The majority of T3 actions will be processed through the SALT program by the district
offices. If current SMI entitlement exists, the program will place the recorded in
LAFU status to initiate SMI premium billing, establish an HOC of “X” to indicate that HI is terminated because monthly benefits are terminated and generate
a date of termination of HI (DOTH) equal to the date of suspension or termination
(DOST). If current SMI entitlement does not exist, the HOC of “X” and DOTH equal to DOST will be established, but the LAF will remain in T3 status.
If HI entitlement was originally based on the renal disease provisions (i.e., the
HENC on the MBR is “K”), the system will change the LAF to U. However, as HI based on renal disease does
not terminate when benefits terminate, the HOC of “X” and DOTH equal to DOST will not be established by the program. If it is later determined
that HI entitlement under the renal disease provisions no longer exists (e.g., dialysis
treatment ceases), a MADCAP conditional adjustment will be necessary to code the HOC/SOC
of “S” and appropriate DOTH/DOTS.
All T3 actions processed through SALT will be alerted to the program service centers
for additional action. The Form SSA-3926-C2 SALT output will contain two alert codes:
code 432, manual letter necessary, and
code 433, award determination necessary.
Instruct the typist to prepare a termination notice, Form SSA-L6901, rather than the
usual SSA-L-597 letter. Taking into consideration the conditions involved in the case
(i.e., whether SMI entitlement exists, if there is ongoing third party, if a verified
BOAN has been established, etc.), instruct the typist to include the various paragraphs
as shown in section C. below.
NOTE: The paragraphs indicated in C. below should be typed before any additional paragraphs;
e.g., overpayment information.
If there is no evidence in the claims folder that an M or T claim was previously established,
attach a Form SSA-567 to route the case to a Claims Authorizer for an award determination
after the beneficiary notice has been released.
When current SMI entitlement exists, the LAP of U established on the terminated record
may remain indefinitely. However, circumstances may dictate that additional activity
will occur or that subsequent processing may be required. For example, if SMI becomes
terminated for nonpayment of premiums, the system will change the LAF to X7.
There will also be instances when the terminated individual may have been previously
entitled as a T or M on another SSN before becoming an auxiliary beneficiary. Or it
is possible that a new award (usually a T or M) may be received simultaneously with
the SALT termination output. In these cases, if SMI entitlement exists, it must be
transferred immediately to the prior or new T or M claim (i.e., do not allow the terminated
record to remain in LAF U status). Two separate manual actions through MADCAP are
change the LAF U on the terminated record to X5 by summarizing a TOCA and RFCA of
“X” and “5” respectively and entering the cross-reference number and BIC in RID 5, and
reinstate or establish the prior or new claim through MADCAP. The two separate manual actions are required even when a new T or M claim is being
processed at a later date.
To reinstate a prior T or M claim from X5 status, use the “Resum” facility with a zero rate. If a T claim is being reinstated, also enter the original
DOEH and HOC of “E” in RID 6. Prepare an SSA-573 showing an SSA-31-C1 as the letter. For a T beneficiary,
include the following paragraphs in the order shown; H09; if renal disease beneficiary
include H22; H21; State buy-in or third party involved, H99; or if beneficiary will
be billed, H60; and H23. For an M beneficiary include the following paragraphs in
the order shown: H98; H21; if State buy-in or third party involved, H99; or if beneficiary
will be billed, H60; MH07; and H23. All appropriate fill-ins must be given. Only the
first paragraph of H21 will be used showing the current SMI premium rate and effective
date. If the M or T has a foreign address include MH04 as the next to last paragraph.
Do not resume a prior M claim if current SMI entitlement does not exist on the terminated
record. If a new M claim is received, it may be assumed that the individual wishes
to be enrolled for SMI.
If a new T or M claim is being established, summarize a zero rate and full HI/SMI