In those cases where Medicare entitlement is retroactive for more than 5 months and CSC starts deducting premiums from the current month only, CMS will prepare an CMS-264-U3, Request for Program Service Center Action Medicare-Civil Service Case, and forward it to the servicing processing center. CMS will complete the beneficiary’s name, Medicare claim number, Civil Service claim number, the beginning date for the withholding of premiums from the beneficiary’s annuity and the Third Party Entitlement date to SMI (TEDS) as indicated on the MBR.

Upon receipt of the CMS-264-U3 in the PSC and association with the claims folder, the following must be done.

1. a. 

   Compute the premium arrearage and annotate it at the bottom of the message portion of the CMS-264-U3.

2. b. 

   Prepare an SSA-5075-U3 to the DO instructing them to develop for equitable relief in accordance with HI 00830.000ff. Advise them that an SSA-795 from the beneficiary is required for premium deductions, either a lump-sum or installments. The DO should prepare a decision based upon their development.

3. c. 

   Attach the white copy of the CMS-264-U3 to the SSA-5075-U3. File the yellow and pink copies in the claims folder.

4. d. 

   Diary the SSA-5075-U3 for return in 60 days.

1. a. 

   Complete the blocks on the form in accordance with the DO decision.

2. b. 

   If the decision is to grant equitable relief for the entire retroactive period, take no action except to forward the original (white) and the pink copy of the CMS-264-U3 to CMS.

3. c. 

   If the decision is for partial or no relief, check the appropriate boxes on the form before forwarding to CMS. Also, if the appropriate TEDS data are not on the MBR, that correction should be input before the CMS-264-U3 is sent to CMS.

If a premium payment is received from a beneficiary, send the check, a copy of the CMS-264-U3, and if available a copy of the SSA-1395-BK (Receipt and Transmittal Form) to:

CMS will 1) make an adjustment in the third party system; 2) credit the beneficiary’s account with additional money; 3) keep a ledger to show the beneficiary paid by check; and 4) deposit the check into the HI trust fund.

If the beneficiary pays cash, deposit the cash into the HI trust fund, document this on the CMS-264-U3, and send the CMS-264-U3 to the address above.