollment
A. Policy on who receives notice of automatic (deemed) enrollment in supplementary medical insurance (SMI)
Automatic (deemed) enrollment in SMI only occurs for beneficiaries who:
reside in the United States, the Northern Mariana islands, the Virgin Islands, Guam and American Samoa; and
receive retirement, survivor or disability insurance (RSDI) benefits at least four months prior to the start of the their Medicare initial enrollment period (IEP).
For more information on automatic enrollment, see HI 00805.110A.1.
The Centers for Medicare & Medicaid Services (CMS) mails notices of automatic (deemed) SMI enrollment in the domestic initial enrollment period (IEP) package, at the beginning of the beneficiary’s IEP, which is:
the 22nd month of receiving benefits for disability insurance benefits (DIB), childhood disability benefits (CDB) or disabled widow(er)’s benefits (DWB); and
three months before the beneficiary’s month of attainment of age 65.
For a description of the contents of the domestic IEP package, see HI 00805.125B.
The Social Security Administration (SSA) mails notices of automatic (deemed) SMI to beneficiaries who obtain Medicare entitlement during or after their IEP, as outlined in HI 00805.110A.2. This may be due to a claim not processing timely or a DIB appeal.
For information regarding SMI enrollment for beneficiaries who are not automatically enrolled in SMI, see HI 00805.110B.
For information regarding SMI enrollment for beneficiaries who reside in Puerto Rico, see HI 00805.115B or a foreign country, see HI 00805.120B.
B. Policy for SMI refusal
Beneficiaries that we automatically enroll in SMI may refuse the coverage if they file a written notification by the specified deadline, as outlined in HI 00805.055B.1. in this section.
NOTE: If a State Buy-in is currently in effect, the beneficiary cannot refuse or terminate SMI, as outlined in HI 00815.001 and HI 00820.035B.5.
When a beneficiary states that he or she wants to refuse SMI, make all reasonable efforts to ensure that the beneficiary refusing or terminating SMI coverage understands the effect of their action, as explained in HI 00820.045 through HI 00820.075 and in TC 24001.070.
1. Opportunity to refuse SMI
All beneficiaries that we automatically enroll in SMI have an opportunity to refuse SMI. Beneficiaries receive written notice of their automatic SMI enrollment, as outlined in HI 0805.055A in this section. This notice:
The notice may be in the form of an IEP package or a Medicare award notice.
a. Deadline for SMI refusal in IEP package
A beneficiary who receives an IEP package must refuse SMI enrollment before the coverage begins.
b. Deadline for SMI refusal in Medicare award notice
A beneficiary has two full calendar months following the date of the Medicare award notice to refuse SMI enrollment.
When we mail the Medicare award notice in the first month of the beneficiary’s IEP, he or she must refuse SMI enrollment before coverage begins.
Example of deadline for refusal based on automatic enrollment during a beneficiary’s IEP:
Ms. Grey files for DIB in March 2012, and we deny her claim. She appeals the denial and receives a favorable decision. We establish her entitlement retroactively, starting in April 2012. Ms. Grey’s Medicare entitlement begins in April 2014. SSA notifies Ms. Grey of her automatic enrollment into SMI on January 10, 2014 (during the first month of her IEP). Because her SMI coverage begins April 2014, Ms. Grey has until March 30, 2014 to refuse SMI enrollment. (The timeframe offered Ms. Grey provides her with two full calendar months following the date of her Medicare award notice.)
When we mail the Medicare award notice any time after the first month of the beneficiary’s IEP, he or she must refuse SMI within two full calendar months following the date of the Medicare award notice.
Example of deadline for refusal based on automatic enrollment after a beneficiary’s IEP:
Mr. Fuller files for DIB in June 2010, and we deny his claim. He appeals the denial and receives a favorable decision. We establish his entitlement retroactively, starting in July 2010. Mr. Fuller’s Medicare Part A entitlement begins in July 2012 and his Medicare Part B begins October 2014. SSA notified Mr. Fuller of his automatic enrollment into SMI on October 20, 2014 (after his IEP). Because he is notified after his IEP, Mr. Fuller has until December 31, 2014 to refuse SMI enrollment.
c. Deadline for SMI refusal when notice is not sent timely
In some instances, the beneficiary may not receive the automatic enrollment notice timely. These beneficiaries may learn they have SMI coverage through a SMI premium bill, a reduced benefit payment, or another benefit notification informing them of the SMI premium deduction. When this occurs, the beneficiary must refuse SMI within two full calendar months after either:
the month the beneficiary says that they received the notice; or
the month the beneficiary receives their first SMI premium bill,
whichever occurs first.
d. Other considerations to determine if refusal is filed by the deadline
CMS does not accept SMI refusals or protect filing dates for SMI refusals.
We must receive the written refusal for SMI by the specified date for it to be timely. If a beneficiary calls the field office (FO) or Teleservice Center (TSC), or visits the FO, to refuse SMI, he or she must still file a written refusal for SMI by the deadline. We do not protect filing dates for SMI refusals.
For information on the 7-day tolerance test for mailed SMI refusals, see SM 03040.080C.
2. Form CMS-2690 (Request for Cancellation of Medicare Part B (Medical Insurance))
The Medicare award notice includes a Form CMS-2690 in cases where we send the notice less than two months before SMI coverage begins or after SMI coverage begins. If the individual requested SMI coverage, the Medicare award notice does not include Form CMS-2690.
Beneficiaries who want to refuse SMI may complete Form CMS-2690 and return it to SSA before the date specified on the form.
Beneficiaries may provide other written notification to SSA to refuse the SMI coverage instead of using Form CMS-2690.
Form CMS-2690 advises TRICARE beneficiaries that they must keep both HI and SMI to remain eligible for TRICARE benefits.
