TN 23 (04-01)

HI 00805.315 GEP Enrollment For Disabled Beneficiaries Who Do Not Enroll During The D-SEP

A. POLICY – GEP ENROLLMENT

Disabled beneficiaries who did not enroll in SMI during the D-SEP may only enroll during a GEP.

B. POLICY – CALCULATION OF THE PREMIUM SURCHARGE

The premium surcharge is calculated by counting the number of months when an individual could have been, but was not, enrolled in SMI after the end of the IEP through the end of the enrollment period in which enrollment occurs. Exclude from the surcharge calculation any months beginning 1/87 (or the end of the IEP, if later) the plan paid primary benefits. The beneficiary must submit the evidence described in HI 00805.300B.2. in order for the premium surcharge to be reduced or eliminated.

C. PROCEDURE – FO

When a GEP enrollment request is received for a beneficiary who did not enroll during the D-SEP, the FO will:

  • Take Form HCFA-40B.

  • Prepare a Report of Contact stating that the beneficiary did not enroll during the D-SEP and indicating the months to be excluded from the premium surcharge calculation.

  • Annotate “Premium Surcharge Rollback” prominently at the top of the Report of Contact.

  • Attach a copy of the employer letter and carrier certification and forward the enrollment package to the PSC.

D. PROCEDURE – TSC

Send the beneficiary a Form HCFA-40B.

Advise the individual that he/she will need a letter from his/her employer and a copy of the Medicare carrier certification in order to verify the months to be excluded from the premium surcharge calculation. Refer the beneficiary to the employer to secure the required evidence.

Tell the individual to take both letters and the Form HCFA-40B to the local Social Security FO to enroll in SMI. Give the beneficiary the FO address.

E. PROCEDURE – PSC

Process the GEP enrollment via MACADE.

F. EXAMPLE

Carole Simms, employed at United Banking, Inc. since 7/85, has been on long term disability since 1993. She was entitled to Part A effective 3/95, but refused Part B. Carole was notified in 10/98 that effective 1/99, the LGHP would no longer pay primary to Medicare. She received the employer letter indicating the months the plan paid primary and the carrier certification. Carole did not enroll in SMI during the D-SEP which was 1/99 through 7/99.

In February 2000, Carole applies for SMI and inquires about the D-SEP. She is told that her D-SEP ended 7/31/99 and her application must be treated as a GEP enrollment. However, all months the plan paid primary are excludable from the premium surcharge calculation. Carole is assessed a premium surcharge of 10 percent since the months the employer was not primary payer of benefits (January 1999 through March 2000, a total of 15 months) are not excludable from the surcharge calculation.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0600805315
HI 00805.315 - GEP Enrollment For Disabled Beneficiaries Who Do Not Enroll During The D-SEP - 04/11/2001
Batch run: 01/27/2009
Rev:04/11/2001