SSA - POMS: GN 02615.140 - Medicare Relief for <Italic>Clark</Italic> Class Members

A. Background on Medicare benefits to Clark Class Members

The government is providing the following Medicare benefits to Clark class members who lost or refused their Medicare Part B (medical insurance) entitlement during the Clark period in connection with nonpayment of Title II Retirement, Survivors, and Disability Insurance (RSDI) benefits based on probation or parole violation (PPV) warrants. Clark class members are defined in GN 02615.100A.2.

1. Class members not enrolled in Part B

Clark class members eligible to enroll in Part B but not currently enrolled:

•

are automatically enrolled in Part B effective with the current operating month (COM) with the right to disenroll;
•

are not charged a premium surcharge for this enrollment;
•

remain subject to surcharges imposed before the Clark period; and
•

may enroll retroactively to the relevant Part B termination date, or for those who refused Part B during the period covered by Clark class membership, to the first month of Part B eligibility. Beneficiaries who enroll retroactively must pay all premiums back to the Part B termination date, or the first month of Part B eligibility, but may request installment payments as described in HI 00805.180 and waiver of past-due premiums per HI 00805.220H.

2. Class members enrolled in Part B

Clark class members currently enrolled in Part B:

•

will have surcharges removed that were incurred during the Clark period in connection with nonpayment of RSDI benefits based on probation or parole violation warrants;
•

will receive a refund of any surcharges already paid for the Clark period if we deduct Part B premiums from benefits. NOTE: The refund will reduce the next premium bill(s) for those in direct bill; and
•

may enroll retroactively to the relevant Part B termination date, or for those who refused Part B during the period covered by Clark class membership, to the first month of Part B eligibility. Beneficiaries who enroll retroactively must pay all premiums back to the Part B termination date or the first month of Part B eligibility, but may request installment payments as described in HI 00805.180, and waiver of past-due premiums per HI 00805.220H.

B. Process for identifying cases for review

The Office of Systems (OS) selects the Clark class members potentially eligible for Medicare relief and identifies the records by adding the following Central Office Message (CO MSG) to the master beneficiary record (MBR):

“CLARK COURT ORDER – CASE SELECTED FOR CLARK RELIEF AND MEDICARE REVIEW”

The OS sends the identified records to the processing centers (PC) for processing. The PC determines if the class member gets Medicare relief using the instructions in GN 02615.140C in this section.

C. PC procedure to determine if the Clark class member gets the Medicare relief

1. Steps to determine the processing date that benefits were suspended for PPV

Step	Action
1	Locate the Clark class member’s period of PPV suspension on the MBR. For information on determining if the beneficiary is a Clark class member, see GN 02615.110.
2	Check the data entries in the History Data Line of the MBR to determine the period(s) S9 with an HFRST of FUGFEL between 01/05 to the present. Check the following fields in the HISTORY data line: STATUS CODE--Position 3, Benefit Paid Designation (BPD) of this entry shows if the monthly benefit was: • paid, code “1,” or • not paid, code “0.” Reason for Suspension or Termination (SUS/TERM)--The code will be “9” with an HRFST of “FUGFEL.” Example of determining the processing date that benefits were suspended for PPV: The History Data Line shows S9 FUGFEL beginning 01/05 to present. However, the status code is 901 from 01/05 through 01/07, meaning benefits were paid. From 02/07 to present, the status code is 900 which means benefits were not paid. Therefore, the processing date that benefits were suspended is 02/07.
3	If there is no S9 FUGFEL period on the MBR, retrieve a prior MBR by selecting folder MBR RTUT MFR on the Online Retrieval System (ORS) to determine months benefits were suspended for PPV.

Step

Action

1

Locate the Clark class member’s period of PPV suspension on the MBR. For information on determining if the beneficiary is a Clark class member, see GN 02615.110.

2

Check the data entries in the History Data Line of the MBR to determine the period(s) S9 with an HFRST of FUGFEL between 01/05 to the present.

Check the following fields in the HISTORY data line:

STATUS CODE--Position 3, Benefit Paid Designation (BPD) of this entry shows if the monthly benefit was:

•

paid, code “1,” or
•

not paid, code “0.”