To view Form CMS-2690, see OS 15060.073.
3. Timely SMI refusal
If the beneficiary files before SMI coverage starts, we always consider this a timely SMI refusal timely.
We consider a SMI refusal timely if we receive it by the deadline indicated in HI 00805.055B.1. in this section.
If the beneficiary files a written refusal for SMI timely, we determine that he or she legally refused this coverage and does not incur any premium liability.
For more information on processing SMI refusals, see SM 03040.080C.
4. SMI refusal not filed timely
A refusal is not timely if we receive it after the deadlines indicated in HI 00805.055B.1. in this section. If the beneficiary files after deadline, we consider this a request for voluntary termination of SMI. In this case, SMI coverage ends with the last day of the month after the month the beneficiary files the written request.
Example of untimely SMI refusal:
In May 2012, we award disability benefits to Mr. Roy effective March 2009. He is entitled to Part A effective March 2011 and Part B effective May 2012. SSA notifies Mr. Roy in his Medicare award letter that he has until July 31, 2012 to refuse SMI. He visits the FO in September 2012 to refuse SMI coverage. Since Mr. Roy didn’t refuse SMI by July 31, 2012, we cannot process his written request for refusal. Instead, we treat his request as a voluntary termination of SMI coverage. His SMI coverage ends on October 31, 2012.
5. Refusal rescinded during IEP
If a beneficiary refuses automatic enrollment but later files a request for SMI enrollment during the remainder of the IEP, the request is a valid IEP enrollment, despite the prior refusal. SMI coverage begins based on the new date of filing, as noted in HI 00805.165B.
C. Policy when a current application is pending
RSDI applications include Medicare enrollment information and an explanation that an eligible beneficiary who obtains entitlement to monthly benefits and HI is deemed to have enrolled in SMI unless he or she answers “no” to the enrollment question.
In some cases, a beneficiary not eligible to enroll in SMI may become eligible before we can fully develop and resolve all issues with the claim. When this occurs, the FO should contact the beneficiary to obtain a SMI election or refusal and document the application with his or her response.
D. Policy for refusal made by an incompetent person
We cannot extend the IEP or the general enrollment period (GEP) for a beneficiary because he or she is mentally incompetent during all or part of the period as explained in HI 00805.100.
Do not consider a refusal for SMI as valid if the beneficiary was:
NOTE: This is true even if the beneficiary currently has SMI based on an enrollment filed after the refusal.
For this policy, consider a beneficiary to be incompetent based on one of the following documents:
a signed statement from a physician indicating that the beneficiary was incapable of managing his or her own affairs at the time he or she filed the refusal; or
a certified copy of a court order showing that the beneficiary was determined, by the court, to be legally incompetent at the time he or she filed the refusal.
Following a determination of incompetence, any future requests for SMI refusal (or SMI enrollment) by the beneficiary must include legal or medical evidence showing that he or she is now competent. For information on developing medical evidence for capability, see GN 00502.050B.
E. Policy for cancelling a refusal by an incompetent person
To cancel a refusal, the responsible representative (or the beneficiary) must submit proof that the beneficiary was mentally incompetent at the time he or she filed the refusal. If the beneficiary makes the request to cancel their prior SMI refusal, he or she must now be competent, as shown with legal evidence or other medical evidence as outlined in GN 00502.050.
Cancel the refusal if we receive the proof outlined in HI 00805.055D during the following timeframes:
within 12 months of the first month of potential SMI entitlement; or
if later, within 12 months of the month of the refusal.
SMI entitlement begins with the month coverage would have started as though the beneficiary never filed the refusal. The beneficiary must pay all premiums owed for any retroactive months of SMI coverage or authorize us, the Railroad Retirement Board or the Office of Personnel Management to withhold them from monthly benefits payable.
Example of cancelling a refusal by an incompetent beneficiary:
Ms. Tessen was born on January 15, 1947, and we entitle her to retirement benefits at age 63. She receives the IEP package in October 2011 (the first month of her IEP). Ms. Tessen refuses SMI in November 2011. She enrolls again in SMI in March 2012, the sixth month of her IEP, and we award SMI coverage as of June 2012. In September 2012, her sister notifies the FO that Ms. Tessen was mentally incompetent at the time she refused SMI in November 2011.
Ms. Tessen’s sister provides a certified copy of a court order dated July 2011 indicating that the court ruled that Ms. Tessen was legally incompetent. Ms. Tessen’s sister, the legal representative, authorizes the retroactive SMI premiums to be withheld from Ms. Tessen’s monthly benefits. We adjust Ms. Tessen’s SMI entitlement date to January 2012 (the first month her SMI coverage would begin as though she never filed the original refusal).
Even if Ms. Tessen had not enrolled later during her IEP, we could award her SMI as of January 2012.
GN 00502.050 Developing Evidence of Capability
HI 00805.100 Individual Incapacitated During IEP, GEP, or SEP
HI 00805.110 SMI Enrollment Process
HI 00805.115 Enrolling Beneficiaries in SMI who Reside in Puerto Rico
HI 00805.120 Enrolling Beneficiaries in SMI who Reside in a Foreign Country
HI 00805.125 Description of CMS Medicare Initial Enrollment Period Package Information Sent to Beneficiaries
HI 00805.165 Individual Enrollment - When A Coverage Period Begins
HI 00815.001 General Description
HI 00820.035 Termination of SMI Entitlement
HI 00820.045 Voluntary Termination of SMI
OS 15060.073 CMS-2690, Request for Cancellation of Medicare Part B (Medical Insurance) Under the Social Security Act
SM 03040.080 Processing SMI Refusals
TC 24001.070 SMI Termination Requests