SSA - POMS: HI 00805.055 - Notice of Right to Refuse Deemed Enrollment

A. Policy for who receives notice of automatic (deemed) enrollment in supplementary medical insurance (SMI)

Automatic (deemed) enrollment in SMI only occurs for beneficiaries who:

•

reside in the United States, the Northern Mariana islands, the Virgin Islands, Guam and American Samoa; and
•

receive retirement, survivor or disability insurance (RSDI) benefits at least four months prior to the start of Medicare initial enrollment period (IEP).

For more information on automatic enrollment, see HI 00805.110A.1.

The Centers for Medicare & Medicaid Services (CMS) mails notices of automatic (deemed) SMI enrollment in the domestic initial enrollment period (IEP) package, at the beginning of the beneficiary’s IEP, which is:

•

the 22^nd month of receiving benefits for disability insurance benefits (DIB), childhood disability benefits (CDB) or disabled spouse's benefits (DWB); and
•

three months before the beneficiary’s month of attainment of age 65.

For a description of the contents of the domestic IEP package, see HI 00805.125B.

The Social Security Administration (SSA) mails notices of automatic (deemed) SMI to beneficiaries who obtain Medicare entitlement during or after their IEP, as outlined in HI 00805.110A.2. This may be due to a claim not processing timely or a DIB appeal.

For information regarding SMI enrollment for beneficiaries who are not automatically enrolled in SMI, see HI 00805.110B.

For information regarding SMI enrollment for beneficiaries who reside in Puerto Rico, see HI 00805.115B or a foreign country, see HI 00805.120B.

B. Policy for SMI refusal

Beneficiaries that we automatically enroll in SMI may refuse the coverage if they file a written notification by the specified deadline, as outlined in HI 00805.055B.1. in this section.

NOTE: If a State Buy-in is currently in effect, the beneficiary cannot refuse or terminate SMI, as outlined in HI 00815.001 and HI 00820.035B.5.

When a beneficiary states that the beneficiary wants to refuse SMI, make all reasonable efforts to ensure that the beneficiary refusing or terminating SMI coverage understands the effect of the action, as explained in HI 00820.045 through HI 00820.075 and in TC 24001.070.

1. Opportunity to refuse SMI

All beneficiaries automatically enrolled in SMI have an opportunity to refuse SMI. Beneficiaries receive written notice of the automatic SMI enrollment, as outlined in HI 0805.055A in this section. This notice:

•

provides the effective date of the SMI coverage; and
•

instructs the beneficiary to notify SSA in writing by a specified date to refuse SMI.

The notice may be in the form of an IEP package or a Medicare award notice.

a. Deadline for SMI refusal in IEP package

A beneficiary who receives an IEP package must refuse SMI enrollment before the coverage begins.

b. Deadline for SMI refusal in Medicare award notice

A beneficiary has two full calendar months following the date of the Medicare award notice to refuse SMI enrollment.

When we mail the Medicare award notice in the first month of the beneficiary’s IEP, the beneficiary must refuse SMI enrollment before coverage begins.

EXAMPLE: Deadline for refusal based on automatic enrollment during a beneficiary’s IEP

Jane Grey files for DIB in March 2012, and we deny Jane's claim. Jane appeals the denial and receives a favorable decision. We establish Jane's entitlement retroactively, starting in April 2012. Jane’s Medicare entitlement begins in April 2014. SSA notifies Jane of automatic enrollment into SMI on January 10, 2014 (during the first month of Jane's IEP). Because Jane's SMI coverage begins April 2014, Jane has until March 30, 2014 to refuse SMI enrollment. (The timeframe offered Jane provides Jane with two full calendar months following the date of Jane's Medicare award notice.)

When we mail the Medicare award notice any time after the first month of the beneficiary’s IEP, the beneficiary must refuse SMI within two full calendar months following the date of the Medicare award notice.

