Under the transfer enrollment period provisions, an individual may enroll for Premium-HI or, if already enrolled, request relief from the Part A premium surcharge.

If the individual wishes to apply for Premium-HI (based on a TEP or a GEP), take a form CMS-18-F5 (Application for Hospital Insurance, OS 15060.085). Process the enrollment via POS or MACADE, as applicable (see SM 03040.060).

If the only action requested is premium surcharge relief, forward the following to the PSC:

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  A signed statement from the enrollee requesting such relief (mark the request in red “Premium-HI MMCP”);

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  Evidence of MMCP enrollment; and

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  A Report of Contact giving the months to be excluded from the surcharge computation.