Reason for Suspension or Termination (SUS/TERM)--The code will be “9” with an HRFST of “FUGFEL.”

Example of determining the processing date that benefits were suspended for PPV:

The History Data Line shows S9 FUGFEL beginning 01/05 to present. However, the status code is 901 from 01/05 through 01/07, meaning benefits were paid. From 02/07 to present, the status code is 900 which means benefits were not paid. Therefore, the processing date that benefits were suspended is 02/07.

3

If there is no S9 FUGFEL period on the MBR, retrieve a prior MBR by selecting folder MBR RTUT MFR on the Online Retrieval System (ORS) to determine months benefits were suspended for PPV.

2. Steps to determine if the Clark class member gets the Medicare relief

Step	Determination
1	When did Part B terminate for nonpayment, voluntary withdrawal, or when did the beneficiary refuse Part B?
2	Is the Step 1 date prior to the processing date the beneficiary was suspended for PPV? If yes, no Medicare relief, STOP; If no, continue to Step 3.
3	Does the Step 1 date fall within the period that the beneficiary was suspended for PPV, starting with the processing date that the beneficiary was suspended for PPV? If yes, continue to Step 6; If no, continue to Step 4.
4	Is the Step 1 date after the PPV suspension ended and the NON COVER RSN is PREM NON PAY? If yes, continue to Step 6; If no, continue to Step 5.
5	Is the Step 1 date within 2 months after the PPV suspension ended and the NON COVER RSN is ENROL WITHDRAW? If yes, continue to Step 6; If no, no Medicare relief, STOP.
6	Is there a concurrent suspension for the entire PPV period, e.g., prisoner? If yes, no Medicare relief; If no, Medicare relief applies.

NOTE: Do not provide Medicare relief if the class member did not lose or refuse Medicare Part B entitlement during the Clark period in connection with nonpayment of benefits based on PPV.

For example, if the class member lost Part B during the Clark period while suspended for some other reason like prisoner suspension, trial work period, or miscellaneous suspension, do not provide Medicare relief.

D. PC procedure for processing instructions for Clark class members who do not get the Medicare relief

If the beneficiary does not meet the requirements for Medicare relief, post the following SPECIAL MESSAGE (SP MSG) to the MBR:

“CLARK COURT ORDER – CLARK RELIEF PROCESSED, NOT ELIGIBLE FOR MEDICARE RELIEF”

E. PC procedure and processing instructions for Clark class members who get the Medicare relief

If the beneficiary meets the requirements for Medicare relief, follow the instructions in this subsection based on the beneficiary’s current Medicare entitlement situation. For instructions on changing enrollment data on MACADE screens, see SM 00850.010C.

1. No Medicare Part B

If the beneficiary is not currently enrolled in Medicare Part B and is eligible to enroll, establish Part B entitlement effective with COM. Give the option to refuse Part B, and give the option to enroll retroactive to the Part B termination date, or if the beneficiary refused Part B, to the first month of Part B eligibility. Take the following actions:

a.
Code the following Manual Adjustment Credit and Award Data Entry (MACADE) System SMI screen entries:
- •
  
  START = COM
- •
  
  BASIS = as shown in previous period on MBR
- •
  
  FILING = month prior to COM
- •
  
  EQUIT RELIEF = G
- •
  
  NON EQIT START = termination date of previous period or first month of Part B eligibility if beneficiary refused Part B. If the prior period termination date or refusal date are less than 6 months before COM, then code the NON EQIT START date equal to COM.
NOTE: Previous period refers to the period of Part B entitlement that the beneficiary refused or terminated after the Clark suspension.
b.

Include Clark Medicare paragraphs in the notice.

NOTE: Sequencing charts and paragraphs are in GN 02615.140F in this section.
c.

