To protect the enrollee's interests, arrange an interview when an enrollee sends in
a written request, unless there is some indication that the enrollee would object
to such an interview.
CAUTION: Under no circumstances should an interview be forced on an enrollee who does not
want one.
Where possible, cover the material set forth in this section, and the pertinent information
from HI 00820.065.
During the interview:
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respond to the enrollee's questions about SMI coverage and the effect of discontinuing
coverage.
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do not dispute the enrollee's concerns.
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provide full information about the enrollee's concerns.
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explore Medicaid eligibility.
2. EGHP Coverage Involved
When a termination request is made by a beneficiary who has coverage under an EGHP/LGHP
based on current employment:
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advise the individual fully about the special enrollment period (SEP) in HI 00805.265ff.,
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explain that the months of coverage under the EGHP/LGHP will not be counted in determining
a premium surcharge for late enrollment.
NOTE: Some individuals covered under an EGHP/LGHP will not benefit from terminating SMI.
This is true if the EGHP/LGHP is small enough that Medicare will be primary payer.
This is also true if their EGHP/LGHP coverage is poor, or if they have extensive medical expenses which SMI (as secondary payer) will help
to defray.
Discuss the consequences of termination and provide the following information to each
enrollee:
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date on which SMI coverage and premium obligation will end.
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any Medicare payment made for services received after the last day of coverage will be an overpayment and subject to collection.
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future election of SMI can only occur during a GEP.
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there will be a delay before coverage begins.
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there may be a premium penalty due to the break in coverage.
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full information about enrolling during an SEP for those covered under an EGHP/LGHP.
If the enrollee does not seem to understand the protection afforded by SMI:
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review the extent of SMI protection using the Medicare Handbook or one of the general
pamphlets as a tool for the discussion.
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give any help necessary to file a claim for benefits for which the enrollee may be
eligible.
5. Government Contribution
Remind the enrollee that the Federal Government is paying three-fourths of the cost
of providing SMI protection.
6. Limited Opportunity to Cancel Termination Request
Advise the enrollee of the limited time in which to cancel the termination request and continue SMI. (See HI 00820.055 for a discussion of cancellation of a termination request.)
7. Premium Bills and Deductions from Benefits at Termination
a. Direct Remittance or Deduction from Benefits
Tell the enrollee that the final premium bill may cover months after the end of SMI
coverage.
REMINDER: The enrollee should pay only for those months prior to the termination of SMI coverage.
If premiums have been prepaid for one or more months beyond the termination date,
or if excess premiums are deducted from the monthly benefit, these premiums will be
refunded automatically.
b. Civil Service Annuitant
Inform the individual that at least one excess premium deduction will be made from
the annuity before an annuity adjustment can be made by the Office of Personnel Management
(OPM). Excess deductions will be refunded to the annuitant by OPM without any need
to contact either SSA or OPM.