TN 9 (06-92)
HI 00820.055 Cancellation of Voluntary Termination Request
1. When and How a Termination Request May Be Cancelled
A request for termination may be cancelled by a signed statement filed on or before the last day of SMI coverage. (The last day of SMI coverage may be a Saturday, Sunday, legal holiday or any other day all or part of which is declared to be a nonwork day for Federal employees by statute or Executive Order. In that case, a request for cancellation of termination received on the next regular workday will be treated as if filed on the last day of SMI coverage.)
The request need simply state, in effect: “I want to keep my Medicare medical insurance. Please disregard my previous request to stop this insurance.” The statement must be signed by the enrollee, and should show both the enrollee's address and claim number. 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.
2. Instructions on When Cancellation Can Occur
Since there will be only 30 to 60 days in which to revoke the termination before it takes effect, the individual should be clearly informed of what action is necessary and when it must occur. For this reason, the date of termination block on the CMS-1763 should be filled in legibly.
3. Termination Request Cancelled During GEP
If cancellation of a termination request is filed during a GEP after coverage terminated, the cancellation request is treated as a reenrollment request in the month it is received by the DO or PSC.