TN 105 (04-24)
If a beneficiary requests termination of SMI or Premium-HI because they will be serving as a volunteer outside the U.S., advise the individual of the eligibility requirements that must be met in order to reenroll during the SEP for International Volunteers. See HI 00805.350A. and HI 00805.350D.
Tell the beneficiary the date SMI and/or Premium-HI coverage ends and that the volunteer service outside the U.S. must begin the month SMI and/or Premium-HI coverage ends or earlier.
NOTE: Beneficiaries eligible for Premium-HI and SMI under the Premium-HI for the Working Disabled provision are not eligible to enroll during the SEP for International Volunteers.
Follow the instructions in HI 00820.070 for SMI termination requests and HI 00820.015 for Premium-HI termination requests.
Process the termination request in accordance with SM 03040.090 or SM 03040.093, as appropriate.
Annotate “Beneficiary eligible for SEP for International Volunteers” on the CMS-1763, as the reason for the termination request.
Follow the procedures in TC 24001.070.
Annotate “Beneficiary will be serving as an International Volunteer” on the CMS-or 1763 as the reason for the termination request.
Mail the CMS-1763 to the beneficiary with a courtesy return envelope to the WBDOC instruct the person to mail the completed form to the following address:
Complete form CMS-1763
Annotate “Beneficiary will be serving as an International Volunteer” on the CMS-1763 as the reason for the termination request.
Mail form the CMS-1763 to the beneficiary with a courtesy return envelope to the WBDOC or instruct the person to mail the completed form to the follwing address:
Process requests for termination of SMI and/or Premium-HI in accordance with SM 03040.090 or SM 03040.093, as appropriate.
See HI 00820.015 for Termination of Premium-HI.
See HI 00820.035 – HI 00820.050 for Termination of SMI Entitlement and Effective Date of Voluntary Termination.