EXAMPLE: Deadline for refusal based on automatic enrollment after a beneficiary’s IEP

Robert Fuller files for DIB in June 2010, and we deny Robert's claim. Robert appeals the denial and receives a favorable decision. We establish Robert's entitlement retroactively, starting in July 2010. Robert’s Medicare entitlement begins in July 2012. SSA notified Robert of automatic enrollment into SMI on October 20, 2012 (after Robert's IEP). Because Robert is notified after Robert's IEP, Robert has until December 31, 2012 to refuse SMI enrollment.

c. Deadline for SMI refusal when notice is not sent timely

In some instances, the beneficiary may not receive the automatic enrollment notice timely. These beneficiaries may learn they have SMI coverage through a SMI premium bill, a reduced benefit payment, or another benefit notification informing the beneficiary of the SMI premium deduction. When this occurs, the beneficiary must refuse SMI within two full calendar months after either:

•

the month the beneficiary says that they received the notice; or
•

the month the beneficiary receives their first SMI premium bill,

whichever occurs first.

d. Other considerations to determine if refusal is filed by the deadline

CMS does not accept SMI refusals or protect filing dates for SMI refusals.

We must receive the written refusal for SMI by the specified date for it to be timely. If a beneficiary calls the field office (FO) or Teleservice Center (TSC), or visits the FO, to refuse SMI, the beneficiary must still file a written refusal for SMI by the deadline. We do not protect filing dates for SMI refusals.

For information on the 7-day tolerance test for mailed SMI refusals, see SM 03040.080C.

2. Form CMS-2690 (Request for Cancellation of Medicare Part B (Medical Insurance))

The Medicare award notice includes a Form CMS-2690 in cases where we send the notice less than two months before SMI coverage begins or after SMI coverage begins. If the individual requested SMI coverage, the Medicare award notice does not include Form CMS-2690.

Beneficiaries who want to refuse SMI may complete Form CMS-2690 and return it to SSA before the date specified on the form.

NOTES:

•

Beneficiaries may provide other written notification to SSA to refuse the SMI coverage instead of using Form CMS-2690.
•

Form CMS-2690 advises TRICARE beneficiaries that they must keep both HI and SMI to remain eligible for TRICARE benefits.

To view Form CMS-2690, see OS 15060.073.

3. Timely SMI refusal

If the beneficiary files before SMI coverage starts, we always consider this a timely SMI refusal timely.

We consider a SMI refusal timely if we receive it by the deadline indicated in HI 00805.055B.1. in this section.

If the beneficiary files a written refusal for SMI timely, we determine that the beneficiary legally refused this coverage and does not incur any premium liability.

For more information on processing SMI refusals, see SM 03040.080C.

4. SMI refusal not filed timely

A refusal is not timely if we receive it after the deadlines indicated in HI 00805.055B.1. in this section. If the beneficiary files after deadline, we consider this a request for voluntary termination of SMI. In this case, SMI coverage ends with the last day of the month after the month the beneficiary files the written request.

EXAMPLE: Untimely SMI refusal

In May 2012, we award disability benefits to Todd Roy effective March 2009. Todd is entitled to Part A effective March 2011 and Part B effective May 2012. SSA notifies Todd in the Medicare award letter that Todd has until July 31, 2012 to refuse SMI. Todd visits the FO in September 2012 to refuse SMI coverage. Since Todd didn’t refuse SMI by July 31, 2012, we cannot process Todd's written request for refusal. Instead, we treat Todd's request as a voluntary termination of SMI coverage. Todd's SMI coverage ends on October 31, 2012.

5. Refusal rescinded during IEP

If a beneficiary refuses automatic enrollment but later files a request for SMI enrollment during the remainder of the IEP, the request is a valid IEP enrollment, despite the prior refusal. SMI coverage begins based on the new date of filing, as noted in HI 00805.165B.

C. Policy when a current application is pending

RSDI applications include Medicare enrollment information and an explanation that an eligible beneficiary who obtains entitlement to monthly benefits and HI is deemed to have enrolled in SMI unless the beneficiary answers “no” to the enrollment question.

In some cases, a beneficiary not eligible to enroll in SMI may become eligible before we can fully develop and resolve all issues with the claim. When this occurs, the FO should contact the beneficiary to obtain a SMI election or refusal and document the application with beneficiary's response.

