In order to participate in a premium surcharge billing arrangement, States or local
governments must provide the CMS Regional Office with a written request that identifies
the class of individuals that will be covered under the surcharge billing arrangement.
The written request should be accompanied by a signed premium surcharge agreement
and completed agency information form. Following the receipt of these documents, CMS
will determine whether the arrangement is appropriate and, if so, signs the agreement
and returns a copy to the State or local government (surcharge agency).