TN 22 (11-01)

HI 01001.295 When Premiums May Be Deemed Paid Timely

When an enrollee has failed to pay his/her premiums within the grace period because he/she did not know that the premiums were due, or that they were unpaid, these premiums may be considered to have been paid timely provided:

  • the enrollee asks for relief by the end of the month after the month in which he/she receives an effective notice that his/her coverage has terminated, and

  • the enrollee pays within 30 days of the request, all premiums due through the month in which he/she requests relief.

If the enrollee's request for relief contains an allegation that the premiums were not paid because the enrollee did not know that the premiums were due, the field office (FO) will take a statement from him/her explaining why he/she did not receive the premium notice timely or at all, and when he/she learned of the overdue premiums and termination. If his/her explanation makes it reasonably clear that his/her failure to pay the premiums timely resulted through administrative fault, his/her SMI may be reinstated provided he/she pays all overdue premiums within 30 days of the request.

(Even though there may have been no administrative error, he/she may be given a 90-day extension of the grace period (to a maximum of 6 months) for good cause, under the conditions set forth in HI 01001.360. Also see HI 01001.310 if the failure to pay premiums resulted from an incorrect termination of entitlement.)

When found eligible for the opportunity to reinstate Supplementary Medical Insurance (SMI) coverage, the enrollee will be asked to pay all premiums due through the month in which he/she requests relief. If he/she is in the FO and can do so, ask him/her to pay these premiums. Otherwise, the enrollee will be given a written notice to pay all these premiums through the FO within 1 month from the date of request. Coverage will not be extended and the termination of entitlement will not be set aside, unless and until the requested premiums are paid within the 30-day limit.

In general, relief should be granted where the enrollee established, by a credible statement not contradicted by any evidence available, that he/she acted timely to pay his/her premiums or to seek relief upon receiving notice very late in the grace period or shortly after it. Relief may be granted where there is a reasonable basis for believing that the premiums were being paid by deduction from benefits or by some source other than direct payment. No relief (other than that available under the 90-day extension of the grace period for good cause, see HI 01001.360) can be given an enrollee who received timely notice but failed to pay premiums because of low income or unusual expenses. Nor can relief be granted when requested more than 1 month after the month in which he/she received the termination notice.

A person may be considered not to have known that the premiums were due and unpaid, and relief may be extended in the following situations:

Example 1: Failure to Receive A Notice

The enrollee failed to receive a billing notice at least 30 days before the end of his grace period, and this failure was caused by no fault on his part. This condition would be met, for example, when the enrollee's notice was misaddressed or lost in the mail.

Example 2: Reasonable Belief That Premiums Were Paid, or Need Not to be Paid

Relief may be extended where the enrollee was advised by the Social Security Administration or the Centers for Medicare & Medicaid Services personnel that the premiums would be paid by a welfare agency or group payer, or would be deducted from the civil service annuity of a nonenrolled spouse, etc.

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HI 01001.295 - When Premiums May Be Deemed Paid Timely - 11/07/2001
Batch run: 11/07/2001