HI 00830.005 When to Consider Relief

1. A. 

   An enrollee’s premium-HI or SMI enrollment or nonenrollment will be considered to have been prejudiced due to the error, misrepresentation or inaction of the Federal Government or its instrumentalities if there is evidence that:

   1. 1. 

      the enrollee took such appropriate and timely measures to assert his or her rights as could reasonably be expected under the circumstances; and

   2. 2. 

      because of administrative fault, delay, or erroneous action or inaction, his or her enrollment or premium rights have been impaired or a serious inequity exists.

2. B. 

   Relief must be at least considered whenever it is noted that an enrollee is being or has been disadvantaged by this or any prior action (including a failure to act) taken by an agent or employee of the Federal Government. The term “disadvantaged” is an all-encompassing term that can mean anything involving our actions regarding enrollments, terminations, billings, and deductions that are not processed timely or correctly.

   The PSC must provide or develop relief when the following conditions are present:

   1. 1. 

      an SMI enrollment is processed 6 or more months after the entitlement date (e.g., a date of entitlement to SMI (DOES) of 7/75 is processed 1/76 or later).

   2. 2. 

      a premium-HI enrollment is processed 2 or more months after the entitlement date (e.g., a date of entitlement to HI (DOEH) of 7/75 is processed 9/75 or later).

   3. 3. 

      an unprocessed premium-HI or SMI enrollment request is discovered that would have established coverage earlier than the date(s) currently recorded (e.g., an unprocessed 1974 GEP enrollment request is found after a DOES of 7/ 75 has been recorded).

   4. 4. 

      HI, including premium-HI, or SMI appears to have been recorded in error (e.g., the enrolled was not age 65, a renal case, or disabled for 25 months in the first month of entitlement).

   5. 5. 

      an incorrectly terminated SMI case is reversed or reinstated 6 or more months after the date of termination.

   6. 6. 

      an incorrectly terminatd premium-HI case is reversed 2 or more months after the termination was recorded.

   7. 7. 

      no premium deductions were made or billing notices sent for a period covering premiums due for:

      1. a. 

         6 months or more for SMI coverage for any enrollee; or

      2. b. 

         2 months or more for premium-HI coverage

   8. 8. 

      delayed deletion from State buy-in rolls results in SMI premium arrearage of 4 or more months.

   9. 9. 

      SMI is shown on the health insurance record and a Medicare card or other notice of SMI entitlement is received, despite a refusal in file.

   10. 10. 

       Delay in receiving evidence of permanent residence status from the Immigration and Naturalization Service (INS).

   11. 11. 

       Reversal on appeal of any SSA decision affecting SMI entitlement or termination.

   Relief from liability will be considered for individuals with smaller than 6 months arrearages if, on their own, they request it or complain that it would be a hardship to pay the arrearage. The same criteria will be applied in determining whether relief from premium liability can be granted as is applied to arrearages of 6 months or greater.

3. C. 

   If none of these conditions are present, but other factors indicate that:

   1. 1. 

      some type of relief should be granted, and

   2. 2. 

      the situation has the potential to affect more than 20 beneficiaries, the Exception and Health Insurance Specialist will prepare a memorandum outlining the facts of the particular situation and estimate the number of individuals actually or potentially affected. Never submit a claims folder with the memorandum. Send the memorandum to:

      Centers for Medicare and Medicaid Services
      Division of Eligibility and Enrollment/Location: C2-12-16
      7500 Security Boulevard
      Woodlawn, MD 21244
      

   File a copy of the memorandum on the right side of the claims folder. Do not process an award or an equitable relief action for any case being sent to CMS, pending a reply from them. Do not delay normal actions (not related to the equitable relief question), including those affecting the health insurance coverage, pending a reply from CMS. Do not send a follow-up to the memorandum.

   If the situation does not have the potential to affect 20 or more beneficiaries, the reviewing office will make the decision.