HI 00830.020 Enrollment/Disenrollment Determination
Whenever one of the situations described in HI 00830.001 is encountered, the case must be given to the Exceptions and Health Insurance Specialist with a description of the facts involved that caused the case to be considered for relief. The Exceptions and Health Insurance Specialist will review these facts and provide a written determination to either affirm or deny relief in the form of a special (outside of normal IEP/GEP) enrollment date. The Exceptions and Health Insurance Specialist will either fully process the case or, if it is returned to the Health Insurance and Inquiries Examiner, will provide the date(s) to be used and a paragraph to be added to the beneficiary notice that explains our action and the options open to the claimant.
In most of the situations wherein the Exceptions and Health Insurance Specialist is permitted to make the determination, the factors involved are clear and simple, can easily be recognized, and the type of relief to be provided is clearly stated. However, as in all determinations of this sort, there will be variations and degrees of involvement that will not be that simple. The specialist will be required to exercise sound judgment and logic considering all the circumstances of each individual case, when making these determinations.
Mr. Smith was enrolled erroneously for HI and SMI coverage. He returns his health insurance card with a letter indicating his belief that he is not entitled to it because he is neither disabled nor age 65. Review of the claims folder indicates that an incorrect date of entitlement to disability, (DOED) was established and Mr. Smith is actually neither disabled nor 64 and 9 months of age. The return of the health insurance card and Mr. Smith's statement that he knows he is not entitled should be accepted as proof that he does not want and did not use the benefits. Delete the enrollment data from the record, and refund any deducted premiums. Send a notice to Mr. Smith telling him of this action and include information as to when he can or will become legitimately enrolled.
What this example attempts to illustrate is that when the claimant's position, needs or desires are clearly stated, variations of the relief to be provided is allowable within the guidelines provided. In this example, it would be foolish to give the claimant a closed period of coverage from which he or she could not benefit.
NOTE: In all cases where an equitable relief determination is made, a carbon copy of the beneficiary notice must be filed in the claims folder with the determination.
A. Enrollment Processed or Beneficiary Notified 6 Months or More After the Entitlement Date
If an enrollment is not processed or the claimant is not notified of the start of coverage within 6 months after the date coverage should have started, we have disadvantaged the claimant and equitable relief is applicable. The form this relief should take is dependent upon both the type of error (i.e., whether the enrollment was not processed or the individual was not notified), and how the error was discovered (i.e., whether we discovered it ourselves or the claimant complained).
1. ENROLLMENT NOT PROCESSED
The majority of these cases will be discovered because an action is being taken to award an individual entitlement to SMI coverage retroactively 6 months or more (i.e., an action is taken to initially establish a DOES that is 6 or more months earlier than the current operating month). This discovery may come about because of a claimant's complaint of nonreceipt of a health insurance card or while processing a program exception. The case must be forwarded to the Exceptions and Health Insurance Specialist for a written determination of relief.
The relief to be granted is simply to provide SMI coverage effective with the current operating month. For example, the enrollee attained age 65 in 1/76 but due to exceptions SMI coverage is not established until 8/76. The equitable relief determination will establish a DOES of 8/76 and notify the individual that coverage beginning 1/76 is possible if he or she requests such coverage and indicates a willingness to pay for it.
Include a paragraph similar to the following in the notice to the claimant:
“We have recently discovered that you should have been entitled to supplementary medical insurance coverage beginning (mo/yr). Action has now been taken to provide you with this coverage and premium liability beginning (mo/yr). You have the right to choose coverage beginning (mo/yr). If you want this earlier date, you must submit a signed request within 60 days of your receipt of this notice.”
If the claimant is in payment status, include the following:
If the enrollee is not in payment status, include the following:
In all instances include:
If the claimant responds by indicating he or she wants no coverage at all, and the reply is dated within 2 months of our notice, process the refusal and refund any premiums paid. The refusal can be processed by using a Form SSA-1598 with a date of filing that is 1 month earlier than the recorded DOES. If both premium-HI and SMI are being refused, 2 forms must be entered with the premium-HI refusal being entered at least 1 day before the SMI refusal.
If the claimant responds by indicating he wants the earlier entitlement date, he must have also indicated the method of payment of the retroactive premiums due. If he remits the total amount of premiums due or authorizes the deduction of all retroactive premiums, process a MADCAP or MISCOR action to establish the new DOES. Since the new DOES should conform to the claimant's normal IEP or GEP, no special processing rules are necessary.
If the claimant chooses to pay the retroactive premiums in installments see HI 00830.060. A slight variation to the above instructions involves the awarding of disability benefits for a closed period. If the beneficiary has entitlement to DIB for more than 25 months, he will be given the choice of fully retroactive SMI or no SMI at all. The HI/SMI termination dates will be equal to the disability benefit termination date. Inform the beneficiary in the award notice of his/her right to SMI coverage. The notice will advise the individual that SMI is available as of the specified month and that if he wishes the coverage, he should advise us of that fact within 2 months after the date of notice and remit payment of the specified amount of premiums due for the closed period.
