TN 9 (06-92)

HI 00820.045 Voluntary Termination of SMI

A. POLICY

1. General

Any SMI enrollee, except persons whose SMI coverage is being paid for under a State buy-in agreement, may file a request to terminate SMI coverage.

If the enrollee is incapable of transacting business, the request may be signed by a representative payee, or, in the case of a nonbeneficiary, by someone providing care or financial support.

A representative payee must be able to show that termination of SMI will directly benefit the enrollee. This also applies to whomever is acting for a nonbeneficiary. (See GN 00502.113 for duties, responsibilities, and authority of representative payees.)

2. Termination Request

A request for termination must:

  • be made in writing,

  • unequivocally show the desire to end coverage,

  • be signed by the enrollee (or representative as indicated in HI 00820.045A.1.), and

  • be filed with SSA or CMS.

3. Personal Interview

SMI is a voluntary program and an enrollee has a right to terminate SMI coverage even though the reasons for doing so may seem unsound or may be based on a misunderstanding. Because of the potentially serious consequences of a discontinuance of SMI coverage, whenever feasible, conduct a personal interview.

  • Try to ensure that the enrollee takes no hasty, unwise, or improperly-advised termination action.

  • Make all reasonable efforts to dispel any misunderstanding which may be the cause of the request for termination.

  • Give full information about the nature and consequences of termination of SMI coverage.

  • Explore Medicaid eligibility.

If the individual comes to the FO to discuss or request termination, see HI 00820.060.

4. Request by Mail

If the individual requests termination by letter, a CMS-L457 will be sent (see HI 00820.902) outlining the consequences of a voluntary termination and of the right to withdraw the termination request before coverage ends. Try to arrange a personal interview (see HI 00820.060).

5. Possible Penalties Upon Reenrollment

The enrollee who terminates coverage will not be able to reenroll until the next general enrollment period (GEP).

In addition to the gap in coverage, the subsequent premium rate may be increased by a surcharge related to the break in coverage.

EXCEPTION: If the enrollee is covered under an employer group health plan (EGHP) (or large group health plan - LGHP), and eligible for a special enrollment period (SEP) as described in HI 00805.265, enrollment can occur in the SEP. Premium penalties are also reduced or waived, as described in those sections.

B. POLICY - RESCINDING TERMINATION - ENROLLEE INCOMPETENT

After SMI coverage has terminated, based on an enrollee"s request, the enrollee, or someone acting on his or her behalf, may ask to have coverage reinstated on the grounds that the enrollee was incompetent at the time the termination request was filed.

1. Requirements for Reinstatement

Coverage may be reinstated if:

  • the enrollee"s responsible representative (or the enrollee, if now competent) submits proof within 12 months of the effective termination date that the enrollee was mentally incompetent  at the time the termination request was filed, and

  • all retroactive premiums owed are paid or SSA, RRB, or CSC is authorized to withhold them from monthly benefits payable.

2. Evidence of Incompetency

An individual is considered incompetent for purposes of this subsection on the basis of either of the two following documents:

  • a signed statement from a physician indicating that the individual was incapable of managing his or her own affairs at the time the request for termination was filed, or

  • a certified copy of a court order showing that, at the time the termination request was filed, the individual had been adjudged legally incompetent.

In addition, if the enrollee is the party requesting reinstatement,  the evidence must also show that he or she is now competent to manage his or her own affairs.