HI 00830.001 Granting Equitable Relief
The 1972 amendments to the Social Security Act granted the Administration the authority
to provide certain forms of relief to individuals whose SMI or premium-HI enrollment
or coverage rights have been prejudiced by the error, misrepresentation, action or
inaction of an employee or agent of the Government. This relief may include, but is
not limited to, providing special enrollment and/or coverage periods and appropriate
adjustment of premium liability. There is total retroactivity in this legislation.
That is, relief can be granted beginning with July 1, 1966. However, no active search
for applicable inequitable situations will be made of past occurrences. Relief will
be considered retroactively if a case is brought to our attention, but no effort should
be made to search for them.
The Centers for Medicare & Medicaid Services (CMS) has the authority and the responsibility
of providing the policy guidelines to be observed in applying this relief to SMI and
premium-HI coverage. No one has the authority to grant relief for enrollment/disenrollment
situations involving the free- HI coverage. However, as indicated later in this section, a back-door type of relief
is possible where payment of health costs was made in good faith but are subsequently
determined to be in error.
CMS has issued certain guidelines in HI 00805.130 that pertain to the extent of relief that can be applied by the PSC (with the cooperation
of the DO"s) without any referral to Central Office. This relief comes in three forms.:
special enrollment periods or entitlement or termination dates; and
the retention of a period of coverage where the requirements for legal entitlement
were never met; and the relief from the liability for the premiums due for specified
periods of time.
This section is intended to augment the interpretation of the amendment found in HI
00805.000ff. It is important to note that more than one type of relief may be applicable
to any one case but each must be individually determined by the appropriate office
having jurisdiction over the type of relief being considered (this is explained in
Because most situations requiring equitable relief considerations will be brought
to our attention through correspondence from claimants, an explanation of the equitable
relief provisions and instructions for granting relief have been incorporated in this
section. However, it must be remembered that these same provisions also apply to any
inequitable situations discovered during any routine folder examination or subsequent
action taken on the claim.