NOTE: If the new DOES provides retroactive entitlement for more than 7 months, include a paragraph similar to the following in the beneficiary notice.
For example, if the claimant is awarded a DOES of 2/75 in or after 8/76, the paragraph would indicate that the DO should be contacted for assistance if services were received during the period 2/75 through 12/75 (because of the need to notify the Medicare carrier about waiving the Medicare law's time limit for filing claims for reimbursement of health care expenses).
2. ENROLLMENT NOT PROCESSED — RD BENEFICIARIES
When a renal disease beneficiary is awarded SMI entitlement and premiums are due for 6 months or more, he has the option of having the coverage begin with:
the original date of entitlement,
the date of filing, if that date is after the original DOE, or
the operating month in which the enrollment is processed by ODO (i.e., notified beneficiary of entitlement dates).
When one of the three above dates is established by ODO, a temporary record is established on the Health Insurance Master (HIM) and an interim award notice is sent. The temporary HIM record allows any medical bills to be paid immediately, while the notice serves as a temporary Health Insurance card.
When the insured RD claim is received in the PSC, the SMI date of entitlement entered by the Benefit Authorizer should be equal to the date of entitlement determined by ODO on the SSA-101-U3 (item 11), SSA-559, or from the copy of the temporary award notice. This action is necessary since the beneficiary has already been notified of a specific date, and the date is already recorded on the HIM.
Even if the premium for an additional 6 months or more are due, record the appropriate date and deduct the premiums. Inform the beneficiary that he has the option of selecting the DOES equal to the later COM (i.e., the COM in which the benefit authorizer processes the case) or he can ask the district office about arrangements for paying the retroactive premiums. Pattern the notice after the language used in HI 00830.020.
A B2 beneficiary became entitled to HI and SMI under the renal provisions of the law. Both HI and SMI are effective 2/79; the date of filing is 7/79; and ODO notified the beneficiary in 11/79. The HI/SMI was effective 11/ 79 and a temporary health insurance record was established. The PSC did not record the HI/SMI entitlement until 7/80. Even though more than 6 months premiums were due, the entitlement date of 11/79 was recorded and all premiums were deducted for 11/79 through 8/80.
3. ENROLLMENT PROCESSED—CLAIMANT NOT NOTIFIED
This situation should be rare and will most likely be encountered as the result of a complaint received from a claimant that a health insurance card has been received showing coverage for a retroactive period of time and that the claimant was unaware of the coverage (and consequently did not avail himself or herself of its benefits) until the card was received. It is not inconceivable that an individual could have had benefit payments adjusted and the premiums deducted without being aware of the coverage. On the other hand, having received billing notices, whether remittances were or were not submitted, the absence of a health insurance card is not, by itself, proof that the claimant was unaware of the coverage.
When a claim is made that the claimant was unaware of the coverage and no billing or deduction of premiums was made but the enrollment was annotated on the MBR and BCM records (and presumably on the HIM), the wish of the claimant should be accommodated if it appears he or she is acting in good faith. For example, if the claimant indicates the need for the period of coverage but an inability to pay the retroactive premiums, the case should be considered for installment payment of the premiums. On the other hand, if dissatisfaction is indicated over having coverage that could not be used because he or she was unaware of it, a later entitlement date is indicated. The most equitable solution for both the claimant and the Administration is to provide a later starting date when no needs or desires are expressed by the claimant or there is strong doubt about the facts as presented by the claimant but there is factual evidence that the Administration did not do all that should have been done in the way of enrolling, notifying, and billing/deducting the premiums for the coverage.
If the information at hand is insufficient to make a sound determination, request the DO via the SSA-5075 to resolve any discrepant issues or develop for missing or incomplete information.
When all issues have been resolved and it is apparent that the enrollee has been disadvantaged by our action or inaction, a written determination must be made by the Exceptions and Health Insurance Specialist containing the circumstances of the case and the entitlement date to be provided. As in the case of an unprocessed enrollment, this date must always be equal to the COM in which the action will be processed. The Specialist must also provide the special paragraph to be included in the beneficiary notice that explains the form of relief awarded and the options available. The paragraph should be patterned after that shown in 1. above.
The manual process to record a later date of entitlement requires the use of SMI entitlement code (SENC) of “B,” whether the action is processed through the MADCAP or the MISCOR CIP R program.
NOTE: The premium rate to be assigned to these cases is the rate that would have applied if no error had been made by the Administration.
4. BENEFICIARY DIES BEFORE AWARD IS MADE
If the beneficiary dies before his choice in 1, 2, or 3 above is made, any of his survivors should be given the option of electing one of the options for SMI or of refusing SMI entirely.
B. Beneficiary Enrolled in Second of Two Timely Enrollments
If it is discovered, at any time, that an individual filed a request for enrollment that would have resulted in an earlier entitlement date than that which is currently recorded, relief must be offered. This discovery may be the result of locating an unprocessed enrollment form or a complaint by the individual. Regardless of the reason for the discovery or whether or not the individual is aware of the error, we are obligated to rectify the situation to the extent possible.
