TN 19 (03-93)

HI 00805.185 Processing Equitable Relief Cases

A. Procedures - Field Office actions

In any case where equitable relief is claimed or is possible, consider whether all the requirements in HI 00805.170B are met.

CAUTION: In the following instructions, the FO takes the actions attributable to the PSC or ODO if DOFA is involved. However, the FO should never submit equitable relief cases directly to the Centers for Medicare & Medicaid Services (CMS) under any circumstances.

  • Include evidence mentioned in HI 00805.175 and prepare an RC giving your analysis of the information and evidence, and your decision as to whether or not equitable relief should be granted.

    NOTE: Ensure that the RC outlines the reasons for believing that relief should or should not be provided.

  • Forward the case to the appropriate PSC or ODO for review and final decision unless it is a DOFA case.

  • Refer to, and adapt, as necessary, the instructions in HI 00805.170 - HI 00805.240.

  • Attach the enrollee’s statement, copies of appropriate records, FO employee’s statement, when appropriate, and all other development.

    IMPORTANT: DOFA cases require this documentation as part of the file even though the FO will make the final decision, using the equitable relief instructions, or applying the general principles outlined in the instructions.

  • If a referral for a decision on equitable relief is necessary, submit the issue to the SSA Regional Office, giving the information as outlined in HI 00805.185C,

B. Process - PSC actions

1. Special determination

In non-DOFA cases, relief will be authorized by adjudicative personnel following the instructions in HI 00805.170 - HI 00805.240. Each case should be decided without referral to CMS by adapting the general principles in all these sections.

The PSC or ODO prepares a special determination on an SSA-553 for each case where equitable relief is considered, setting down the issue, facts, and conclusion as to whether relief is granted and the type of relief, or whether relief is denied. The SSA-553 is filed in the claims folder.

2. Notice of decision

After the decision is reached regarding equitable relief, the PSC notifies the individual in writing of the type of relief, if any, to be provided.

NOTE: The notice should follow the appropriate guides in sections HI 00805.195.

IMPORTANT: Any mention of appeal rights should refer to the basic issue, e.g., date of entitlement, rather than the equitable relief decision itself (which is not appealable).

C. Procedures - Referrals to CMS by the PSC

If a situation arises that affects more than 20 (potential) beneficiaries and is not specifically covered in these instructions, submit the question by memorandum before any award or relief action is taken, to:

CMS
Center for Medicare
Medicare Enrollment and Appeals Group,
Division of Enrollment and Eligibility Policy
C2-12-16
7500 Security Blvd
Baltimore MD 21244

In the memo:

  • State all the pertinent facts and considerations; and

  • Estimate the number of individuals actually or potentially affected.

Never send claims folders with the submittals.

D. Policy - State buy-in involved

If an individual is shown to meet in a specific month the requirements for SMI entitlement, and in that month is also eligible for State buy-in, SMI enrollment is always effective with that month, unless it could begin earlier without regard to State buy-in. (See HI 00805.195G for specific information on State buy-in where an award of SMI is delayed.)

In all cases where State buy-in considerations result in an earlier award of SMI than that which would be possible based on the following equitable relief instructions, State buy-in considerations take precedence.

EXAMPLE: HI 00805.240B.7.c. gives instructions on handling claims where no application was filed while an alien awaited a delayed decision from DHS on a change of status to lawfully admitted for permanent residence. If State buy-in is not involved, the date of issuance of the I-151 or I-551 is the fourth month of the IEP. However, if the I-151 or I-551 (along with the required evidence of age and length of residence) shows that the claimant met the requirements in some earlier month, and if State buy-in applies to that month, or any later month that occurred before receipt of the I-151 or I-551, SMI is awarded based on the State buy-in date.

E. Policy - Open applications

If the requirements are met for an award based on an “open” application, and the beneficiary is, as a result, subject to an automatic enrollment in SMI that is retroactive, the instructions in HI 00805.195 should be followed. This means that the delay in processing entitlement based on the “open” application is considered as a delay in awarding SMI.

F. Policy - Part A time limit

Ordinarily, claims for HI benefits for covered services received during the 12- month period ending September 30 of any year must be filed on or before December 31 of the next year. Equitable relief does not apply to premium-free HI.

However where administrative error causes failure of a provider of Part A services to file a request for payment within the usual time limit, the time limit may be extended. The extension will end with the last day of the sixth month following the month in which the error is rectified and notice is sent.

Therefore, special language may be required for notices of awards or reinstatements of HI entitlement involving retroactive months. This would occur where the usual claims filing time limit for services furnished in any of those months has ended (or will end within 6 months after the month of notice). The language should be similar to the following:

“If you received any services covered by Medicare during the period before October 1, (year), hospital benefits for such services can be paid only if the provider which furnished the services submits a claim for payment on or before (the last day of the 6th month after the date of the notice). You should telephone your local social security office if you have any questions regarding this matter.”

This language is in addition to any language required under HI 00805.195 or HI 00805.215 concerning the individual’s right to elect retroactive SMI entitlement. Language concerning SMI services for which the usual claims filing time limit has expired is sent only after an individual elects retroactive SMI entitlement in response to the initial award or reinstatement notice.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0600805185
HI 00805.185 - Processing Equitable Relief Cases - 07/23/2012
Batch run: 06/05/2015
Rev:07/23/2012