TN 75 (02-23)

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 the individual. 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 the individual, 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 they 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 they can have coverage beginning with that date only if within 60 days they complete 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. Mr. Brown who is the Number Holder (NH) became entitled to RIB and HI (but refused SMI) beginning 11/91. Mr. Brown telephoned the DO on 3/20/92 (the last month of the 1992 GEP) and wanted to obtain SMI at the earliest possible date. The DO should have told Mr. Brown to submit a signed statement requesting SMI. Instead the DO sent Mr. Brown a HCFA-40B, which was received on 3/31/92.

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

Mr. Brown protested because the was not effective on 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 the correct information was given to NH.

2. Misinformed about eligibility

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

NH was advised of NH rights to obtain SMI effective 4/91 provided that NH requested earlier coverage and paid all accrued premiums.

3. Termination

The claimant (Mr. Graves) phoned the DO on 3/15/92 and stated that the claimant wanted to “cancel” SMI enrollment at the earliest date. Despite receiving pertinent information from the DO about the importance of SMI and the effect of termination, the claimant still wished to terminate SMI. The claimant was advised to submit a signed statement requesting SMI termination. The claimant submitted the statement on 4 /2/92.

When the claimant was notified that coverage and premium liability would end on 5/31/92 (the end of the month after the month in which the termination request was filed), the claimant protested this delay in termination, stating that when the claimant telephoned in 3/92 to request information about termination the claimant had not been advised of the importance of submitting a termination request before the end of 3/92.

Although the DO had no record of Mr. Graves' call, it stated that such incomplete advice had been given before and that Mr. Graves was no doubt miss advised. Mr. Graves' SMI coverage and premium liability, therefore, ended with 4/30/92.

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HI 00805.205 - Delayed or Incorrect Advice Frustrated Enrollment or Termination Rights - 02/06/2023
Batch run: 02/06/2023