TN 48 (11-22)

HI 01001.365 DO Action When Enrollee Requests Relief

When the enrollee (or someone acting on behalf) applies to the DO for relief, obtain a signed statement of the reasons why premiums were not paid within the 90-day grace period. Include information concerning any prior reinstatements. Accept as true a credible statement which is not contradicted by any evidence or information in file.

If relief was requested timely, and the situation meets the criteria of HI 01001.360 tell the nonbeneficiary enrollee to pay all premiums due through the end of the extended grace period. (Ask a beneficiary in suspense to pay all premiums through the current calendar quarter, but is required to pay only premiums for months in the past year, since premiums for the current year are not due until February 5 after the end of the year.)

Make the determination as to whether good cause has been established and relief granted. Enter on an RC a determination as to whether or not good cause has been found for the enrollee's failure to pay premiums timely. Include a brief summary of the enrollee's statement and any other pertinent facts, and a statement regarding the enrollee's credibility.

The DO determination that good cause exists will normally not be reviewed by the reviewing office. If the determination is favorable, mail the material to the special P.O. Box for the Premium and Recovery Cash Collection Section in the reviewing office, see HI 01005.802; in an envelope marked “Reinstatement of SMI enrollment in accordance with HI 01001.355. ”Notify the servicing PSC.

Route unfavorable determinations for review by the Exception and Health Insurance Specialist.

If the enrollee states has already mailed part or all of the necessary premiums to the reviewing office, obtain a DO premium query reply from central office. This shows the amount of premiums due and reflects whether any prepaid premiums had been refunded. Always get this query reply when payments have been alleged. If the query reply does not show the alleged premium payment, obtain a statement setting forth necessary information concerning the amount of payment, when and how payment was made (by check, money order, etc.) and any available proof or corroboration of such payment, e.g., a check stub. For purposes of the premium payment requirement in HI 01001.355 B.2. assume the statement is true, if it is credible.

NOTE: In some cases the enrollee will have monthly benefits becoming payable for a month prior to the expiration of the extended grace period. When the DO knows (e.g., from an annual report or cessation-of-work notice) that the overdue premiums can be deducted from such benefits, record this information on an RC. This will suffice in lieu of a premium payment. However, if there is any question, ask the enrollee to pay the overdue premiums in cash or by check. An appropriate adjustment will be made by the reviewing office upon reinstatement of SMI coverage.

If the enrollee is unable to pay all overdue premiums immediately and wishes some additional time to make the necessary payment, give a written notice that SMI coverage may be continued, provided that premiums of (specified amount) now overdue and unpaid are received no later than (date extended period ends), and that unless the premiums are received by that date, no further action will be taken with regard to SMI enrollment. If the enrollee does not pay the requested premiums by the end of the extended grace period, no good cause determination or further action is necessary. Send a copy of the notice and any other pertinent material to the reviewing office for association with the folder.

Any premium payments received should not be held pending development of the good cause issue. Give the enrollee a receipt, see HI 01001.090, and forward the remittance to the special address. To prevent a possible refund, identify the payment as related to a pending request for reinstatement under HI 01001.355.