TN 34 (04-19)

HI 00805.324 Equitable Relief for Enrollment Request Affected by Major Disasters

A. Introduction

As described in HI 00830.001 and HI 00805.170 , we have the authority to provide relief to individuals whose SMI or premium HI enrollment or coverage rights have been impacted by the error, misrepresentation, action or inaction of an employee or agent of the Government.

Medicare entitlement and enrollment decisions are normally transmitted through letters delivered by the U.S. Postal Service. Beneficiaries may elect to enroll in premium Part A and/or Part B or decline automatic Part B enrollment by mailing their enrollment decision to SSA. Weather-related events may become so severe that mail delivery are disrupted for extended periods or force local SSA field office closings, preventing individuals from enrolling or declining Medicare enrollment under Part A and/or B in a timely manner. Consider the disrupted mail delivery and/or SSA office closings to be an inaction by a government agent or instrumentality that may prevent some beneficiaries from making their premium Part A or Part B enrollment requests during their Initial Enrollment Period (IEP), General Enrollment Period (GEP), or Special Enrollment Period (SEP).

B. Part B (and Premium Part A) Enrollment and Part B Refusal Request

Under normal circumstances, beneficiaries must submit a timely request to enroll in Medicare premium Part A (Hospital Insurance), Part B (Supplementary Medical Insurance), or both within an applicable enrollment period as outlined in HI 00801.133, HI 00805.010, HI 00805.130, and HI 00805.275.

Beneficiaries automatically enrolled in Part B, but who don’t want the coverage, must refuse coverage as outlined in HI 00805.055 and HI 00805.080.

C. Equitable Relief for Part B Enrollment and Refusal Requests for Beneficiaries Impacted by Mail Disruptions inWeather-Related Emergencies or Major Disasters.

Equitable relief may be considered on a case-by-case basis for beneficiaries who, due to a weather-related emergency or natural disaster, did not receive the initial enrollment package by mail or had difficulties submitting timely IEP, GEP, or SEP enrollment requests. Relief may also be considered for beneficiaries who had difficulties submitting a timely Part B refusal request.

Where weather-related events affected U.S. mail delivery and/or operations at local field offices, equitable relief may be considered for beneficiaries who:

  • At the start of a weather-related incident period, were in their IEP, GEP, or SEP, and

  • Resided in areas for which the Federal Emergency Management Agency (FEMA) declared a weather-related emergency or major-disaster.

    When you make a favorable equitable relief determination:

  • Consider the late premium Part A and/or Part B IEP, GEP, or SEP enrollment request as filed timely if it is received no later than 90 days beyond the applicable enrollment period deadline.

  • Consider the late Part B refusal as timely filed if received no later than 90 days after the normal refusal deadline.

D. Processing Instructions

Process these cases following the normal rules for equitable relief cases as outlined in HI 00805.185. We encourage technicians to be as responsive and flexible as possible when a current or new beneficiary affected by a weather-related emergency or major disaster contacts us for any of the following reasons:

  • Non-receipt of his or her Medicare award notice or Initial Enrollment Period package; or

  • Inability to file an enrollment request or refusal timely.

Equitable relief FO/N8NN steps

Follow these steps:

  1. 1. 

    Consider whether the case meets the requirements in Section C of these instructions.

  2. 2. 

    Document the beneficiary’s statement on the SSA-5002 (Report of Contact) identifying him or her as a resident of an area affected by a weather-related emergency or major disaster.

  3. 3. 

    For beneficiaries requesting premium Part A or Part B enrollment, complete the following steps:

a. If the beneficiary expresses dire need of medical attention, refer the action to the program service center (PSC) of record following existing instructions in GN 01070.228.

b. If the beneficiary wants to enroll in:

  • Part B, complete Form CMS-40B (Application for Enrollment in Medicare Part B (Medical Insurance)).

  • Part A, complete Form CMS-18-F5 (Application for Hospital Insurance). For SEP enrollment:

    For SEP enrollment:

  • Attempt to obtain evidence of Group Health Plan (GHP) or Large Group Health Plan (LGHP) coverage based on current employment via Form CMS-L564 (Request for Employment Information).

  • If the CMS-L564 can’t be obtained, you may process the case using alternative documentation as outlined in HI 00805.295 .

c. If the beneficiary wants a retroactive effective date, explain the following to the beneficiary:

  • The individual must pay all premiums for all months of coverage.

  • Explain that the total amount of premiums for all months, including the next coverage month, may be deducted all at once from his or her benefit amount.

  • Make sure the beneficiary understands the implications for a retroactive effective date before processing.

