TN 19 (03-93)

HI 00805.205 Delayed or Incorrect Advice Frustrated Enrollment or Termination Rights

A. Introduction

An individual may be prevented from taking timely action to enroll for or terminate SMI because a Government employee or agent failed to promptly provide correct and complete information.

For example, an individual may write SSA to inquire about SMI enrollment during or shortly before an enrollment period open to him/her. However, the individual is prevented from enrolling because SSA did not respond to the inquiry until most or all of the period expired.

Relief in such cases is provided to ensure that the enrollee's desires are met. That is, the result is the one that would have occurred if correct, complete, and timely information had been given and the individual had acted promptly to enroll in accordance with such information.

Similar relief should be provided for an enrolled individual who inquires about SMI termination. This would be where SSA did not reply to the inquiry in time to permit the filing of a voluntary termination request within the same calendar month in which the individual inquired about termination.

B. Procedure

1. Enrollment desired

Where an individual:

  • inquired about SMI within 9 months prior to the start of an enrollment period open to him/her, and

  • from the nature of the inquiry it is clear that the individual wanted SMI,

award SMI based on filing on the first day of that period.

  • Do not delay the award of coverage by obtaining a second enrollment request.

If providing such relief would result in the award of 6 or more months of retroactive coverage:

  • award SMI with the month in which the claim is adjudicated, and

  • notify the individual of the right to obtain earlier coverage by requesting such coverage and paying the accrued premiums. (See HI 00805.195 B.)

2. Enrollment desires unclear

If the inquiry does not express a clear and unequivocal desire to enroll:

  • send the individual an enrollment card and a letter (in duplicate) advising that he/she may obtain coverage as of a specified date (when coverage would have begun if SSA had responded promptly to the inquiry), and

  • explain in the letter that he/she can have coverage beginning with that date only if within 60 days he/she completes the application and returns it to the DO together with a copy of the letter and a premium payment (give amount) (or the amount will be deducted from social security benefits that are payable).

NOTE: If the application and letter are returned promptly, along with the premium payment (if required), the individual will be deemed to have enrolled when the inquiry was filed.

C. Examples

1. Enrollment at end of GEP

Mr. Brown was born 11/20/26. He became entitled to RIB and HI (but refused SMI) beginning 11/91. He telephoned the DO on 3/20/92 (the last month of the 1992 GEP) and stated that he now wished to obtain SMI at the earliest possible date. The DO should have told him to submit immediately a signed statement that he wanted SMI. Instead the DO sent him a HCFA-40B, which he received on 3/31/92.

He returned the HCFA-40B electing SMI on 4/10/92 and his enrollment request was denied because it had not been filed during an enrollment period open to him.

Mr. Brown protested because he wanted coverage effective 7/92. Equitable relief should be provided so that Mr. Brown's SMI coverage begins with 7/92, the month coverage would have begun if he had been given correct information and acted on it promptly.

2. Misinformed about eligibility

Mrs. Sanchez, who attained age 65 in 4/91, visited the DO in 3/91 and attempted to apply for SMI enrollment. At that time, she was erroneously informed that she was ineligible for SMI because she had no insured status. In 9/91 she again inquired about SMI and was told that since her IEP had ended she could not enroll before 1/92 with coverage effective 7/92. She protested this delay in the start of her coverage, stating that her failure to enroll in her IEP had resulted from SSA misadvice. The DO was able to corroborate her statement, and she was awarded SMI effective with the month her claim was finally adjudicated.

She was also advised of her right to obtain SMI effective 4/91 provided that she requested such earlier coverage and paid all accrued premiums.

3. Termination

Mr. Graves phoned the DO on 3/15/92 and stated that he wanted to R