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
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:
“Your request must also authorize the Social Security Administration to withhold $ from your monthly benefits to pay the premiums due from (mo/yr) through (mo/yr) .”
If the enrollee is not in payment status, include the following:
“A check in the amount of $ must accompany your request to pay for the premiums due from (mo/yr) through (mo/yr) .”
In all instances include:
“If you wish the earlier coverage, but would have difficulty paying all the retroactive
premiums at one time, ask your social security office about arrangements that may
be made for payment.”
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
NOTE: If the new DOES provides retroactive entitlement for more than 7 months, include
a paragraph similar to the following in the beneficiary notice.
“If you received any services covered by Medicare in the early months of your entitlement
(DOES through December of that year), you should telephone any social security office
for assistance in filing your claim for these benefits.”
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).