Identification Number:
HI 00805 TN 36
Intended Audience:See Transmittal Sheet
Originating Office:Centers for Medicare & Medicaid Services (CMS)
Title:Supplementary Medical Insurance Entitlement
Type:POMS Transmittals
Program:Medicare,Medicaid
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part HI – Health Insurance
Chapter 008 – Requirement for Entitlement and Termination
Subchapter 05 – Supplementary Medical Insurance Entitlement
Transmittal No. 36, 11/16/2020

Audience

PSC: BET, BTE, CR, CST, CTE, DEC, EHI, LCC, PAS, PCS, PETL, RECONR;
OCO-OEIO: BET, BIES, CCRE, CR, CTE, EIE, ERE, FCR, PETL, RECONE, RECONR;
OCO-ODO: BET, BTE, CR, CST, CTE, CTE TE, DEC, PAS, PETE, PETL;
FO/TSC: CS, CS TII, CSR, CTE, DRT, FR, OA, OS, RR, TA, TSC-CSR;

Originating Component

CMS

Effective Date

Upon Receipt

Background

This new section outlines the policy and procedures for equitable relief for certain individuals who are/were dually enrolled in both Medicare Part A (Hospital Insurance) and Marketplace coverage. This POMS section incorporates the policies and procedures currently outlined in EM-16033 REV7.

Summary of Changes

HI 00805.721 Equitable Relief for Certain Individuals Enrolled in Medicare and the Exchange

 

HI 00805.721 Equitable Relief for Certain Individuals Dually Enrolled in Both Medicare and a Marketplace Plan

A. Introduction

Individuals with Medicare Part A are not eligible to receive premium and cost-sharing assistance (often referred to as advanced payments of the premium tax credit (APTC) or income-based cost sharing reductions (CSRs)) to help pay for a Marketplace plan premium and covered services to make the costs of a Marketplace plan more affordable. Individuals receiving an APTC while dually-enrolled in coverage through the Marketplace and Medicare Part A may have to pay back all or some of the APTC received for months an individual was enrolled in both Marketplace coverage with APTC and Medicare Part A when they file their federal income tax returns.

These individuals may not have received the information necessary at the time of their Initial Enrollment Period (IEP) or Special Enrollment Period (SEP) to make an informed decision regarding their Medicare enrollment and Marketplace coverage resulting in them either:

1) declining to enroll in Medicare Part B at all;

2) dropping Part B; or

3) enrolling in Medicare Part B during the General Enrollment Period (GEP) and being assessed a Medicare Part B late enrollment penalty.

B. Limited availability of equitable relief

Equitable relief is available to certain individuals who refused or dropped Part B because they are or were enrolled in an individual Marketplace plan.

We may consider equitable relief on a case-by-case basis for certain dually-enrolled beneficiaries (those who have or had both Medicare and Marketplace coverage) of any age who refused or dropped Part B and for those who subsequently enrolled in Part B during the 2015, 2016, 2017, 2018, 2019 or 2020 GEP.

NOTE: Beneficiaries who meet the eligibility criteria can request the relief at any time.

Beneficiaries who refused or dropped Part B may receive equitable relief in the form of an enrollment opportunity with an effective date outlined in Section D of this instruction. No late enrollment penalty will apply for individuals who enroll in Part B under this limited equitable relief.

Beneficiaries eligible for equitable relief who enrolled in Part B during the 2015, 2016, 2017, 2018, 2019 or 2020 GEP and are paying a premium surcharge, may request to have the surcharge reduced. We will reduce premium surcharges to zero for eligible individuals. Excess premiums will be refunded or applied to retroactive premiums, if applicable.

C. Criteria for equitable relief

Beneficiaries must meet certain criteria for consideration of equitable relief.

To be eligible, the beneficiary must have entitlement to premium-free Part A AND meet one of the following:

  • Part A entitlement date must be between July 2013 and June 2020 (i.e., have an IEP that begins no earlier than April 1, 2013 and ends no later than September 30, 2020), OR

  • Was notified of retroactive Part A entitlement between October 1, 2013 and June 30, 2020, OR

  • SEP must have ended between October 1, 2013 and June 30, 2020.

