1. Consider whether all the requirements in Section D of this instruction are met.
2. Collect the beneficiary’s statement, proof of Marketplace coverage, and any available evidence.
3. For beneficiaries requesting Part B enrollment, complete the following steps:
· If the beneficiary expresses dire need of medical attention, refer the action to the program service center (PSC) of record following existing instructions in GN 01070.228.
· Complete Form CMS-40B (Application for Enrollment in Medicare Part B (Medical Insurance)).
· For beneficiaries whose SEP ended between October 1, 2013 and June 30, 2020, obtain evidence of Group Health Plan (GHP) coverage or Large Group Health Plan (LGHP) coverage based on current employment via Form CMS-L564 (Request for Employment Information).
· If the beneficiary wants a retroactive effective date, explain that payment of all premiums for all months of coverage is required. Explain that the total amount of premiums for all months, including the next coverage month, may be deducted all at one from his or her benefit amount. Be sure the beneficiary understands the implications for a retroactive effective date before processing.
· Include in the remarks sections of the CMS-40B the beneficiary’s Part B effective date choice according to section E of this EM.
· Print the CMS-40B barcode from NDRED.
4. Prepare a Form SSA-5002 (Report of Contact) giving your analysis of the information, any evidence provided, request for surcharge removal, and your decision as to whether relief should or should not be provided. Include the reasons for approval or disapproval based on your review.
5. Fax the completed CMS-40B, SSA-5002 and supporting documentation (e.g., the CMS-L564 and the beneficiary’s notice from CMS) into CFRMS.
6. Forward the case to the appropriate PSC for review and processing.