TN 33 (04-19)

HI 00805.195 Enrollment Not Processed Timely

For a variety of reasons involving government fault or error, we may have delayed processing a Medicare Part B enrollment for several months or years after coverage should have started. There also may be a delay in notifying an enrollee that we awarded coverage.

These delays may result in beneficiaries not getting healthcare services they need or paying for services out-of-pocket. They also may be unable to pay the premiums owed for the period we delayed the case.

For a discussion of equitable relief when we do not process a Premium-Part A enrollment timely, see HI 00805.235.

A. Policy for relief

Consider equitable relief when the beneficiary owes six or more months of past-due premiums due to the delayed award of the Medicare Part B enrollment.

1. Enrollee owes six or more months of premiums

Award Part B prospectively beginning the month we process the award (i.e., current operating month (COM)), if the beneficiary owes six or more months of retroactive premiums at the time we finally notify him or her about the start of Part B coverage.

  • Do not include the premium for the COM nor future months of coverage

  • Notify the enrollee of the option to choose the earliest possible entitlment date, and that the retroactive premiums are paid or deducted from benefits.

  • If an enrollee elects the earlier coverage date, he/she must notify us in writing within 60 days of the date on the notice and pay all premiums due.

    NOTES:

  • To calculate the late enrollment penalty for late filing: Do not count the months between the end of the enrollment period that the enrollee filed the request (or deemed filed) and the Part B entitlement date.

  • Beneficiaries may pay retroactive premiums in installment payments. For establishing installment plans, see HI 008030.060 .

2. Part B start date restrictions

The beneficiary may only chose coverage to start at:

  • COM or

  • The earliest possible entitlement date

The beneficiary cannot choose any other date for coverage to begin. This protects the Part B Trust Fund from substantial expenses by beneficiaries choosing to only have Part B coverage begin when they had numerous or costly services

Begin the coverage and premium liability with the month we take final action to award the claim or, if the beneficiary requests retroactive coverage, the date provided by the initial enrollment period (IEP) in HI 00805.165.

 

.

B. Procedures for relief

Refer to these possible scenarios when we determine if equitable relief may be applicable.

1. Enrollee chose enrollment date before award

  • Enrollee wants only current coverage

    • Award Part B beginning COM according to section B.2. Do not include retroactive coverage language (i.e., do not include equitable relief paragraph mentioned in section B.2.b).

  • Enrollee wants the earliest date and is willing to pay the past premiums

    • Award Part B according to section B.3.

2. Relief granted with enrollment date of COM

Follow these procedures when the beneficiary does not request either

  • current month Part B coverage only or

  • the earliest possible enrollment date.

When the beneficiary makes no definitive request for his or her Part B coverage start date, as outlined in section B.1., refer to the default process outlined below.

  1. a. 

    Award coding.
    Follow the procedures in the chart in this section B.2.b to notify the beneficiary that we are providing relief.

  2. b. 

    Notice of award
    Send the enrollee a notice of current Part B award (or earlier, proper month according to State buy-in) which includes:

  • “Required language” stating the current entitlement dates and premium rates, similar to:

    • You are entitled to Medicare Part B (medical insurance) beginning (date).

    • We charge a monthly premium for your Medicare Part B medical insurance.

Universal text options for entitlement and premium rates are in NL 00720.145 and NL 00720.180 respectively.

  • The beneficiary in current pay must pay or have deducted from monthly benefits past due Part B premiums. The beneficiary can choose to have Part B coverage begin with the first month of eligibility. This is the date coverage would have begun if we processed the enrollment request correctly and promptly. For more information on coverage period starts dates, see HI 00805.165 .

    • Use the chart in this section.

Universal text options for equitable relief paragraphs for the scenarios in the chart are in NL 00720.180.

  • If Part A is retroactive, please also determine if the Supplementary Medical Insurance based on Disability (SMID) paragraph is necessary according to section B.3.b.

    Scenario

    Follow coding in:

    Add language similar to:

    Delays in awards (UTI HIB252

    HI 00805.196B

    Medicare Part B
    We did not give you an earlier start date for Medicare Part B (medical insurance) because we did not process your request timely. If you want to have this coverage start earlier, you can choose to have Part B coverage start <earlier date>. If you want Part B coverage to start earlier, you must:

    • Contact us within 60 days after the date of this notice;

    • Tell us in writing that you want the Part B coverage beginning <earlier date>;

    • Pay us <$> (This covers the premiums due from <earlier date> through <date of COM >; or,

    • Tell us we can withhold this amount from your monthly benefit payment

    If you want the Part B coverage to start on the earlier date, but find it hard to pay the premium amount in a lump sum, ask us about other ways to pay the money.

