TN 19 (03-93)

HI 00805.210 SMI Awarded Erroneously

A. Introduction

Sometimes, after an individual has been enrolled in SMI, evidence is discovered indicating that SMI was awarded in error or the date of entitlement is wrong. This may occur, for example, if information shows that the individual had not yet attained age 65, refused SMI enrollment, or did not file the enrollment request during an enrollment period.

B. Policy - Timely protest

If the individual protests timely against enrollment (i.e., before the SMI entitlement date, or, if later, within 6 months after the month in which he/ she is sent a notice of SMI entitlement), the SMI award may be set aside, as described in C., below.

C. Procedure - Timely protest

Follow the procedures below in handling timely protests of enrollment.

If a timely protest as shown in B. is received:

  • delete the erroneous period of SMI coverage, and

  • refund any premiums paid provided that the individual repays any SMI benefits paid pursuant to the erroneous enrollment.

  • Record on a Form SSA-795 the individual's statement that he/she does not want SMI, and the agreement to repay any SMI benefits paid by the Medicare program.

EXAMPLE: Mr. Thomas, age 71, files a GEP election of SMI during 3/ 90.

His application is erroneously handled like a special enrollment period enrollment and he is awarded SMI coverage effective 4/90. Shortly after receiving the award notice, Mr. Thomas protests the SMI award because he will continue to be covered under his employer group health plan until he retires on 6/30/90.

The SMI award is corrected to 7/90. The erroneous period of SMI coverage is deleted and SMI premiums withheld from his social security checks are refunded to him.

On the other hand, if Mr. Thomas does not protest until more than 6 months after the month he is sent notice of SMI entitlement, his protest can only be treated as a request for voluntary termination. (See HI 00820.035 B.4.)

D. Policy - Wants to keep SMI

Ordinarily, the individual will wish to retain SMI because he/she may have given up nongovernmental health insurance or incurred substantial medical expenses in reliance on the SMI award. Erroneous SMI awards will be handled in accordance with E., below.

E. Procedure - Wants to keep SMI

1. Error discovered in or after IEP

If the error is discovered after the start of the individual's IEP, do not disturb the SMI award unless it was procured through fraud or similar fault of the individual.

EXAMPLE: In 4/88, Mrs. Howe enrolls for SMI with coverage beginning 5/88, based on a finding that she was born 5/17/23. Newly discovered evidence, submitted in 6/90, shows that she was born 5/17/24. There is no evidence of fraud or similar fault.

Regardless of any action which may have to be taken with regard to her social security benefit and HI, do not change the SMI award.

2. Fraud or similar fault

If there was fraud or similar fault:

  • do not grant equitable relief, and

  • annul the SMI award.

NOTE: Any Part B payments made during the period of erroneous entitlement will be treated as overpayments.

  • Offset any premium refund that may be due by the amount of the overpayments.

3. Error discovered before the IEP

When an individual is -

  • enrolled erroneously, and

  • corrective action can be effected before the start of the individual's IEP, and

  • fraud or similar fault is not involved,

terminate the SMI coverage effective with the last day of the calendar month in which the termination action is taken.

Notify the individual of the reason for the termination, and when he/she may again enroll.

If the enrollment was obtained through fraud or similar fault, follow E.2. above.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0600805210
HI 00805.210 - SMI Awarded Erroneously - 06/08/2015
Batch run: 06/08/2015