Add a Special Message (SP MSG) to the MBR:

“CLARK COURT ORDER – CLARK RELIEF AND MEDICARE RELIEF PROCESSED”

2. General Enrollment Period (GEP) with premium surcharge

If the beneficiary already enrolled in Medicare Part B during a GEP, after:

•

refusing Part B,
•

terminating for nonpayment of premiums, or
•

voluntarily withdrawing from Medicare Part B, and is paying a premium surcharge, remove any late enrollment surcharge incurred in connection with the nonpayment of benefits based on PPV and give the option to enroll retroactive to the Part B termination date, or if the beneficiary refused Part B, to the first month of Part B eligibility.

Take the following actions, but note that when the GEP is already on the MBR, the SMI occurrences will propagate and be overlaid with the following data:

a.
Code the following MACADE SMI screen entries:
- •
  
  START = SMI Start of current period on MBR (GEP start) or COM if the case is worked prior to COM 07/2013 and 07/2013 is the GEP START on the MBR. To overlay 2013 GEP follow coding in GN 02615.140E.1. in this section.
- •
  
  BASIS = as shown on MBR
- •
  
  FILING = as shown on MBR, January, February, or March
- •
  
  EQUIT RELIEF = G
- •
  
  NON EQIT START = termination date of previous period or first month of Part B eligibility if beneficiary refused Part B.
b.
Code the following MACADE SMI PREMIUM HISTORY (SPH) screen entries:
- •
  
  START = GEP start date (e.g., 07/2010)
- •
  
  PENALTY PERCENTAGE = 000
  
  NOTE: If there was a penalty on the MBR prior to the termination addressed here, then roll the current penalty back to the prior amount instead of zero.
NOTE: If there is an earlier SMI period on SPH with a penalty of “000”, delete the penalty surcharge and the GEP Start date from the SPH screen.
c.

Include Clark Medicare paragraphs in the notice. Sequencing charts and paragraphs are in GN 02615.140F in this section.
d.

Add an SP MSG to the MBR:

“CLARK COURT ORDER – CLARK RELIEF AND MEDICARE RELIEF PROCESSED”

3. GEP with no premium surcharge

If the beneficiary already enrolled in Medicare Part B during a GEP, after refusing Part B, terminating for nonpayment of premiums, or voluntarily withdrawing from Medicare Part B, give the option to enroll retroactive to the Part B termination date, or if the beneficiary refused Part B, to the first month of Part B eligibility. Take the following actions:

a.
Code the following MACADE SMI screen entries:
- •
  
  START = SMI Start of current period on MBR (GEP start) or COM if the case is worked prior to COM 07/2013 and 07/2013 is the GEP START on the MBR. To overlay 2013 GEP follow coding in GN 02615.140E.1. in this section.
- •
  
  BASIS = as shown on MBR
- •
  
  FILING = as shown on MBR, January, February, or March
- •
  
  EQUIT RELIEF = G
- •
  
  NON EQIT START = termination date of previous period or first month of Part B eligibility if the beneficiary refused Part B
b.

Include Clark Medicare paragraphs in the notice. Sequencing charts and paragraphs are in GN 02615.140F in this section.
c.

Add an SP MSG to the MBR:

“CLARK COURT ORDER – CLARK RELIEF AND MEDICARE RELIEF PROCESSED”

4. Third-party buy-in

If a third party bought in after the beneficiary refused Medicare Part B, Part B terminated for nonpayment of premiums, or voluntarily withdrew from Part B, give the option to enroll retroactive to the Part B termination date, or if the beneficiary refused Part B, to the first month of Part B eligibility.

Example of third-party buy-in after Part B terminated for nonpayment of premiums:

Part B terminated for nonpayment of premiums January 2011. Third party bought in February 2012. Offer the beneficiary Medicare Part B retroactive to the date of Part B termination.

Take the following actions:

a.
Code the following MACADE SMI screen entries:
- •
  
  START = date 3rd party bought in
- •
  
  BASIS = as shown on MBR
- •
  
  FILING = as shown on MBR
- •
  
  EQUIT RELIEF = G
- •
  
  NON EQIT START = termination date of previous period or first month of Part B eligibility if the beneficiary refused Part B. If the prior period termination date or refusal date is less than 6 months before the 3^rd-party buy-in date, then code the NON EQIT START date equal to the date 3^rd party bought in.
b.

Include Clark Medicare paragraphs in the notice. Sequencing charts and paragraphs are in GN 02615.140F in this section.
c.

