If an individual refuses to cooperate with SSA to establish eligibility for enrollment, advise the local welfare office, so that the State can take any action that is appropriate to obtain the cooperation of the individual.

Although an application by the individual is required for Part A entitlement, it is not required for Part B (SMI) enrollment under a State buy-in agreement. If an individual refuses to cooperate in establishing their age, U.S. citizenship (or lawful alien status), and residence in the U.S., the State must assume the burden of proving the individual's SMI eligibility. If the State cannot prove the recipient's eligibility, the State's request for their enrollment must be denied.

Each file must be documented to show that the welfare recipient was requested to apply for HI and SMI but refused to do so. When the DO/BO contacts the recipient, they will be advised that:

1. 1. 

   By filing an application, they may establish entitlement to HI. This will enable them to obtain needed medical care from most hospitals simply by presenting their health insurance card.

2. 2. 

   The filing of an application will permit SSA to determine whether they are eligible for monthly benefits.

3. 3. 

   Even if they refuse to file, the State may enroll them for SMI under the terms of its agreement. Such enrollment will not give them HI protection.

If, after this is explained, the recipient still refuses to file, document the file with an RC, or signed statement by the recipient, showing the basis for their refusal. Notify the public assistance office that an CMS-4040 (Application for Enrollment in Supplementary Medical Insurance Plan) is required to enroll the individual.

If the individual fails to respond to the DO/BO's efforts to contact them, the public assistance office will attempt a personal contact (if it has not already done so) before completing the CMS-4040. If the recipient refuses to file, a statement (on the CMS-4040 or other writing) signed by an authorized welfare representative, showing the reason the individual refused must be included in the file. The top margin of the CMS-4040 received from the public assistance office is annotated by the DO/BO “Enrolled pursuant to section 1843 of the Act.”

Although an CMS-4040 is an application form, its use in this case is not as an application, but as a device for the State to transmit information which is needed to establish the individual's eligibility for SMI. A signature or application by the individual is not required for SMI enrollment under a State buy-in agreement.

In addition to completing the CMS-4040, the public assistance office must submit the normal evidence required for HI-SMI cases:

1. 1. 

   Proof of individual's age.

2. 2. 

   Proof of U.S. residency.

3. 3. 

   Proof of U.S. citizenship or status as a lawfully admitted alien.

Any evidence from the public assistance records which is used to establish age, citizenship, or residence requirement must be described as to type of document and recordation date. The certification of evidence may be entered on the CMS-4040. If the public assistance record does not contain sufficient evidence to establish the recipient's eligibility, additional evidence is required.

The “date claim filed” shown in item 6 of the award form is the date the CMS-4040 is received. The first month of SMI coverage is shown as the first month of entitlement, as determined by HI 00815.018.