TN 9 (06-92)

A. POLICY - GENERAL

Premium-HI for the Aged ends with the earliest of the:

• Date of death (the HI premium is owed for the month of death, even if the individual dies on the first day of the month).

• End of the month following the month the individual files a request for termination, unless the termination request is filed in the last month of Part A buy-in coverage or during the 6 succeeding months. In the latter case, Premium-HI ends with the end of the month in which the request is filed.

• End of the grace period for non-payment of premiums (the last day of the second month following the due date for payment of the premiums; see HI 01001.095).

• Date SMI coverage ends.

• Date an individual becomes eligible for HI under either the regular insured or deemed insured provisions.

  NOTE: In the first month of such eligibility, the individual is deemed to have filed an application for entitlement to HI only under the applicable provision.

B. POLICY - VOLUNTARY TERMINATION

To terminate Premium-HI, an individual must complete an CMS-1763 (Request for Termination of Premium Hospital and/or Supplementary Medical Insurance). The HI enrollee must specify whether he or she wishes to terminate only Premium-HI or both Premium-HI and SMI.

Generally, the same considerations and limitations that apply to requests for termination of SMI also apply to Premium-HI (see HI 00820.045 - HI 00820.070).

NOTE: An individual covered for Premium-HI under a State buy-in agreement as a QMB may not voluntarily terminate his or her coverage.

C. PROCEDURE - FO

If only Premium-HI is being terminated, give or send the enrollee a completed CMS-L458 (Acknowledgment of Request for Premium Hospital Insurance Termination).

If an individual indicates that he or she wishes to terminate Premium-HI solely because of inability to pay the Part A premium, be sure to discuss with the individual the requirement that States pay Medicare premium, deductible and coinsurance amounts for “qualified Medicare beneficiaries (QMB)” under their Medicaid programs. Refer interested individuals to the State or local Medicaid agency to file for QMB status.

NOTE: QMBs are individuals entitled to HI (including Premium-HI)  whose income does not exceed 100% of the Federal poverty guidelines and whose resources do not exceed twice the SSI resource limit.

D. EXAMPLE

Mrs. Leroy was entitled to Premium-HI beginning 9/87. She died in 5/90 and, in connection with an LSDP claim filed on her SSN, it was established that she became eligible for RIB in 2/89, but had never filed an application. She is deemed to have filed an application for HI in 2/89. Thus, her Premium-HI entitlement ended with 1/89 and the premiums she paid for months thereafter are excess premiums which may be paid (or added to survivor benefits). Monthly benefits are not payable since no valid application was filed.

E. REFERENCE

Age 115 Termination, SM 03020.380