Add an SP MSG to the MBR:

“CLARK COURT ORDER – CLARK RELIEF AND MEDICARE RELIEF PROCESSED”

5. Beneficiary in developmental suspense

If the beneficiary is in developmental suspense, e.g., S6 or S8, place an SP MSG on the MBR advising that when development is complete, process Medicare relief per GN 02615.140E in this section.

6. Deceased beneficiaries

Do not establish Part B entitlement effective COM for deceased beneficiaries.

Notify survivors of the option to enroll on behalf of the deceased beneficiary retroactive to the Part B termination date, or if the beneficiary refused Part B, to the first month of Part B eligibility.

Take the following actions:

•

use HIB273, and HIB277 to notify the survivor of the option to elect Part B retroactive to the Part B termination date, or if the beneficiary refused Part B, to the first month of Part B eligibility. Do not include Appeals language if this Medicare language is the only information in the notice;
•

add an SP MSG to the MBR with the earlier date offered; and
•

add an SP MSG to the MBR:

“CLARK COURT ORDER – CLARK RELIEF AND MEDICARE RELIEF PROCESSED”

If the deceased beneficiary enrolled in Medicare Part B during a GEP:

•

remove any late enrollment surcharge incurred in connection with the nonpayment of benefits based on PPV,
•

notify survivors of the option to enroll on behalf of the deceased beneficiary retroactive to the Part B termination date, or
•

if the beneficiary refused Part B, to the first month of Part B eligibility.

Take the following actions:

a.
Code the following MACADE SMI screen entries:
- •
  
  START = GEP start date
- •
  
  BASIS = as shown on MBR
- •
  
  FILING = as shown on MBR, January, February, or March
- •
  
  EQUIT RELIEF = G
- •
  
  NON EQIT START = termination date of previous period or first month of Part B eligibility if beneficiary refused Part B. If the prior period termination date or refusal date are less than 6 months before GEP, then code the NON EQIT START date equal to GEP start date.
b.
Code the following MACADE SPH screen entries:
- •
  
  START = GEP start date (e.g., 07/2010)
- •
  
  PENALTY PERCENTAGE = 000
  
  NOTE: If there was a penalty on the MBR prior to the termination addressed here, then roll the current penalty back to the prior amount instead of zero.
c.

Use HIB275, HIB273, and HIB277 to notify the survivor of the option to elect Part B retroactive to the Part B termination date, or if the beneficiary refused Part B, to the first month of Part B eligibility. Do not include Appeals language if this Medicare language is the only information in the notice.
d.

Add an SP MSG to the MBR:

“CLARK COURT ORDER – CLARK RELIEF AND MEDICARE RELIEF PROCESSED”

If a third party bought in after the deceased beneficiary refused Medicare Part B, Part B terminated for nonpayment of premiums, or voluntarily withdrew from Part B, notify survivors of the option to enroll on behalf of the deceased beneficiary retroactive to the Part B termination date, or if the beneficiary refused Part B, to the first month of Part B eligibility.

Take the following actions:

a.
Code the following MACADE SMI screen entries:
- •
  
  START = date 3rd party bought in
- •
  
  BASIS = as shown on MBR
- •
  
  FILING = as shown on MBR
- •
  
  EQUIT RELIEF = G
- •
  
  NON EQIT START = termination date of previous period or first month of Part B eligibility if the beneficiary refused Part B
b.

Use HIB275, HIB273, and HIB277 to notify the survivor of the option to elect Part B retroactive to the Part B termination date, or if the beneficiary refused Part B, to the first month of Part B eligibility. Do not include Appeals language if this Medicare language is the only information in the notice.
c.

Add an SP MSG to the MBR:

“CLARK COURT ORDER – CLARK RELIEF AND MEDICARE RELIEF PROCESSED”

F. PC procedure for Clark sequencing charts and Medicare paragraphs

Include the following Medicare paragraphs (UTIs) in the order shown on the sequencing charts. Manually input the Medicare paragraphs specific to Clark. Clark Medicare paragraphs do not automatically generate via MADCAP. They are only available to request manually via the Manage text (AURORA) processing system.