  • Follow normal processing procedures if a beneficiary believes he or she cannot afford to pay retroactive premium Part A, Part B or both premiums in a lump sum.

d. Include the following:

  • Beneficiary's Part B effective date and

  • Annotate "Resident of the Federal Emergency Management Agency (FEMA) declared disaster areas" in the remark sections of the CMS-40B.

If the beneficiary is enrolling in premium Part A, include:

  • Beneficiary's premium Part A effective date and

  • Annotate "Resident of Federal Emergency Agency (FEMA) delcared disaster areas" in the remarks section of the Form CMS- 18-F5.

    NOTE: Limit the premium Part A and/or Part B effective date to a month granted under normal processing procedures for timely IEP, GEP, and SEP filing.

e. Print the barcode from NDRED for Form CMS-18-F5 and/or the CMS-40B and, if applicable, the CMS-L564.

4. Field office (FO) employees complete Form SSA-5002 (Report of Contact) with your analysis of the information, and your decision as to whether we should provide relief. Include the reasons for approval or disapproval based on your review.

5. Fax the completed CMS-40B or CMS-18-F5, SSA-5002, and if applicable, the CMS-L564, and supporting documentation into CFUI and add remark on SSA-5002 “Resident of the Federal Emergency Management Agency (FEMA) declared disaster areas.”

6. FO forwards the case to the appropriate PSC via Paperless to review and process. TSC follows routine instructions to send the case to the PSC to review and process.

Equitable relief PSC steps

Follow these steps:

1. Review the beneficiary’s statement and available evidence in support of the SSA-5002 determination.

2. Process approved equitable relief cases following normal equitable relief procedures.

Part B refusal FO steps

Follow these steps:

1. Consider whether the case meets the requirements in Section C of these instructions. If not, equitable relief does not apply.

NOTE: If State Buy-in is currently in effect, the beneficiary cannot refuse or terminate Supplemental Medical Insurance (SMI).

2. Obtain a written statement from the claimant requesting SMI refusal as a resident of the Federal Emergency Management Agency (FEMA ) declared disaster areas. When a beneficiary states that he or she wants to refuse SMI, make all reasonable efforts to ensure that the beneficiary refusing or terminating SMI coverage understands the effect of their action.

3. Complete the “timely” refusal request by following normal business procedure. Fax the written statement and store in CFRMS.

NOTE: Forward SMI refusals exceeding six months to the PSC of jurisdiction to process via Paperless.

Part B refusal N8NN steps

Follow these steps:

1. Consider whether the case meets the requirements in Section C of these instructions. If not, this equitable relief does not apply.

NOTE: If State Buy-in is currently in effect, the beneficiary cannot refuse or terminate SMI.

2. Providing a complete explanation of the consequences of terminating SMI.

3. If the caller still wishes to terminate his or her coverage, fully complete the Form CMS-1763, Request for Termination of Premium Hospital and/or Supplementary Medical Insurance.

Include the following information:

  • Name of beneficiary

  • Medicare claim number, name of person, if other than enrollee who is making this request.

  • Indicate that this is a Request for Termination of SMI, and the date SMI ends.

  • Annotate that the beneficiary requesting SMI refusal is a resident of the Federal Emergency Management Agency (FEMA) declared disaster areas.

4. Mail the CMS-1763 to the beneficiary with a courtesy return envelope to the servicing PSC.

PSC steps

Follow these steps:

1. Review the written statement and available evidence in support of SMI refusal.

2. Process approved SMI refusal by following normal business procedure.

References:

 

HI 00801.138 Application for Premium HI

HI 00805.010 Rules on Enrollment Periods

HI 00805. 055 Notice of Right to Refuse Deemed Enrollment

HI 00805.080 Withdrawal of Enrollment Before It Goes Into Effect

HI 00805.130 When an Enrollment Received by Mail is Considered Filed

HI 00805.170 Conditions for Providing Equitable Relief

HI 00805.180 Payment of Premium Arrearage

HI 00805.185 Processing Equitable Relief Cases

HI 00805.275 Special Enrollment Period (SEP) Enrollments

HI 00805.277 Processing SEP Enrollments

HI 00830.001 Granting Equitable Relief

HI 00830.060 Installment Payments for Retroactive Premiums

TC 24001.040 Initial Enrollment Period (IEP)

TC 24001.050 Special Enrollment Period (SEP) For the Aged and Disabled


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0600805324
HI 00805.324 - Equitable Relief for Enrollment Request Affected by Major Disasters - 04/11/2019
Batch run: 04/11/2019
Rev:04/11/2019