D. Policy for refusal made by an incompetent person

We cannot extend the IEP or the general enrollment period (GEP) for a beneficiary because the beneficiary is mentally incompetent during all or part of the period as explained in HI 00805.100.

Do not consider a refusal for SMI as valid if the beneficiary was:

•

eligible for automatic enrollment in SMI; and
•

mentally incompetent at the time of the refusal.

NOTE: This is true even if the beneficiary currently has SMI based on an enrollment filed after the refusal.

For this policy, consider a beneficiary to be incompetent based on one of the following documents:

•

a signed statement from a physician indicating that the beneficiary was incapable of managing the beneficiary's own affairs at the time the beneficiary filed the refusal; or
•

a certified copy of a court order showing that the beneficiary was determined, by the court, to be legally incompetent at the time the beneficiary filed the refusal.

Following a determination of incompetence, any future requests for SMI refusal (or SMI enrollment) by the beneficiary must include legal or medical evidence showing that the beneficiary is now competent. For information on developing medical evidence for capability, see GN 00502.040.

E. Policy for cancelling a refusal by an incompetent person

To cancel a refusal, the responsible representative (or the beneficiary) must submit proof that the beneficiary was mentally incompetent at the time the beneficiary filed the refusal. If the beneficiary makes the request to cancel their prior SMI refusal, the beneficiary must now be competent, as shown with legal evidence or other medical evidence as outlined in GN 00502.023.

Cancel the refusal if we receive the proof outlined in HI 00805.055D during the following timeframes:

•

within 12 months of the first month of potential SMI entitlement; or
•

if later, within 12 months of the month of the refusal.

SMI entitlement begins with the month coverage would have started as though the beneficiary never filed the refusal. The beneficiary must pay all premiums owed for any retroactive months of SMI coverage or authorize us, the Railroad Retirement Board or the Office of Personnel Management to withhold them from monthly benefits payable.

EXAMPLE: Cancelling a refusal by an incompetent beneficiary

Linda Tessen was born on January 15, 1959, and we entitle Linda to retirement benefits at age 63. Linda receives the IEP package in October 2023 (the first month of Linda's IEP). Linda refuses SMI in November 2023. Linda enrolls again in SMI in March 2024, the sixth month of Linda's IEP, and we award SMI coverage as of April 2024. In September 2024, Linda's sister notifies the FO that Linda was mentally incompetent at the time Linda refused SMI in November 2023.

Linda’s sister provides a certified copy of a court order dated July 2023 indicating that the court ruled that Linda was legally incompetent. Linda’s sister, the legal representative, authorizes the retroactive SMI premiums to be withheld from Linda’s monthly benefits. We adjust Linda’s SMI entitlement date to January 2024 (the first month Linda's SMI coverage would begin as though Linda never filed the original refusal).

Even if Linda had not enrolled later during Linda's IEP, we could award Linda SMI as of January 2024.

F. References

•

GN 00502.023 Developing Legal Evidence of Capability
•

GN 00502.040 Developing Medical Evidence of Capability
•

HI 00805.100 Individual Incapacitated During IEP, GEP, or SEP
•

HI 00805.110 SMI Enrollment Process
•

HI 00805.115 Enrolling Beneficiaries in SMI who Reside in Puerto Rico
•

HI 00805.120 Enrolling Beneficiaries in SMI who Reside in a Foreign Country
•

HI 00805.125 Description of CMS Medicare Initial Enrollment Period Package Information Sent to Beneficiaries
•

HI 00805.165 Individual Enrollment - When A Coverage Period Begins
•

HI 00815.001 General Description
•

HI 00820.035 Termination of SMI Entitlement
•

HI 00820.045 Voluntary Termination of SMI
•

OS 15060.073 CMS-2690 Request for Cancellation of Medicare Part B (Medical Insurance) Under the Social Security Act
•

SM 03040.080 Processing SMI Refusals
•

TC 24001.070 SMI Termination Requests

Social Security

Program Operations Manual System (POMS)

HI 00805.055 Notice of Right to Refuse Deemed Enrollment