The following lists contain the sequencing for Medicare paragraphs in the MADCAP Clark relief notices. Place all Medicare paragraphs under caption HIBC01. An “R” indicates a required paragraph, while an “O” indicates an optional paragraph. Below the sequencing charts are the manual paragraphs with fill-ins.

1. Sequencing chart for Medicare Part B award action

UTI Number	Required or Optional
HIBC01	R
HIB272	R
HIB005	R
HIB220	O
HIB221	O
HIB039	O
HIB273	R
HIB276	O
HIB277	O
HIB279	O
HIB280	O
HIB002	R
HIB052	R
HIB186	R

2. Sequencing chart for GEP enrollment with premium surcharge

UTI Number	Required or Optional
HIBC01	R
HIB274	R
HIB005	R
HIB273	R
HIB278	O
HIB276	O
HIB277	O
HIB279	O
HIB280	O
MHP069	O

3. Sequencing chart for GEP enrollment with no premium surcharge or third-party buy-In

UTI Number	Required or Optional
HIBC01	R
HIB275	R
HIB273	R
HIB276	O
HIB277	O
HIB279	O
HIB280	O

4. Clark Medicare paragraphs

HIB272

We enrolled __F1__ in Medicare Part B (medical insurance) starting __F2__. We did this because __F3__ a class member of the Clark court case. We enrolled certain Clark class members who refused or stopped their medical insurance while their benefits were suspended. We explain below how __F4__ can choose an earlier enrollment date. We also explain how __F5__ can refuse this medical insurance.

Fill-ins:

F1-1 - you

F1-2 - Beneficiary Name

F2 - Current Operating Month - MM/CCYY

F3-1 - you are

F3-2 - they are

F4-1 - you

F4-2 - they

F5-1- you

F5-2- they

HIB273

We are offering __F1__ the option to get medical insurance coverage__F2__ back to an earlier date. __F3__ may choose this coverage starting with the date that it stopped or __F4__refused it while __F5__ benefits were suspended.

Fill-ins:

F1-1 - you

F1-2 - Beneficiary Name

F2-1 - for Beneficiary Name

F2-2 - NULL

F3-1 - You

F3-2 - They

F4-1 - you

F4-2 - they

F5-1 - your

F5-2 - their

HIB274 – Removed or reduced late enrollment penalty

__F1__ a class member of the Clark court case. We enrolled certain Clark class members in Medicare Part B (medical insurance). __F2__ already enrolled in medical insurance starting __F3__. __F4__ paid a late enrollment penalty for __F5__ medical insurance. We removed the penalty for the months connected with being a Clark class member.

Fill-ins:

F1-1 - You are

F1-2 - Beneficiary Name is

F2-1 - You are

F2-2 - Beneficiary Name is

F3 - SMI entitlement date – MM/CCYY

F4-1 - You

F4-2 - They

F5-1 - your

F5-2 - their

HIB275

__F1__ a class member of the Clark court case. We enrolled certain Clark class members in Medicare Part B (medical insurance). __F2__ already enrolled in medical insurance starting __F3__.

Fill-ins:

F1-1 - You are

F1-2 - Beneficiary Name is

F2-1 - You are

F2-2 - Beneficiary Name is

F3 - SMI entitlement date – MM/CCYY

HIB276 – Beneficiary in suspended or deferred status beyond this calendar year/benefits terminated but eligible to enroll in Medicare Part B, VSMI involved.

If __F1__ medical insurance to start earlier, __F2__ can choose to have it start in __F3__. If __F4__ this earlier date, we will reduce __F5__ current monthly premium to __F6__. We can reduce__F7__ premium because of a rule that protects people from premium increases. If __F8__ choose the earlier date, __F9__ current monthly premium will be __F10__.

To start __F11__ medical insurance earlier, __F12__ must do the following things within 60 days after the date of this letter:

Tell us in writing that __F13__ medical insurance starting __F14__, and

Pay us $__F15__. This amount covers the premiums due from __F16__ through __F17__.

If it would be hard for you to pay the premium amount in a lump sum, please ask us about other ways to pay the premium.