    Delays in awards that span over variable SMI year(s) according to HI 01001.004D

    (UTI HIB249 )
    HI 00805.196B Medicare Part B

    If you want your Medicare Part B (medical insurance) to start earlier, you can choose to have it start in (earlier date). To start your Part B earlier, you must do the following things within 60 days after the date of this notice:

    • tell us in writing that you want medical insurance beginning (earlier date);AND

    • pay us ($) or tell us we can withhold this amount from your check. This amount covers the premiums due from (earlier date) through (date to close gap).


    • pay us ($) or tell us we can withhold this amount from your check. This amount covers the premiums due from (earlier date) through (date to close gap).
      If you would find it hard to pay the premium amount you would owe in a lump sum, ask us about other ways to pay the premium
      If you choose to have your Part B start in (earlier date), your current monthly premium will be (variable premium). If you do not choose the earlier date, your monthly premium will be (current standard Part B premium).

    Delays in resumptions for granting relief under HI 00805.185 (UTI HIB231 HI 00830.030 Medicare Part B

    We stopped your Medicare Part B (medical insurance) coverage on <termination date> by mistake. We are sorry if our error caused you any inconvenience. We corrected the mistake, and are starting your Part B coverage again beginning <current operating month>.

    It might be to your advantage to start your Part B coverage at an earlier date. We can start the coverage beginning <termination date>. However, if you want Part B coverage to start earlier, you have to pay the premiums for this coverage. The total amount of premiums from <termination date> through <month before current operating month> is ($).

    If you want Part B coverage to start on the earlier date, you must:

    • Contact us within 60 days after the date of this notice. ….

    • Tell us in writing that you want the Part B coverage beginning <earlier date>

    • Pay us <$> (This covers the premiums due from <earlier date> through <date of COM >; or,

    • Tell us we can withhold this amount from your monthly benefit payment.

    If you want the Part B coverage to start on the earlier date, but find it hard to pay the premium amount in a lump sum, ask us about other ways to pay .

    Delays in resumptions for erroneous terminations under HI 00805.215

    (UTI HIB231

    HI 00830.030

    Same as in “ Delays in resumptions for granting relief under HI 00805.185 ” scenario.

    Medicare Part B

    Same as in “Delays in resumptions for granting relief under HI 00805.185 scenario.

     

3. Relief granted with enrollment date of earliest month allowable (or for …, enrollment date is continuous)

If the enrollee is requesting the earlier entitlement date, ask whether he or she is willing to pay the past premiums before you take any award action.

  1. a. 

    Award Coding
    If the enrollee wants the Part B coverage to be at the earliest date or continuous, he or she must pay the premiums according to the guidelines in HI 00805.180.
    If the enrollee meets the requirements, adjust the award to show the earlier starting date of coverage. Review the case after the award as outlined in HI 00805.196.

  2. b. 

    Notice of award and special paragraph for awards or reinstatements involving retroactivity
    We require special language for awards or reinstatements involving retroactivity. Beginning January 1, 2010, providers must file all Medicare Part A and Part B claims for payment of services to the appropriate Medicare claims processing contractor no later than 12 months (one calendar year) after the date of service.
    Medicare policy extends the time limit in the following situations:

    • Part A, Part B, or entitlement to both does not exist at the time the beneficiary received the service, and

    • The beneficiary receives notice of Part A or Part B entitlement effective retroactively to or before the date of the furnished service.

    When the beneficiary meets these criteria, the provider or beneficiary has six months from the date, he or she receives the notice of the retroactive award to submit the claim for payment. Send the enrollee a notice of Part B award, which includes: Required language in all notices to state current dates of entitlement and premium rates; see section B.2.b.

  • Required language in all notices to state current dates of entitlement and premium rates; see section B.2.b.

  • Include supplementary medical insurance based on disability (SMID) universal text identifier (UTI) in the notice of award or reinstatement when the retroactivity of Part B enrollment is 6 or more months.
    For retroactive awards: Determine if you must include the SMID UTI using the steps in the chart in this section.