The beneficiary must also:

  • Request enrollment in Part B or request premium surcharge rollback or removal; or

  • Mention equitable relief or being enrolled in both a Marketplace plan and Medicare Part A; and

  • Present proof of Marketplace enrollment for any period between January 2014 and June 30, 2020.

Acceptable forms of proof may include, but are not limited to the following:

  1. 1. 

    Periodic data match (PDM) notice mailed to dually-enrolled aged beneficiaries (those enrolled in both Medicare and the Marketplace);

  2. 2. 

    Marketplace Eligibility Determination Notice;

  3. 3. 

    Form 1095 A (Health Insurance Marketplace Statement) that demonstrates months of coverage and/or subsidy amounts;

  4. 4. 

    Marketplace premium invoices and proof of payment;

  5. 5. 

    Receipt from issuer indicating payment of binder payment effectuating Marketplace enrollment; an

  6. 6. 

    Other Marketplace notices confirming enrollment.

NOTE: This relief does not apply to individuals enrolled through the Small Business Health Options (SHOP) Marketplace through an employer.

The following beneficiaries are not eligible for the relief:

  • Those who are in their Initial Enrollment Period (IEP). For a beneficiary with Part A entitlement and still in the IEP, process the Part B enrollment as outlined in HI 00805.110.

  • Those who are uninsured and filing an initial application for Part B or premium Part A (see HI 00801.131 for premium Part A eligibility and HI 00801.138 for the premium Part A application). Process such enrollments following HI 00805.110B.3.

  • Those who have a Part A start date of September 30, 2013 or earlier, or were notified of retroactive Part A entitlement on September 30, 2013 or earlier.

Examples for approval of equitable relief:

  • Ms. Jones has premium-free Part A effective June 2014. She visits her local Field Office (FO) to enroll in Part B and says that she found out she has to repay all the discounts she got while in the Marketplace plan because she has Medicare Part A. She submits Form 1095-A that indicates she is a Marketplace enrollee. This meets the requirement to mention being enrolled in both a Marketplace plan and Medicare Part A, and the Form 1095-A shows proof of Marketplace enrollment.

  • Mr. Raimondi’s IEP for entitlement to premium-free Part A began February 2015. He indicates in his interview that he received a letter that says he should drop his Marketplace plan because he has Medicare Part A. He presents the PDM notice and expresses interest in enrolling in Part B. This meets the requirement to mention dual enrollment in a Marketplace plan and Medicare, and the PDM notice shows proof of Marketplace enrollment.

  • Ms. Levin’s IEP for entitlement to premium-free Part A began March 2016. She contacts her local FO asking about Medicare Part B enrollment. She says that she enrolled in the Marketplace instead of enrolling in Part B because she was approved for the tax credits. She submits a receipt of binder payment indicating Marketplace enrollment. This meets the requirement to request Part B coverage and her receipt of binder payment shows proof of Marketplace enrollment.

  • Mr. Simon’s IEP for entitlement to premium-free Part A began July 2014. He enrolled in Part A, but refused Part B because Marketplace coverage was cheaper than Part B. He later discovered that this Marketplace plan did not provide the coverage he needed. He subsequently enrolls in Part B during the 2016 GEP and is assessed a premium surcharge. He also terminates his Marketplace coverage as of July 2016. Mr. Simon contacts his local FO in August 2016 to inquire about the amount of his Part B premium and provides a copy of the invoices and the payments for his Marketplace coverage for the period from July 2014 through June 2016. This meets the requirement to request a premium surcharge reduction, and the invoices and payment receipts show proof of Marketplace enrollment.

