TN 54 (02-23)

HI 01001.295 When Premiums May Be Deemed Paid Timely

When an enrollee has failed to pay their premiums within the grace period because the enrollee 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 they receive an effective notice that their coverage has terminated, and

• •

  the enrollee pays within 30 days of the request, all premiums due through the month in which they request 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 the enrollee explaining why they did not receive the premium notice timely or at all, and when they learned of the overdue premiums and termination. If the enrollee's explanation makes it reasonably clear that the enrollee failure to pay the premiums timely resulted through administrative fault, their SMI may be reinstated provided that they pays all overdue premiums within 30 days of the request.

(Even though there may have been no administrative error, they 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 they request relief. If the enrollee is in the FO and can do so, ask them 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 they acted timely to pay their 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 they 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 their grace period, and this failure was caused by no fault on their 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.