While most persons are deemed to have enrolled for SMI, many individuals are excepted from automatic enrollment (see HI 00805.050) and must take action to enroll. Additionally, those who refuse automatic enrollment, or terminate a period of SMI entitlement, must take action to enroll during an enrollment period.

To be entitled (or re-entitled) to SMI, individuals mentioned in HI 00805.060A in this section (or their representatives - see HI 00805.070) must file either:

• •

  a properly executed enrollment form (CMS-40B or CMS 4040 and CMS-L564 [if needed]), or

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  any signed statement that unequivocally shows an intent to enroll.

The form or statement requesting SMI can only be filed with SSA during a prescribed enrollment period.

Any form which is unclear about the individual's intent to enroll is an improperly completed enrollment form.

Any component receiving an improperly completed enrollment form will notify the potential enrollee that, to enroll, they must file or verbally confirm their intent to file within 60 days of the date of the notice.

Verbal Confirmations Acceptable in the Following Situations:

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  If a signature is missing:

  1. 1. 

     The FO can contact the beneficiary and confirm their intention to enroll.

  2. 2. 

     Use a Report of Contact (SSA-5002) form to document the communication with the beneficiary and scan into Evidence Portal (EP).

  3. 3. 

     Upon verbal confirmation, process the enrollment.

• •

  If the form was signed by mark “X” and the witness’ signature is missing:

  1. 1. 

     The FO can contact the beneficiary and confirm their intent to enroll.

  2. 2. 

     Use a Report of Contact (SSA-5002) form to document the communication with the beneficiary and scan into EP.

  3. 3. 

     If the beneficiary is not available, send a letter to explain to the beneficiary they need to have a witness sign the enrollment request. Scan the incomplete form into EP and send a new enrollment form to them to complete.

  4. 4. 

     Once one of the above is received, you may process the enrollment.

• •

  If the check box (….wishing to sign up for Medicare….) isn’t checked:

  1. 1. 

     The FO can contact the beneficiary and confirm their intention to enroll.

  2. 2. 

     Use a SSA-5002 to document the communication with the beneficiary and fax the SSA-5002 into EP.

  3. 3. 

     Upon verbal confirmation, process the enrollment.

• •

  If the form is not dated, use the receipt date of the enrollment request. Among the improperly completed enrollment forms which may establish the application date are those which the individual:

  • –

    Signed but failed to answer “yes” or “no.”

  • –

    Answered “yes” but failed to sign.

  • –

    Answered both “yes” and “no” and signed or did not sign.

  • –

    Signed with an unwitnessed mark, with or without answering “yes” or “no.”

Documenting the Report of Contact (SSA-5002)

When contacting the beneficiary, make sure you document your conversation via an SSA-5002. Document the following information on the 5002:

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  The beneficiary’s name;

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  Date contacted;

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  Reason for contacting the beneficiary. Example: Contacted the beneficiary due to missing signature and to confirm their intention to enroll in SMI;

• •

  A detailed summary of the conversation between the technician and applicant; and

• •

  Technician’s name.

• •

  If the individual fails to verbally confirm or respond to the letter within 60 days, the incorrectly completed form is not effective.

  • –

    If a person writes on an enrollment form, “I am already enrolled” or a similar phrase, this means “yes”.

  • –

    If the person writes, “I am a welfare recipient” or any statement constituting an allegation of State Buy-in coverage, the office receiving the qualified or restricted enrollment application will initiate action to resolve the issue. (See HI 00815.088.)