TN 23 (04-01)
HI 00805.320 Equitable Relief for Disabled Individuals Covered Under a GHP/LGHP
A. POLICY – APPLYING EQUITABLE RELIEF
1. Equitable Relief - Disabled Beneficiaries
A disabled beneficiary may allege he/she was misinformed about whether the GHP or LGHP was the primary payer of benefits. If there is proof, or the likelihood, that the information alleged was given by an employee or agent of the Federal Government (e.g. SSA or a Medicare carrier), the employer, or by the GHP/LGHP, equitable relief may be granted to correct the results of the incorrect information. Premium surcharges may be waived or reduced, and an SEP may be granted in cases of errors from the above-mentioned sources.
a. Evidence Requirements
The individual may enroll or reenroll in SMI under the equitable relief provisions if he/she submits a letter or other information from the employer that states:
the GHP or LGHP has been primary payer of benefits for some period of time in or after 1/87;
the GHP/LGHP should not have been primary payer; and
the GHP/LGHP stopped (or will stop) making primary payments as of a specified date.
b. Enrollment Requirements
The individual must enroll within 7 months of the date of notice from the employer advising that the GHP/LGHP is no longer primary payer or, if later, within 7 months of the last month for which the GHP/LGHP is primary payer.
c. SMI Effective Date
The SMI entitlement date for a beneficiary who complies with these conditions is:
the first day of the month of enrollment in SMI, or
the first month the GHP/LGHP is no longer primary payer. (Note: the beneficiary must agree to pay all premiums due, if applicable.)
d. Premium Surcharges
When calculating the premium surcharge, exclude all months beginning 1/87, during which the GHP/LGHP was the primary payer of benefits.
2. Equitable Relief – Aged Beneficiaries
Errors made by an employee or agent of the Federal Government (e.g. SSA, Medicare carriers, etc.) are the only basis for granting equitable relief to the aged.
See HI 00805.170ff. — Conditions for Applying Equitable Relief