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