Refer to the SMID Paragraph Calculator determines the dates.

Step

Action

1

Calculate month of the notice minus 5 (this helps to analyze the retroactivity of the coverage dates to determine if the enrollee needs an extension to file claims)

2

Compare your result from Step 1 to your Part A coverage date. Did you award a Part A coverage month that is earlier than the month calculated in Step 1?

  • If no, do not

    include SMID UTI for Part A.

  • If yes, include SMID UTI for Part A.

Continue to Step 3.

3 Compare your result from Step 1 to your Part B coverage dates. Did you award a Part B coverage month that is earlier than the month calculated in Step 1?
  • If no, do not

    include SMID UTI for Part B.

  • If yes,include SMID UTI for Part B.

If you answered “yes” to Step 2 or Step 3, move to Step 4.

4 If you awarded Part A coverage, Part B coverage, or both, in a month that is earlier than the month calculated in Step 1, then:
You must includeSMID UTI, available through AURORA.
Move to Step 5
5 Calculate month of notice plus 6 (the last day of the sixth calendar month after receiving notice of your retroactive entitlement).
6 Use the result from Step 1 as the first fill-in (first day of the month).

Use notice language similar to the following:


Use the result from Step 5 for the third fill-in (the last day of the sixth calendar month after receiving notice of your retroactive entitlement.).

Use notice language similar to the following:

“For Medicare services received before *F1, Medicare *F2 benefits may be paid only if the service provider submits a claim on or before*F3. Please give your providers a copy of this letter immediately. Ask the providers to include a copy of this letter when they submit these claims to Medicare.

”Fill ins:

*F1- MMDDCCYY – Month of notice minus 5 (first day of that month)(Example: if the award notice is sent in May 2016, the fill-in is December 1, 2015)

*F2-1 Part A

*F2-2 Part B

*F2-3 Part A and Part B

*F3 – The last day of the sixth calendar month after receiving notice or your retroactive entitlement)

(EXAMPLE: If we send the award notice in May 2016, the fill in is November 30, 2016).

C. Example of retroactive Part A and Part B awards

  1. 1. 

    Example of premium-free Part A and B retroactive award
    We process Mr. Casey's disability claim on August 15, 2016 (COM August 2016). Monthly benefits are payable effective March 2013 and Part A begins retroactive March 2013 and Part A begins retroactive to March 2015. Equitable relief applies and Part B coverage is effective August 2016.

    Step 1:

    Award notice received-August 2016

    Minus 5 months

    ____________________________________

    Result =February 2016

Step:2

Compare your results from Step 1 to Mr. Casey’s Part A coverage date. February 2016 (Step 1 result) vs March 2015 (Part A coverage date)Since, his Part A coverage is earlier then the month calculated in Step 1, include SMID UTI for Part A.

Step 3:

Compare your result from Step 1 to Mr. Casey’s Part B coverage dates .February 2016 (Step 1 result) vs August 2016 (Mr. Casey Part B coverage date)Was the Part B coverage month (August 2016) earlier than the month calculated in Step 1 (February 2016)?

Since, Mr. Casey’s Part B coverage is later than the month calculated in Step 1, do not include SMID UTI for Part B.

Since you answered “Yes” to Step 2 OR Step 3, move to Step 4.

Step 4:

Award notice received for Part A (March 2015), Award notice for Part B (August 2016).Since Mr. Casey’s Part A (March 2015) coverage, Part B (August 2016) coverage (or both) are in a month that is earlier than the month calculated in Step 1 (February 2016) you must include SMID UTI available through AURORA.

Step 5:

Calculate the month of award notice received for Part A plus 6 months (the last day of the sixth calendar month after receiving Mr. Casey’s retroactive entitlement).

Award notice received for Part A = March 2016.

Plus 6 months

________________________________________________________

Result =September 30, 2016

Step 6

Input the results from Step 1-5 into the SMID Calculator to obtain the special notice language.

D. Other situations

See situations in this section relating to a retroactive refusal to Part B, closed periods of entitlement before Part B award, and State Buy-in.

  1. 1. 

