HI 01001.370 Reviewing Office Action on Request for Relief

A. Favorable Determination Made by DO

A DO determination granting a good cause extension will normally not be reviewed. The case will be routed directly to the Premiums and Recovery Cash Collection Section for reinstatement action. If however, the file contains clear evidence that casts doubt on the finding of good cause, forward the case to the Exception and Health Insurance Specialist for approval or resolution of the problem.

Except for the situation calling for routine reinstatement (see B.1. below), send the enrollee a notice advising him of the reinstatement. Include the date through which his premiums have been paid.

B. Premium Payment and/or Request for Relief Received Directly From Enrollee

When the enrollee contacts the reviewing office directly, and the reviewing office records contain all necessary information for disposition (allowance or denial of the extension), dispose of the case. When necessary in the discretion of the reviewing office, refer the matter to the DO for development. In such cases, prepare and forward to the DO (along with the reinstatement request and any other pertinent information) a copy of the HCFA-1589A (Record of Termination) from the claims file. The DO can utilize this record in determining when the termination was effective, when the notice was sent, and the amount of premiums owed.

1. PAYMENT RECEIVED IN TIME FOR ROUTINE REINSTATEMENT

If the reviewing office receives the overdue premiums shortly after the end of the initial grace period, reinstate SMI coverage without further development. (See HI 01001.350).

2. PAYMENT RECEIVED LATE WITH GOOD CAUSE EXPLANATION

The enrollee's payment together with an explanation which establishes good cause for late payment may be received within the extended grace period but after the cut-off date for reinstatement. Provided that all premiums overdue by the end of the usual grace period are paid, diary the case for reinstatement action and send the enrollee a notice that before his coverage can be reinstated, he must remit within 30 days from the date of the notice or if later, the end of the extended grace period all premiums due through the end of the extended period.

3. LATE PAYMENT RECEIVED WITHOUT GOOD CAUSE DETERMINATION

If, after the cut-off date for reinstatement but during the extended period, the enrollee submits a payment to cover the premiums due through the end of the initial or extended grace period, but without a good cause explanation, accept the payment and send him the following notice:

  • “We have received and credited to your account your recent premium payment of $        for months ending        . Your premium payment was received too late to prevent termination of your SMI coverage effective        . However, your coverage may be reinstated if there was good cause for your failure to pay your premiums before that date. If you believe there was good cause for such failure, and wish to retain your SMI coverage, please contact your local social security office within the next thirty days. They will ask you to explain why your payment was delayed (and will also ask you to pay any premiums now overdue if your coverage is reinstated).

    You should have this letter with you when you contact that office.”

    NOTE: Omit the parenthetical clause about payment of additional overdue premiums if the enrollee is a beneficiary in suspense, or if the enrollee has already paid all premiums currently due (through the extended grace period).

To have his coverage reinstated he must request such relief and establish good cause within one month (A) of the date of the letter from the reviewing office, or if later, (B) the end of the extended grace period. If the reviewing office has heard nothing further from the DO or the enrollee two months after such date, refund any excess premiums (for months after the initial grace period) to the enrollee.

C. Notification of Disallowance

Cases in which the DO determines that the enrollee has failed to show good cause will not be processed by the Premium and Recovery Collection Section. The case should be routed to the Exception and Health Insurance Specialist for approval (or further development if indicated). A determination that the enrollee has not shown good cause for failure to pay his premiums within the ordinary grace period is an initial determination, subject to reconsideration, hearing, and further appeal rights (including court review). Notice of such a determination will include the usual appeal paragraph (giving the enrollee 60 days from the date of the receipt of the notice to request reconsideration), and will inform him that any premiums paid for months after termination of his SMI coverage will be refunded to him.