  • Mrs. Shuman’s IEP for entitlement to premium-free Part A began April 2011, and she has Part A. She refused Part B when first eligible because she was working and had group health plan coverage through her employer. She retired in 2014 and her SEP eligibility ended November 2014. She visits Marketplace enrollee. This meets the requirement to mention being enrolled in both a Marketplace plan and Medicare Part A, and the Form 1095-A shows proof of Marketplace enrollment.

Examples that do not meet approval of equitable relief:

  • Mr. Chin’s IEP began August 2016, and he has Part A. He contacts his local FO in January 2017 and asks about enrollment in Part B. He states that he chose to enroll in Marketplace coverage instead of Part B because it has dental coverage. He was recently diagnosed with a serious illness and wants Medicare Part B. This does not meet the requirements for equitable relief because he is still in his IEP at the time he requests enrollment. We would process his Part B enrollment request under IEP processing rules.

  • Ms. Moody’s IEP ended August 2012, and she has Part A. She asks about enrollment in Part B stating she chose to enroll in Marketplace coverage with the subsidy instead of Part B. She shows her Form 1095-A as proof of her Marketplace enrollment. This does not meet the requirements for equitable relief because her IEP ended prior to April 2013.

  • Mrs. Richard’s IEP began September 2012, and she has Part A, but she refused Part B. She later enrolled in Part B during the 2016 GEP and was assessed a premium surcharge. Mrs. Richard contacts her local FO and requests to have her Part B premium surcharge reduced. She explains that her neighbor’s Part B premium was reduced because she was eligible for equitable relief. We denied Mrs. Richard’s request for Part B premium surcharge reduction because her IEP began prior to April 2013.

  • Mrs. Parker’s IEP began May 2010, and she has Part A. She refused Part B when first eligible because she was working and had group health plan coverage through her employer. She retired in 2012 and her SEP eligibility ended September 2012. She contacts her local FO in July 2017 and requests to enroll in Part B. We denied Mrs. Parker’s request for Part B enrollment because her SEP eligibility ended prior to October 1, 2013.

  • Mr. Harper’s IEP ended September 2009, and he has Part A. He refused Part B when first eligible because he and his wife were working and he had group health plan coverage through his wife’s employer. She retired February 2016. He visits his local FO on February 15, 2017 and requests to enroll in Part B. His SEP eligibility ended October 2016 and he has no proof of Marketplace enrollment. We denied his request for Part B enrollment because he has no proof of Marketplace enrollment.

D. Medicare Part B effective dates

Individuals who meet the criteria for equitable relief can enroll in Medicare Part B. The effective date for Medicare Part B coverage can begin either:

  • The month the beneficiary enrolls, or

  • At the beneficiary’s option, any of the two months prior to the month of enrollment.

E. Processing equitable relief

FO steps:

  1. 1. 

    Consider whether the beneficiary meets all of the requirements in Section C of this instruction.

  2. 2. 

    Collect the beneficiary’s statement, proof of Marketplace coverage, and any available evidence.

  3. 3. 

    For beneficiaries requesting Medicare 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 once from his or her benefit amount. Be sure the beneficiary understands the implications for a retroactive effective date before processing.

  • Include in the remarks section of the CMS-40B the beneficiary’s Medicare Part B effective date choice.

  • 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 to provide relief. 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 to review and process.

PSC steps:

  1. 1. 

    Review the beneficiary’s statement, proof of Marketplace coverage, proof of GHP/LGHP coverage based on current employment, and any available evidence in support of SSA-5002 determination.

  2. 2. 

    Process approved equitable relief case following normal Equitable Relief procedures.

  3. 3. 

    If the beneficiary is eligible for surcharge reduction, remove the existing surcharge. Apply excess premiums to any past-due premium amounts owed. If the beneficiary does not owe any past-due amounts, refund the excess premiums to the beneficiary.Direct all program-related and technical questions to your Regional Office (RO) support staff or PSC Operations Analysis (OA) staff. RO support staff or PSC OA staff may refer questions or problems to their Central Office contacts.

F. References


HI 00805 TN 36 - Supplementary Medical Insurance Entitlement - 11/16/2020