TN 2 (06-12)

HI 00830.015 Premium Waiver Determinations

The responsibility for the waiver of premiums (called “relief from premium liability” by the Centers for Medicare and Medicaid Services (CMS)), rests with the servicing Field Office (FO). The FO must find out the claimant’s ability to pay the amount owed, without incurring an undue hardship, and provide a written determination either granting or denying the waiver. A favorable determination must include the period of liability involved. The FO will only consider past months of premium liability for waiver.

The FO forwards all determinations to the Program Service Center (PSC); favorable determinations to the attention of the Post Entitlement Technical Expert (PETE). Denials should be sent to the attention of the Debt Specialist (DS), Claims Authorizer (CA), Claims Technical Examiner (CTE), or Senior Case Processing Specialist (SCPS) as is applicable.

The determinations must be:

  • written on an SSA-5002 (Report of Contact),

  • signed by a claims representative or manager, and

  • accompanied by the completed SSA-632-BK (Request for Waiver of Overpayment Recovery or Change in Repayment Rate).

Using an SSA-5002, the FO may send a decision to grant equitable relief by waiving premium payments for limited periods of coverage. In either case, the decision must include both the period of coverage for which the FO waived the premiums (this may consist of a simple “all months still owed before, or up to, month/year,” rather than specified inclusive months) and the facts upon which the FO made the decision. In all cases, the SSA-632-BK (used to determine the claimant’s ability to pay) must accompany the determination. For information regarding completion of the SSA-632-BK, see GN 02250.240.

Upon receipt of the waiver determination, the technician takes action in accordance with the FO decision, and the current payment or nonpayment status, of the particular record.

A. Claimant in payment status

In cases where the claimant was in payment status, the system will already have deducted the amount that the FO is now waiving from the benefit payments. You must verify the information that the FO supplied to ensure that the system actually deducted the coverage period or money amount waived from this beneficiary’s benefits, and verify that the information represents only coverage months prior to the month in which the system made the deduction. The verification process consists of analyzing the data found on the:

  • Medicare Direct Billing Query (MDBQ),

  • Master Beneficiary Record (MBR), and

  • Payment History Update System (PHUS).

After verifying these factors, follow this procedure:

Step

Action

1

Determine if a DBS record was established.

If yes, go to Step 2.

If no, go to Step 7.

2

Prepare a CMS 1592 (SMI Premium Accounting Card) using a RIC “3,” “F,” or both, as appropriate, and the current month as a postmark date. A batch code of ‘WAIVER’ should be input in the OPERATING DAY and TYPE fields. For instructions on how to prepare the CMS 1592, see SM 00711.200.

NOTE: The adjustment action normally processes in 2 business days.

3

Request the MDBQ to ensure that the adjustment action produced the desired result.

  • If you find the desired results, proceed to step 4.

  • If the results are not proper, prepare and input a new CMS 1592 to complete the process.

    NOTE: You should see the result of the adjustment in the CURRENT SMI DUE field.

4

Process a refund for waived premiums as soon as they are determined. Do not wait for the scheduled quarterly refund operations. Prepare an SSA-2691 (Special Indicator Card) using a SIC “G,” or “A,” to refund the waived amount. For instructions on how to prepare the SSA-2691, see SM 00711.250.

NOTE: Take this action after you have verified that the adjustment action (CMS 1592) has processed.

5

Request a Medicare Premium Due Adjustment Query (MPAQ) the day after entering the SIC “G” or “A” to ensure that we issued a refund.

6

Send a dictated notice to the claimant indicating:

  • we approved relief,

  • the coverage months involved, and

  • the amount of the refund that the claimant already received or will receive.

    STOP

7

Code the special entry Premium Additions “PA” in MACADE summary to refund SMI premium deductions. For instructions on coding the special entry “PA”, see SM 00848.340.

NOTE: If HI premiums for a retroactive period are involved, code the special entry “AA” with subsequent required PHUS coding. For instructions on coding the special entry “AA,” see SM 00848.305.

8

Send a dictated notice to the claimant indicating:

  • we approved relief,

  • the coverage months involved, and

  • the amount of the refund that the claimant already received or will receive.

9

Input a special message explaining the waiver, coverage months involved, and the amount of the refund.

STOP

B. Claimant in nonpayment status

In this situation, the waiver determination must include the claimant’s billing notice and an SSA-1395 BK (Manual Receipt) or some other evidence showing that the claimant paid the current premiums. “Current”, in this case, means all premiums from the month prior to the month indicated by the due date on the billing notice through the current quarter.

EXAMPLE:

We billed the claimant for October 2009 through September 2010 in a billing notice, with a due date of July 5, 2010. The FO affirms waiver for the period of October 2009 through May 2010. The FO must submit some evidence that it received a remittance for the period of June 2010 through September 2010.

Follow this procedure:

Step

Action

1

If you do not receive evidence of the remittance, hold the waiver material and request the information from the FO by inputting a paperless request for assistance.

If the original information supplied by the FO, or its reply to the request for assistance, indicates that the claimant mailed the remittance directly to the PSC, verify receipt of the premium payment by obtaining a Medicare Premium Payment Query (MPPQ) before taking action on the waiver.

NOTE: If you cannot confirm payment after reviewing the MPPQ, review the DMS Receipt and Remittance queries to determine if the payment was processed as a direct remittance. Otherwise, ask the FO (via a request for assistance), to provide proof of the payment from the claimant.

2

After you receive all necessary documents, review the MDBQ, MBR, and PHUS to verify the months and premium arrearage of the waiver determination.

NOTE: You must resolve discrepancies with the FO before you take any action.

3

If all the facts agree, prepare a CMS 1592 using the money amount necessary to agree with the determination, a RIC of “3,” or “F,” and the current month as a postmark date. A batch code of “WAIVER” should be input in the OPERATING DAY and TYPE fields. For instructions on how to prepare the CMS 1592, see SM 00711.200.

NOTE: The adjustment action normally processes in 2 business days.

4

Request an MDBQ to ensure the results of this action.

NOTE: You should see the result of the adjustment in the CURRENT SMI DUE field.

5

Send the claimant a dictated notice indicating:

  • we granted relief,

  • the month through which premiums are paid,

  • the amount of the next billing notice, and

  • when the claimant can expect the billing notice.

NOTE: CMS normally mails bills from Baltimore between the 1st and 12th of each month.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0600830015
HI 00830.015 - Premium Waiver Determinations - 12/04/2015
Batch run: 12/04/2015
Rev:12/04/2015