TN 19 (03-93)

A. Introduction

For a variety of reasons involving Government fault or error, an individual's SMI enrollment request may not be processed until several months or years after coverage should have started. There also may be a delay of several months or years in notifying an enrollee that coverage has been awarded.

Serious inequity is likely to result where people are required to pay for a long period of retroactive coverage which they may not have known they had. They may continue to carry other health insurance, or defer necessary treatment. They may also be unable to pay the premiums which accumulated over a long period of months.

B. Policy - Relief available

1. Six or more months' premiums are owed

If retroactive premiums for 6 or more months are due when an enrollment request is processed or the enrollee is notified about the start of SMI, SMI is awarded with the month in which final action is taken to process the award (i.e., current operating month).

NOTE: Months between the end of the enrollment period in which the request was filed (or deemed to have been filed) and the SMI entitlement date are not counted in determining whether or how much the enrollee's premiums must be increased for late filing.

2. Intermediate date not allowable

The individual cannot choose an intermediate date for coverage to begin because it would enable the individual to select the month most advantageous to him/her and most costly to the SMI Trust Fund, such as the first month in which he/she incurred substantial covered expenses.

The coverage and premium liability must begin either as provided in HI 00805.165 or with the month final action is taken to award the claim.

C. Procedures

1. Award coding

Follow the procedures below to notify the individual of the relief available.

Use the SMI entitlement code (SENC) of “B” - equitable relief - in processing the cases.

2. Notice of award

Unless State buy-in is involved, as described in G. below, send the enrollee a notice of current SMI award which includes the special paragraph noted in B.2. below.

NOTE: The option referred to in that paragraph of having SMI coverage begin with a specified date means the date coverage would have begun under HI 00805.165 if the enrollment request had been processed correctly and promptly.

3. Special paragraph

Include language similar to the following in the award notice sent to the enrollee:

“We have recently discovered that your Supplementary Medical Insurance enrollment was not processed timely. Corrective action has now been taken, and you have coverage and premium liability beginning (date). If you wish to have your coverage begin earlier, you have the right to choose coverage beginning (date), provided that within 60 days after the date of this notice you:

• submit a signed request for coverage beginning as of (date); and

• pay the amount of, which represents premiums due for coverage from (date) through (date). (Authorize the SSA to withhold the amount of from your monthly benefits for premiums due from (date) through (date).) If you wish the earlier coverage but would have difficulty paying the retroactive premiums in a lump sum, ask your social security office about arrangements that may be made.”

4. Enrollee chose date before award

If an enrollee has already made it clear that he/she wants only prospective coverage or that he/she wants (and is willing to pay for) earlier entitlement, award SMI accordingly without mentioning the option.

If the enrollee is currently requesting the earlier entitlement date, ascertain whether he/she is willing to pay the premium arrearage before any award action is taken.

5. Enrollee wants SMI at earliest date

If the individual

• pays the accrued premiums in full, or

• agrees to installments after the social security office gives him/ her the information in HI 00805.180, or

• agrees to benefit deductions,

adjust the award to show the earlier starting date of coverage.

Determine whether it is necessary to alert the enrollee to the need for filing Part B claims promptly for any covered services he/she may have received during the first months of the period of SMI entitlement.

REMINDER: Ordinarily, claims for SMI benefits for covered services received during the 12-month period ending September 30 of any year must be filed on or before December 31 of the next year.

6. Notice of time limit for claims reimbursement

If the time limit for filing Medicare claims has expired for some services, or will expire within 6 months after the month the award is approved, advise the enrollee in the amended award notice that such claims will be honored if submitted within 6 months after the month of notice. Include language similar to the following:

“If you received any services covered by Medicare during the period before October 1 (year), SMI benefits for such services may be paid only if your claim is submitted on or before (the last day of the sixth month after the month of the notice) along with a copy of this notice. You should telephone your local social security office if you wish help in filing such claims.”

D. Example

Mr. Carr, whose first month of SMI eligibility is 7/90 files an application for SMI enrollment in 5/90. Due to an error, his application was not processed until 6/92.

He will be awarded SMI coverage beginning 6/92 (23 months later than SMI coverage would normally have begun), and his premiums will not be increased, since he filed the enrollment request during his IEP.

Mr. Carr will be notified that his coverage could be made retroactive to 7/1 /90 if he pays the back premiums for 7/90 through 5/92 of $689.40 (or authorizes the deduction of this amount from monthly benefits payable to him).

Assuming he elects 7/90 and the amended award is prepared in 8/92, the notice of award will advise him that he must file on or before 2/28/93 for services received before 10/1/91.

E. Policy - SMI no longer wanted

In some cases where a person is awarded prospective SMI beginning many months after enrollment (or deemed enrollment), the individual may protest that he/ she does not desire SMI enrollment, e.g., because he/she has secured other coverage which he/she now prefers to retain.

In such cases (including automatic enrollment cases), if the enrollee's protest is filed within 2 months after the month in which he/she is notified of the SMI coverage:

• the SMI award is reversed:

• any premiums paid are refunded; and

• the individual is deemed not to have enrolled or, in automatic enrollment cases, is deemed to have refused enrollment.

F. Procedures - SMI termination date occurs before award is made

When a SMI award is delayed so that the choice in B., above could not be made by the individual prior to the termination date of SMI (due to death, or to the termination of HI for an individual under age 65), contact the individual (or any of the survivors) as soon as possible and give him/her the option of electing SMI as of the date entitlement should have begun and paying the premiums, or refusing SMI entirely.

In other cases, an amended award, which would cause earlier SMI entitlement, is made to a person who already has been awarded SMI but the SMI termination date occurs before the individual (or survivors, if the enrollee is deceased) is able to make the choice of having earlier SMI entitlement. In these cases, offer the enrollee (or the survivors) the choice of accepting the new (earlier) SMI entitlement date and paying the additional premiums or refusing earlier entitlement.

G. Procedures - State buy-in

If a SMI award is delayed for an individual who would be on State buy-in for each month of the retroactive entitlement period, make the SMI award effective with the proper month since the State will pay all the retroactive premiums.

If State buy-in is involved, but would not apply for the first month of retroactive coverage, or for some intervening months during the retroactive period, award the individual a closed period of SMI for the buy-in period, and SMI as of the month of processing, with a choice of coverage for the non-buy-in months, if he/she will pay the premiums due.

EXAMPLE: Mary's award is processed in 4/92. Her first month of SMI entitlement should be 1/91. She was on State buy-in from 6/91 through 10/ 91. She should be awarded a closed period of buy-in coverage from 6/91 through 10/91, and continuous SMI from 4/92 on. She should also be informed that she may have SMI from 1/91 or from 11/91 if she will pay the premiums due from whichever date she elects (if she elected 1/91, she would not, of course, pay premiums for the intervening buy-in months).