Effective Dates: 01/04/2024 - Present Previous | Next

TN 58 (01-24)

HI 01001.375 Premium Problems

A. Policy

Premium problems are those in which there is a question about one or more of the following:

  • •

    Incorrect premium deduction (dual Social Security, civil service, or railroad retirement premium deductions are not incorrect premium deductions). This type of problem cannot be resolved by reviewing the Health Insurance Query Response (HIQR). Use an overprint SSA-5002-HB and refer the problem to the appropriate program service center (PSC);

  • •

    Incorrect premium billing or incorrect check amount applied to enrollee’s record;

  • •

    Hospital Insurance-Supplementary Medical Insurance terminated for nonpayment of premiums;

  • •

    Premium refund due;

  • •

    Private third party group payer; or

  • •

    Civil service deductions of premiums from an annuity from the U.S. Office of Personnel Management (OPM).

It is very important to correctly identify the nature of the enrollee’s problem since this dictates the action to be taken.

Example: Mr. James comes into the field office (FO) and alleges nonreceipt of either a HI card or any premium bills. The Master Beneficiary Record (MBR) and the HIQR show no information on file or "NIF" even though the enrollee has alleged an apparent premium problem. This is actually an "entitlement problem" and the procedure in HI 00930.001 applies. This situation cannot be a premium problem since no entitlement exists.

Premium problems are divided into three categories: individual payer, group payer, and civil service/OPM. Individual payer problems include problems that do not involve a private third party group or civil service/OPM.

B. Process -- Problems Correction

Once it is determined that a premium problem exists, and proper documentation has been provided, proceed as follows:

  1. 1. 

    For individual payer problems, obtain an HIQR (see MSOM QUERIES 008.001). (There will not be a direct billing record if the beneficiary has always been in current pay status.) Make every effort to resolve the problem using the HIQR.

    For group payer and civil service problems, obtain a Master Beneficiary Record and a copy of the HIQR (Third Party).

  2. 2. 

    If the inquiry relates to a premium payment that is not shown on the direct billing record, send proof the payment was processed by CMS, including:

    • •

      a copy of the canceled check (back and front) showing it was endorsed for CMS Premiums Retail by the Federal Reserve Bank in Cleveland,

    • •

      or a copy of the beneficiary’s bank statement or credit card statement showing the payment to CMS,

    • •

      or if the payment was deposited by SSA – the IPAC number as proof the funds were transferred from SSA’s Trust Fund to CMS’s Trust Fund.

      Send the required proof of payment to DirectBilling@cms.hhs.gov. If no substantive response is received to the first follow-up, follow up again in 15 business days. Form SSA-5002-HB is not required.

    1. 3. 

      If the inquiry relates to a premium issue involving Civil service deductions of premiums from an annuity from OPM, please note only Federal Retirees who aren't receiving Social Security benefits can have Medicare premiums withheld from their Civil Service Annuity/OPM payments.

      To request Medicare premiums withheld from a Civil Service Annuity/OPM payment, beneficiaries should contact their local Social Security Field Office to initiate the request. If they have already followed up on their initial request with Social Security, beneficiaries should contact CMS at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

    1. 4. 

      If the inquiry is to report a Puerto Rico address-related case, based on SSA FOs contact with the beneficiary, the CMS Form 1957 should be used and submitted to the state buy-in mailbox at statebuy-in@cms.hhs.gov. Form SSA-5002-HB is not required.

    1. 5. 

      If it is necessary to refer the problem for resolution, submit your problem via the Modernized Development Worksheet (MDW) or on an overprint SSA-5002-HB to the servicing PSC. Outline the situation. If using an overprint 5002-HB, also attach documentation. The specifically designed form is shown in HI 01001.380. This form should be reproduced locally and used to document and refer premium problem cases.

    For group payer and Civil Service Commission (CSC) problems, review the HIQR query to determine if the information is correct. If the inquiry cannot be resolved by reviewing the on-line HIQR, attach documentation to the SSA-5002-HB and send it to:

    Centers for Medicare & Medicaid Services (CMS)

    Accounting Management Group

    Division of Premium Billing

    Mailstop: C3-19-08

    7500 Security Boulevard
    Baltimore, Maryland 21244-1850

C. Procedure--Premium Problem Follow-Up

1. Individual Payer Problem Case Follow-Up Procedures

FO follow-up efforts on premium problems should be made only in accordance with the following:

a. FO Referral to PSC

If the initial problem remains unresolved 10 days after the referral, send a follow-up to the appropriate PSC and annotate in red that this is a duplicate of the original premium problem.

b. FO Referral to the Centers for Medicare & Medicaid Services (CMS)

If the initial problem remains unresolved 30 days after the referral, send a follow-up to CMS. Annotate in red, "Second Request." This follow-up should be a duplicate of the original problem referral. If the corrective action has not been taken within 45 days from the second request or if the problem is not corrected within 60 days from the original request, send a third request to CMS at the above address. Annotate "third request" on the form in red and follow the identical procedures as for the second request.

If the inquiry relates to a premium payment that is not shown on the direct billing record, and proof the payment was processed by CMS was sent with the first request, per Section B, above, send a follow up email to DirectBilling@cms.hhs.gov. If no substantive response is received to the first follow-up, follow up again in 15 business days. Form SSA-5002-HB is not required.

c. Critical and Congressional Cases

If the case becomes critical or if Congressional interest develops and no corrective action is indicated on the HIQR after the initial referral of the case, call the appropriate critical case or Congressional case component of the servicing PSC. Give all pertinent facts. In these cases, a telephone reply will always be given to the FO when corrective action is taken.

2. Group Payer Problem Case Follow-Up Procedures

FO follow-up efforts on private third party group payer premium problems should be made in accordance with the following:

a. FO Referral to CMS

If the initial problem remains unresolved 30 days after the referral, send a follow-up to:

Centers for Medicare & Medicaid Services

Accounting Management Group

Mailstop: C3-19-08

7500 Security Boulevard

Baltimore, Maryland 21244-1850

Annotate in red, "Second Request." This follow-up should be a duplicate of the original problem referral. If the corrective action has not been taken within 45 days from the second request or if the problem is not corrected within 60 days from the original request, send a third request to CMS at the above address. Annotate "third request" on the form in red and follow the identical procedures as for the second request.

b. Critical and Congressional Cases

If the case becomes critical or if Congressional interest develops and no corrective action is indicated on the current MBR, call the Division of Exceptions Processing on 410-786-0303. Give all pertinent facts. In these cases, a telephone reply will always be given to the FO when corrective action is taken.

D. Procedure--Premium Problem Format

The FO should use the MDW whenever possible or the SSA-5002-HB overprint to submit premium problems to the servicing PSC. The SSA-5002-HB is not always required to submit premium problems to CMS. It is suggested that the form be reproduced locally as needed. In addition to documenting the problem on the form itself, be sure to include the name, mailing address, and telephone number of the FO representative making the referral. Teleservice Representatives/SPIKE should complete the SSA-5002-HB and forward a copy to the FO for control purposes.

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0601001375
HI 01001.375 - Premium Problems - 01/04/2024
Batch run: 01/04/2024
Rev:01/04/2024