If the current premium rate is a penalty amount, determine what the rate would have been based on the earlier filing date and resultant DOES. Process a manual action to record the new (lesser) premium rate, again using the SENC of “B,” when applicable. Inform the beneficiary of the action. If the claims folder reflects a current or timely protest (one filed within 6 months of the notice) against the existing SMI date of entitlement, notify the beneficiary that he can have his SMI coverage begin as of the date of the first SMI enrollment provided that he or she either pays the retroactive premiums due or authorizes their deduction from benefit payments. The premium rate remains at what it would have been at the earlier entitlement date regardless of whether or not the claimant chooses to exercise the option to have the earlier entitlement.
If the earlier entitlement date is chosen and all retroactive premiums then due are received, or authorization for their deduction is given, record the new DOES via either MADCAP or MISCOR CIP R and use of the SENC of “B.” Inform the individual that he or she must reply within 30 days of receipt of our notice advising the options or the recorded date will become the permanent date.
C. Claimant Disadvantaged by Incorrect or Delayed Advice
Often claimants are easily misled, confused, or generally unsure of what is required of them when it comes to protecting their rights. Replies to inquiries are not always clear, concise, correct, and timely.
The intent of the relief to be provided in this situation is to ensure that the result to be achieved is that which would have been achieved had the enrollee been provided correct, complete, and timely information and had acted accordingly.
An individual may inquire about enrolling or disenrolling for coverage in or before an enrollment period open to him or her and is either provided an incorrect reply or given an accurate reply too late to obtain the earliest entitlement or termination date available. In these cases, very little proof or documentary evidence will be available to substantiate or disprove a statement by the claimant. For instance, an indication in the claims folder that a reply, correct and complete, was prepared timely is not absolute proof that the claimant ever received it. Usually, in a district office interview, the individual is made fully aware of both his or her rights and obligations, but barring such a statement from the DO, the word of the claimant must be accepted at face value.
If the entitlement date that would have resulted from a timely enrollment is less than 6 months prior to the current operating month, process the enrollment via MADCAP, or the PEPPER (SSA-1598) program, as appropriate. If the SSA-1598 is used, enter a date of filing equal to the first month of the enrollment period in question.
If the entitlement date is 6 or more months, prior to the current operating month, establish the current month as the entitlement date. Enter an SENC of “B” for both the MADCAP and PEPPER input.
In the first situation (the established DOES is less than COM—6), a normal letter must be prepared informing the claimant of the DOES and the amount of premiums deducted from the benefit payment (or due if in nonpayment status).
In the second situation (the established DOES is equal to COM), prepare the letter in triplicate. Send two copies to the claimant and file the last copy in the claims folder. This letter must inform the claimant that an entitlement date of can be obtained if it is requested within 30 days of the receipt of this letter and the request for the earlier date indicates the arrangement to be used for payment of all retroactive premiums. Ask the claimant to include a carbon copy of your letter with the request.
Relief must be provided when “an enrolled individual inquiries about SMI termination and SSA does not reply to the inquiry in time to permit the filing of a voluntary termination request within the same calendar quarter in which the inquiry was made.”
Mrs. Jones, an SMI enrollee, phoned the DO in March and stated that she wanted to “cancel” her enrollment at the earliest date. She was given information about the importance of her SMI coverage and the affect of termination of her SMI. She still wishes to terminate her SMI and was advised to submit a signed statement clearly expressing her desire to terminate SMI. She submitted the statement in April and was notified that coverage and premium liability would end on the last day of September (the end of the calendar quarter after the calendar quarter in which the termination request was filed). She protested this delay in termination, stating that when she called in March to request information about termination she had not been advised of the importance of submitting her termination request before the end of March. Although the DO had no record of her call, it stated that such incomplete advice may have been given and that she was probably misadvised as she alleged. Her SMI coverage and premium liability will, therefore, end on the last day of June; i.e., with the close of the calendar quarter after the calendar quarter in which her termination request would have been filed by prompt action in accordance with correct and complete advice.
In this example, the initial contact was early enough to have been replied to within the same quarter and the DO admits to having provided incomplete advice. However, the initial query may be made by telephone on the last few days of the quarter, and the DO may state they have no record of recollection of the call but that they always impress on the caller the importance of acting promptly. As in all determinations, sound judgement based on the individual merits of each case must be exercised to ensure that the intent of the equitable relief provisions is accomplished. The assumption must be made that the claimant is acting honorably and in good faith and the claim of faulty advice or service must be accepted as true unless there is some positive reason to believe otherwise. For example, if a claimant states an inquiry or actual request to withdraw from the program was made in June but the DO and PSC didn't do anything about it until July, accept the statement at face value unless the DO or PSC can show some definite reason for not allowing the earlier termination date. A definite reason may be that there is a record that the inquiry was made later than alleged or that the claimant had been fully informed at the time of, or before the inquiry in question. Evidence or positive assurance will very rarely be available and the earlier termination date will usually be granted based solely on the allegations of the claimant.
The change in termination date can be routinely processed through MADCAP for insured cases and MISCOR CIP R for uninsured cases. No special coding is needed.