TN 64 (11-22)

HI 00805.105 Enrollee Needs Help in Paying Premiums or Claiming Reimbursement

A. Introduction

A person, though competent and able to enroll for SMI, may need help in the mechanics of paying premiums or in claiming reimbursement for medical expenses.

NOTE: This latter situation should be rare since physicians, suppliers, and other providers of services must submit claims for the beneficiary.

The beneficiary's need for help may be temporary or indefinite and may come to light during the enrollment process or later.

The arrangements for assisting an individual to overcome the problem, will vary with the nature and duration of the impairment. The procedure described below is intended to guide FO's in procuring the necessary assistance for such enrollees.

The fact that SSA provides help, does not relieve the enrollee of the responsibility to pay premiums promptly, or to claim reimbursement timely in an acceptable manner.

B. Procedures

1. Locating a person to help enrollee

Ask the enrollee whether there is some relative or friend who might be willing to help the enrollee mail premiums, or claim reimbursement. Try to have the enrollee nominate a relative or friend who:

  • is likely to be reliable,

  • lives near the enrollee,

  • has the enrollee's confidence,

  • is interested in the enrollee's welfare, and

  • sees the enrollee frequently.

If there is such a person, interview the person.

REMINDER: In the meantime, take care to avoid termination of coverage or a loss of reimbursement. It may be necessary, pending the selection of someone to assist the enrollee, for the FO to give the help the enrollee needs.

2. Representative payee

If the enrollee is an RSDI beneficiary for whom a representative payee has been or should be appointed, explain to the representative payee that the representative payee is expected to give the necessary assistance.

3. Interviewing relative or friend

  • Schedule an interview as soon as possible after you see the need for someone to assist the enrollee.

  • If another FO is the servicing FO, ask that office to conduct the interview.

REMINDER: Be sure to give the servicing DO full particulars about the situation.

  • Determine if the relative or friend lives near the enrollee.

  • Explain the situation to the relative or friend.

  • Instruct the relative or friend in detail how to assist the beneficiary in paying premiums and claiming reimbursement.

NOTE: Stress the importance of prompt payment of premiums (where premiums must be paid by remittance) and give the enrollee's relative or friend a copy of the “Medicare Handbook.”

  • Tell the friend or relative who agrees to act for the person that, if the friend or relative wishes to withdraw from the arrangement at any time, SSA would like 30 days advance notice.

NOTE: This should allow sufficient time to select another representative to ensure that the enrollee will have necessary assistance continuously.

  • Explain, if appropriate, that any reimbursement checks due the enrollee from the carrier will be sent directly to the enrollee as long as the enrollee is capable of managing financial affairs.

  • If the enrollee receives RSDI checks, ask the relative or friend to notify SSA promptly if the enrollee's condition deteriorates so that the enrollee might need help in managing benefits.

REMINDER: Stress that, although beneficiaries are encouraged to get help if they need it, this does not relieve the beneficiary of the responsibility for paying premiums promptly, and for claiming reimbursement promptly and properly. (See HI 01001.225.)

4. Selecting premium payer for enrollee

If a nonbeneficiary enrollee's premiums must be paid by remittance, and it appears advisable or necessary to send the enrollee's premium notices to the relative or friend in order to ensure continuance of the SMI enrollment, see HI 01001.225 for information on completing the CMS-2384, Third Party Premium Billing Request.

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HI 00805.105 - Enrollee Needs Help in Paying Premiums or Claiming Reimbursement - 11/28/2022
Batch run: 11/28/2022