TN 19 (03-93)
HI 00805.080 Withdrawal of Enrollment Before It Goes Into Effect
An individual, or proper party on his/her behalf, can withdraw the enrollment application by requesting withdrawal any time before SMI coverage is effective.
NOTE: The processing center processes these as a refusal of SMI coverage.
2. How to withdraw
To serve as a withdrawal or termination, there must be an appropriately signed and unequivocal statement that:
the individual no longer wishes SMI coverage, or
he/she wishes to withdraw or cancel the enrollment request, etc.
This statement should preferably be made on Form CMS-1763 adapted for the purpose, but may also be made in a signed letter, or by an unequivocal sentence written on one of the prescribed enrollment forms listed in HI 00805.075 signed by (or on behalf of) the individual.
3. When withdrawal must be filed
An individual may withdraw an enrollment request any time before SMI coverage becomes effective.
A withdrawal of the enrollment request is also honored if filed after the effective month of SMI coverage but within 2 months after the month the enrollment request was filed.
An individual who enrolls during a GEP may withdraw the enrollment request at any time up to the following July when SMI becomes effective.
When withdrawal of an enrollment request is not filed in time to prevent enrollment, it serves as a request for voluntary termination of SMI coverage, effective (as of 7/87) with the end of the month after the month in which the request is filed, as explained in HI 00820.050.
EXAMPLE: Millie enrolls in 7/92, the third month of her IEP. She may file an effective withdrawal at any time prior to 10/92 (2 months later).
On the other hand, if the withdrawal request is not filed until 10/92, it is treated as a voluntary termination. This means that the SMI coverage (which begins 8/1/92) is terminated 11/30/92 (the end of the month following the month the withdrawal request was filed).
4. Cautions on withdrawing
Whenever an individual indicates that he/she wants to withdraw or terminate SMI enrollment, the FO should ensure that he/she realizes the effect of such action (see HI 00820.060ff).
If an enrollment form is received which is merely answered “no” and signed by a person who has enrolled for SMI, it should not be treated as a withdrawal or termination of SMI enrollment without further development by the FO or PSC that received it. The individual should be promptly contacted for an unequivocal signed statement clarifying his/her intent.
If withdrawal or termination was intended, it can be considered filed as of the date of receipt of the “no” option form only if the unequivocal statement is submitted within 60 days of such receipt.
NOTE: If Premium-HI for the aged is involved, withdrawal or termination of SMI ends Premium-HI, as well.