Fill-ins:

F1-1 - you want your

F1-2 - they want their

F2-1 - you

F2-2 - they

F3-1 - SMI termination date – MM/CCYY

F3-2 - First month of SMI eligibility – MM/CCYY

F4-1 - you choose

F4-2 - they choose

F5-1 - your

F5-2 - their

F6 - Monthly VSMI premium amount – $$$.¢¢

F7-1 - your

F7-2 - their

F8-1 - you do not

F8-2 - they do not

F9-1 - your

F9-2 - their

F10 - Current Standard monthly premium amount – $$$.¢¢

F11-1 - your

F11-2 - their

F12-1 - you

F12-2 - they

F13-1 - you want

F13-2 - they want

F14-1 - SMI termination date – MM/CCYY

F14-2 - First month of SMI eligibility – MM/CCYY

F15-1 - Amount of premiums due from SMI termination date through month before COM or 3rd-party buy-in – $$$$.¢¢

F15-2 - Amount of premiums due from first month of SMI eligibility through month before COM or 3rd-party buy-in – $$$$.¢¢

F16-1 - SMI termination date – MM/CCYY

F16-2 - First month of SMI eligibility – MM/CCYY

F17 - Month - MM/CCYY

HIB277 – Beneficiary in suspended or deferred status beyond this calendar year/benefits terminated but eligible to enroll in Medicare Part B, VSMI not involved.

If __F1__ medical insurance to start earlier, __F2__ can choose to have it start in __F3__. To start __F4__ medical insurance earlier, __F5__ must do the following things within 60 days after the date of this letter:

Tell us in writing that __F6__ medical insurance starting __F7__, and

Pay us $ __F8__. This covers the premiums due from __F9__ through __F10__.

If you would find it hard to pay the premium amount you would owe in a lump sum, please ask us about other ways to pay the premium.

Fill-ins:

F1-1 - you want your

F1-2 - they want their

F1-3 - you want their

F2-1 - you

F2-2 - they

F3-1 - SMI termination date – MM/CCYY

F3-2 - First month of SMI eligibility – MM/CCYY

F4-1 - your

F4-2 - their

F5-1 - you

F5-2 - they

F6-1 - you want

F6-2 - they want

F7-1 - SMI termination date – MM/CCYY

F7-2 - First month of SMI eligibility – MM/CCYY

F8-1 - Amount of premiums due from SMI termination date through month before COM or 3rd-party buy-in – $$$$.¢¢

F8-2 - Amount of premiums due from first month of SMI eligibility through month before COM or 3rd-party buy-in – $$$$.¢¢

F9-1 - SMI termination date – MM/CCYY

F9-2 - First month of SMI eligibility – MM/CCYY

F10 - Month – MM/CCYY

HIB278

Because we removed the late enrollment penalty, __F1__ paid us too much money for __F2__ medical insurance premiums. We will use the extra money to reduce __F3__ next premium bill(s).

Fill-ins:

F1-1 - you have

F1-2 - they have

F2-1 - your

F2-2 - their

F3-1 - your

F3-2 - their

HIB279 – Beneficiary in Current Pay, Suspense, or Deferred status due to come out this calendar year – VSMI not involved.

If __F1__ medical insurance to start earlier, __F2__ can choose to have it start in __F3__. To start __F4__ medical insurance earlier, __F5__ must do the following things within 60 days after the date of this letter:

Tell us in writing that __F6__ medical insurance starting __ F7__, and

Pay us $__F8__ or tell us we can withhold this amount from __F9__ check. This covers the premiums due from __F10__ through __F11__.

If __F12__ would find it hard to pay the premium amount __F13__ would owe in a lump sum, please ask us about other ways to pay the premium.

