Use the Form CMS-40B (Application for Medicare Part B (Medical Insurance)) for D-SEP enrollment requests. For retroactive supplementary medical insurance (SMI) elections, indicate in the remarks section the date the beneficiary wants SMI coverage to begin.

Annotate “DISABILITY SEP” prominently at the top of the enrollment request.

Forward a copy of the employer letter, the carrier certification and any necessary clarifying documentation along with the enrollment request to the processing center (PC). For information about the employer and carrier documentation, see HI 00805.300B.2. Include a Form SSA-5002 (Report of Contact) that lists the months excluded from the premium surcharge calculation.

Refer Railroad Retirement Board (RRB) annuitants that inquire about SMI enrollment to the appropriate RRB office. To obtain the appropriate RRB field office and search using the Zip code locator. Tell the beneficiary that the RRB will process the SEP request.

Take the following actions when the beneficiary does not have the evidence described in HI 00805.300B.2.:

1. a. 

   If the beneficiary has only one of the two required documents (either the employer letter or carrier certification):

   • •

     take a Form CMS-40B;

   • •

     advise the beneficiary to contact their employer to obtain the other required document; and

   • •

     hold the enrollment request until we receive the document.

2. b. 

   If the beneficiary does not have either the employer letter or carrier certification:

   • •

     do not take a SMI enrollment; and

   • •

     advise the beneficiary to contact the employer to obtain the required evidence; and

   • •

     tell the beneficiary to bring the letters to the FO.

3. c. 

   If the employer letter does not include months of LGHP coverage, give the beneficiary Form CMS-L564 (Request for Employment Information). The form includes a place for the employer to indicate the months the large group health plan was primary payer and when the claimant’s coverage began.

   NOTE: It is possible to obtain the information from the employer via telephone. Document a form SSA-5002 with the name and position of the individual supplying the information.

Follow the procedures below when the beneficiary owes three or more months of retroactive premiums at the time the enrollment application is filed.

1. a. 

   If the beneficiary owes premiums for three to five months:

   • •

     Ask the beneficiary how they prefers to pay the premium arrearage if the enrollment application is not processed timely.

   • •

     Prepare an SSA-795 (Statement of Claimant or Other Person) with language similar to the following: “If my enrollment request is not processed timely, I authorize the deduction of the retroactive premium amount from my monthly benefit payment, or I request that the retroactive premium amount be paid in monthly installments of [amount.”

   • •

     Forward the SSA-795 with the enrollment package to the PC.

2. b. 

   If the beneficiary owes premiums for six or more months:

   • •

     Tell the beneficiary that they must arrange to pay the premium arrearage before we process the SMI enrollment.

   • •

     Take a statement on an SSA-795 that authorizes the deduction of the past due amount from monthly benefits or establishes an installment payment schedule. In cases of financial hardship, develop for waiver of the premium arrearage as outlined in HI 00805.220I and GN 02250.002.

   • •

     Forward the SSA-795 or waiver determination along with the enrollment package to the PC.

3. c. 

   Process premium remittances received from beneficiaries who wish to pay the arrearage in advance in accordance with GN 02403.000.