    Enrollee no longer wants Part B

    When we award an enrollee prospective Part B beginning many months after enrollment (or deemed enrollment), the enrollee may protest that he or she does not want Part B enrollment (e.g., the enrollee has other coverage, which he or she wants to retain). In such cases (including automatic enrollment cases), if the enrollee files a protest within two months after the month we notified him or her of the Part B coverage, do the following:

    • Reverse the Part B award;

    • Refund any premiums paid; and

    • Deem the enrollee not to have enrolled or, in automatic enrollment cases, deem him or her to have refused enrollment.

    For more information on when the enrollee no longer wants Part B, see HI 00805.055 B.1.c.

  2. 2. 

    Part B termination date occurs before we process award to Part B

    a. Closed period of entitlement

    If the beneficiary is no longer eligible for Part B when we finally process the case (due to death or loss of Part A for a beneficiary under age 65) when we process a delayed Part B award, do the following:

    • Do not award prospective Part B coverage

    • Notify the enrollee (or any of the survivors) as soon as possible, giving him or her the option to:

      • refuse Part B entirely, or

      • elect Part B as of the date entitlement should have begun and pay the premiums.

        For more information on closed period awards, see HI00805.196, HI 00820.035, and HI 00820.120

        b. Amended awards

        In some cases, we process an amended award allowing earlier Part B entitlement to a person to whom we already awarded Part B , but the Part B termination date occurs before the enrollee (or his or her survivors) is able to make the choice to have earlier Part B entitlement. In these cases, do the following:

        • Notify the enrollee (or the survivors) of the choice to:

          • refuse Part B entirely or

          • elect the new, earlier Part B entitlement date and pay the additional premiums

  3. 3. 

    State buy-in involved

    a. State buy-in effective with entitlement month

    If a Part B award is delayed for an enrollee who is eligible for State buy-in for each month of the retroactive entitlement period, make the Part B award effective with the proper month because the State pays all retroactive premiums. Therefore, do the following:

    • Award Part B effective with the proper month.

      For more information on determining the state buy-in month and enrollment month, see HI 00815.018

      b. State buy-in effective with a month later than initial entitlement month

      If the beneficiary is eligible for State Buy-in but it would not apply for the first month of retroactive coverage, or for intervening months of State Buy-in during the retroactive period, then do the following:

    • Award the individual a closed period of Part B for the buy-in period, and

    • Award Part B as of the month of processing, with a choice of coverage for the non-buy-in months, if he or she will pay the premiums.

      We processMary ’s award in March 2016. Her first month of Part B entitlement is January 2015. The State imposed buy-in from June 2015 through October 2015. Award her a closed period of buy-in coverage from June 2015 through October 2015, and continuous Part B from April 2016 on. Inform her that she may have Part B from January 2015 or from November 2015 if she pays the premiums due from whichever date she elects. If she elects January 2015, she is not liable for premiums for the buy-in months. If she elects November 2015, she is only liable for the premiums from November and continuing.

      For more information on routine and closed periods of State buy-in coverage, see HI 00805.196, HI 00815.039, and HI 01001.215.

E. References

  • GN 02403.030 Processing Medicare Premium Remittances Received in the FO

  • HI 00805.055 Notice of Right to Refuse Deemed Enrollment

  • HI 00805.165 Individual Enrollment - When A Coverage Period Begins

  • HI 00805.180 Payment of Premium Arrearage

  • HI 00805.185 Processing Equitable Relief Cases

  • HI 00805.196 Coding Instructions for Sensitive Policy Operations Manual System

  • HI 00805.215 SMI Terminated Erroneously

  • HI 00805.235 Special Considerations for Premium-HI

  • HI 00815.018 When A Buy-In Coverage Period Begins

  • HI 00815.039 Effect of Buy-In on the Individual

  • HI 00820.035 Termination of SMI Entitlement

  • HI 00820.120 Establishing a Closed Period of Disability Entitlement

  • HI 00830.030 Incorrect SMI Termination

  • HI 00830.060 Installment Payments for Retroactive Premiums

  • HI 01001.004 The Variable Supplementary Medical Insurance (VSMI) Premium

  • NL 00720.145 ENT Entitlement

  • NL 00720.180 HIB Health Insurance Benefits


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0600805195
HI 00805.195 - Enrollment Not Processed Timely - 04/04/2019
Batch run: 05/16/2019
Rev:04/04/2019