TN 35 (02-20)

HI 00805.185 Processing Equitable Relief Cases

A. Procedures - Field Office actions

When a beneficiary requests equitable relief or equitable relief is possible, consider whether the request meets all the requirements in HI 00805.170B.

CAUTION: Do not submit equtiable relief cases directly to the Centers for Medicare & Medicaid Services (CMS) under any circumstances. Take the actions attributable to the FO if the request involves District Office Final Authorization (DOFA).

  • Prepare an SSA-5002 (Report of Contact/RC) include the following:

    1. 1. 

      Evidence. For information on acceptable evidence, see HI 00805.175 and

    2. 2. 

      Your analysis of the information and evidence and

    3. 3. 

      Your reasons and decisions as to whether or not we should grant equitable relief.

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

  • Include the beneficiary’s request to enroll, copies of appropriate records, the completed employee’s Report of Contact, and any pertinent development. For more information on Part B enrollment, see HI 00805.060 .

  • In non-DOFA cases, forward the case via Paperless to the appropriate PC for review and final processing . Refer to GN 01010.027 for the definition of DOFA and non-DOFA .

  • 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,

    NOTE:If a situation arises which affects equitable relief for more than 2 (potential) enrollees that we do not specifically cover in these instructions, refer to the regional office (RO) analyst to refer to PC Operations Analysis Staff (OAS) to follow section HI 00805.185A.3. Procedures for processing center (PC) processing actions.

B. Process - PSC actions

1. Special determination

In non-DOFA cases (refer to GN 01010.027 for definition), adjudicative personnel authorize relief by following the instructions in HI 00805.170 through HI 00805.240. Use the instructions in this section to make a decision about equitable relief, without a referral to CMS.

Use the instructions in this section to make a decision about equitable relief, without a referral to CMS.

  • Prepare an SSA-553 Prepare an SSA-553 (Special Determination) for each case you consider equitable relief, stating the following:

    1. 1. 

      The issue and

    2. 2. 

      The facts and

    3. 3. 

      Conclusion to grant relief and the type of relief, or whether to deny relief.

  • File the SSA-553 in the electronic claims folder refer to GN 01010.360

2. Notice of decision

Notify the enrollee in writing to explain the type of relief or if relief is denied. Follow the appropriate guidelines in section HI 00805.195.

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

3. PC Referrals to CMS

If a situation arises that affects more than 20 (potential) beneficiaries that we do not specifically cover in these instructions, the PC OAS should refer the formal written request directly to:

Centers for Medicare & Medicaid Services Medicare Enrollment and Appeals Group, Division of Enrollment and Eligibility Policy C4-14-15 7500 Security Blvd Baltimore MD 21244

In the memo:

  • State all the pertinent facts and considerations; and

  • Estimate the number of enrollees actually or potentially affected.

Never send claims folders with the submittals.

C. Policy - State Buy-in

 

Award Part B enrollment base on the following scenarios:

Scenario

Part B coverage starts

Date of State Buy-in eligibility is earlier than the Part B award date possible under equitable relief

The month of State Buy-in eligibility

Date of State Buy-in eligibility is the same date as Part B award date possible under equitable relief

The month of State Buy-in eligibility

Date of State Buy-in eligibility is later than the Part B award date possible under equitable relief

The current operating month or month of the Part B award date possible under equitable relief. Follow instructions in HI 00805.185D.3.

Special Case: There are cases when there is State Buy-in involvement for a person filing an initial claim outside an enrollment period because of delays by the Department of Homeland Security (DHS) in changing his or her alien status to lawfully admitted for permanent residence.

Part B coverage starts the month of State Buy-in eligibility when:

  • The claimant meets the requirements for Part B enrollment earlier than the date of issuance of DHS document I-151 (Alien Registration Receipt Card) or I-551 (Permanent Resident Card), or

  • State Buy-in eligibility occurs before the date of issuance of the DHS document, and

  • State Buy-in eligibility starts on or after the earliest Part B eligibility date.

For additional equitable relief policies and instructions regarding delays by DHS, see HI 00805.240B.7.

Example of a special case: Mr. Velasco files an initial claim to enroll in Part B in April 2018. His documentation from DHS was issued in March 2018. Based on the data included in his DHS documentation and his other evidence of age and length of residence, his earliest date of Part B eligibility is April 2016. Based on his income, he is also eligible for State Buy-in starting September 2016. Because the State Buy-in eligibility is after Mr. Velasco’s earliest Part B eligibility date and before the date that DHS issued the documentation, his Part B award is effective September 2016.

D. Policy for open applications

For retroactive award of Part B when we would normally automatically enroll the beneficiary had we processed the award timely, follow instructions in HI 00805.195. Consider the delay in processing entitlement as a delay based on “open application” as a delay in awarding Part B.

NOTE:For delays in awards where the time limit for providers and beneficiaries to file Medicare claims for payment expired or will expire within six months after the month of the award, see HI 00805.195 .

E. References

  • GN 01010.027 District Office Final Authorization (DOFA) exclusions

  • GN 01010.375 Payment Center (PC) Responsibilities in Preparing or Reviewing Special Determinations

  • HI 00805.005 Eligibility for SMI

  • HI 00805.060 Voluntary Request for Enrollment

  • HI 00805.170 Conditions for Providing Equitable Relief

  • HI 00805.175 Evidence of Government Error or Delay

  • HI 00805.195 Enrollment Not Processed Timely

  • HI 00805.240 Other Situations Where Equitable Relief May Apply


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0600805185
HI 00805.185 - Processing Equitable Relief Cases - 02/03/2020
Batch run: 02/03/2020
Rev:02/03/2020