TN 24 (03-07)

A. Policy- Calculation of the Premium Surcharge

The SMI and Premium-HI surcharge is determined by counting the number of months an individual could have been enrolled in SMI or Premium-HI after the end of the IEP through the end of the enrollment period in which enrollment occurs. When calculating the number of months during which an individual could have been enrolled in SMI or Premium-HI, exclude the following months:

• All months beginning January 2007, during which the individual served as a volunteer outside of the United States through a program sponsored by a tax-exempt organization and had health insurance that provided coverage for the individual outside of the United States for the duration of the volunteer service.

• All months of SMI and/or Premium-HI entitlement.

B. Policy - When Premium Surcharge Rollback can be Requested

There is no time limit for requesting premium surcharge rollback. An individual who is already entitled to SMI or Premium-HI, or who is filing a GEP enrollment and meets the requirements in HI 00805.350A., may request relief from the premium surcharge at any time.

C. Procedure - Request for Premium Surcharge Rollback is not Part of the SEP Package

FO PROCEDURE:

• If the individual is enrolling in SMI or Premium-HI during the GEP, forward the appropriate enrollment request to the PSC for input via MACADE. Annotate “Premium Surcharge Rollback – INT’L VOLUNTEERS” on the request form. Include the evidence discussed in HI 00805.355.

• If the individual is already enrolled in SMI or Premium-HI and is requesting premium surcharge rollback, annotate “Premium Surcharge Rollback – INT’L VOLUNTEERS” on the request form. Include the evidence discussed in HI 00805.355 and form SSA-5002 giving the months FO personnel have determined should be excluded from the surcharge calculation.