If only Premium-HI is being terminated, give or send the enrollee a completed CMS-L458
(Acknowledgment of Request for Premium Hospital Insurance Termination).
If an individual indicates that he or she wishes to terminate Premium-HI solely because
of inability to pay the Part A premium, be sure to discuss with the individual the
requirement that States pay Medicare premium, deductible and coinsurance amounts for
“qualified Medicare beneficiaries (QMB)” under their Medicaid programs. Refer interested individuals to the State or local
Medicaid agency to file for QMB status.
NOTE: QMBs are individuals entitled to HI (including Premium-HI) whose income does not exceed 100% of the Federal poverty guidelines and whose resources
do not exceed twice the SSI resource limit.