Fill-ins:

F1-1 - you want your

F1-2 - they want their

F2-1 - you

F2-2 - they

F3-1 - SMI termination date – MM/CCYY

F3-2 - First month of SMI eligibility – MM/CCYY

F4-1 - your

F4-2 - their

F5-1 - you

F5-2 - they

F6-1 - you want

F6-2 - they want

F7-1 - SMI termination date – MM/CCYY

F7-2 - First month of SMI eligibility – MM/CCYY

F8-1 - Amount of premiums due from SMI termination date through June/Year of GEP Enrollment or Month/Year of 3rd-party buy-in – $$$$.¢¢

F8-2 – Amount of premiums due from first month of SMI eligibility through June/Year of GEP Enrollment or Month/Year of 3rd-party buy-in – $$$$.¢¢

F9-1 - your

F9-2 - their

F10-1 - SMI termination date – MM/CCYY

F10-2 - First month of SMI eligibility – MM/CCYY

F11 - Month/year of GEP enrollment or 3rd-party buy-in – MM/CCYY

F12-1 - you

F12-2 - they

F13-1 - you

F13-2- they

HIB280 – Beneficiary in Current Pay, Suspense, or Deferred status due to come out this calendar year – VSMI involved.

If __F1__ __ _ medical insurance to start earlier, __F2__ can choose to have it start in __F3__. If __F4__ this earlier date, we will reduce __F5__ current monthly premium to __F6__. We can reduce __F7__ premium because of a rule that protects people from premium increases. If __F8__ choose the earlier date, __F9__ current monthly premium will be __F10__.

To start __F11__ medical insurance earlier, __F12__ must do the following things within 60 days after the date of this letter:

Tell us in writing that __F13__ medical insurance starting __ F14__, and

Pay us $__F15__or tell us we can withhold this amount from __F16__ check. This covers the premiums due from __F17__ through __F18__.

If it would be hard for you to pay the premium amount in a lump sum, please ask us about other ways to pay the premium.

Fill-ins:

F1-1 - you want your

F1-2 - they want their

F2-1 - you

F2-2 - they

F3-1 - SMI termination date – MM/CCYY

F3-2 - First month of SMI eligibility – MM/CCYY

F4-1 - you choose

F4-2 - they choose

F5-1 - your

F5-2 - their

F6 - Monthly VSMI premium amount – $$$.¢¢

F7-1 - your

F7-2 - their

F8-1 - you do not

F8-2 - they do not

F9-1 - your

F9-2 - their

F10 - Current Standard monthly premium amount – $$$.¢¢

F11-1 - your

F11-2 - their

F12-1 - you

F12-2 - their

F13-1 - you want

F13-2 - they want

F14-1 - SMI termination date – MM/CCYY

F14-2 - First month of SMI eligibility – MM/CCYY

F15-1 - Amount of premiums due from SMI termination date through June/Year of GEP Enrollment or Month/Year of 3rd-party buy-in – $$$$.¢¢

F15-2 - Amount of premiums due from first month of SMI eligibility through June/Year of GEP Enrollment or Month/Year of 3rd-party buy-in – $$$$.¢¢

F16-1 - your

F16-2 - their

F17-1 - SMI termination date – MM/CCYY

F17-2 - First month of SMI eligibility – MM/CCYY

F18 - Month/year of GEP enrollment or 3rd-party buy-in – MM/CCYY

Social Security

Program Operations Manual System (POMS)

GN 02615.140 Medicare Relief for Clark Class Members

A. Background on Medicare benefits to Clark Class Members

1. Class members not enrolled in Part B

2. Class members enrolled in Part B

B. Process for identifying cases for review

C. PC procedure to determine if the Clark class member gets the Medicare relief

1. Steps to determine the processing date that benefits were suspended for PPV

2. Steps to determine if the Clark class member gets the Medicare relief

D. PC procedure for processing instructions for Clark class members who do not get the Medicare relief

E. PC procedure and processing instructions for Clark class members who get the Medicare relief

1. No Medicare Part B

2. General Enrollment Period (GEP) with premium surcharge

3. GEP with no premium surcharge

4. Third-party buy-in

5. Beneficiary in developmental suspense

6. Deceased beneficiaries

F. PC procedure for Clark sequencing charts and Medicare paragraphs

1. Sequencing chart for Medicare Part B award action

2. Sequencing chart for GEP enrollment with premium surcharge

3. Sequencing chart for GEP enrollment with no premium surcharge or third-party buy-In

4. Clark Medicare paragraphs