TN 9 (06-92)

A. Procedure - Written Requests

1. Different Types of Requests

Differentiate among the three types of written termination requests:

• a clear request to terminate, indicating that the enrollee either does not want an interview or, after the interview, still wants to terminate enrollment,

• a clear request to terminate without indication that the enrollee would object to an interview, and

• an ambiguous request which requires the enrollee's signature to an unequivocal statement.

2. Interview Is Desirable

For the latter two situations, arrange an interview, if possible. Do not imply that the interview is required, but stress that we want to be sure that he or she is fully aware of the effect of the termination, particularly because of the short time-frame for a change of mind before the termination of SMI is effective.

3. Interview Is Required

If the request is so ambiguous that it is not certain that the enrollee wishes to terminate SMI, notify the individual that the request cannot be honored unless he or she submits an unequivocal signed statement, preferably on a CMS-1763 (Request for Termination of Premium Hospital and/ or Supplementary Medical Insurance).

4. Forward Termination Request to PSC

(Hold the termination request while trying to arrange for the interview.)

Forward the request to the appropriate PSC when the earliest of the following occurs:

• You determine no interview is wanted.

• After the interview is conducted.

• The request for termination is cancelled.

• The beginning of the last month of coverage.

5. Acknowledge Receipt of Termination Request

Unless the beneficiary cancels the request for termination, give or send him or her a completed form CMS-L457 (Acknowledgement of Request for Medical Insurance Termination).

Put a note in the file that you are sending to the PSC that you furnished the CMS-L457 to the beneficiary.

6. Date Stamp

Make sure that all requests for termination and cancellations of such requests are date-stamped. Also, attach the envelope if the mailing date is going to be used for effectuation.

B. Procedure - Personal Interview

1. Termination Request

Follow the interview guides in HI 00820.060 and HI 00820.065. If the enrollee still wants to terminate SMI, ask him or her to complete a CMS-1763. Verify the SMI Medicare Number with the enrollee's HI card or other document, or with FO records.

Write the date of the interview in the space provided in the upper right hand corner of the CMS-1763. If the date of any earlier written request is material to the effective date of termination, note this in red in the “date filed” block, and attach the earlier request to the form.

Make sure the enrollee explains why he wishes to terminate SMI in specific, not general, terms.

2. Medicare Card

Do not annotate the Medicare card about termination of SMI. If the enrollee has HI as well as SMI, a new Medicare card will be received showing HI only. Tell him or her to destroy the old card when the new one is received. If the enrollee has only SMI, ask him or her to send the Medicare card to the FO to be destroyed when coverage ends.

3. CMS-L457

Give the enrollee a completed CMS-L457 at the end of the interview. If you do not give the CMS-L457 to the enrollee, mail it to him or her. If you were unable to conduct an interview, send the CMS-L457 to the enrollee before forwarding the termination request to the PSC. Advise the PSC that attempts to arrange an interview were unsuccessful, but that you did send the CMS-L457.

4. Enrollee Wants to Keep SMI

If the enroll decides to continue SMI, have him or her sign a statement to that effect. Attach it to the termination request, date stamp both, and forward them to the PSC.

C. References

• Interviewing guides, HI 00820.060 and HI 00820.065.

• Exhibit of CMS-1763, HI 00820.901.

• Exhibit of CMS-L457, HI 00820.902.

• Information on the effect of mailing dates, HI 00805.130.

• Processing Supplementary Medical Insurance (SMI) Withdrawals via Post Entitlement Online System (POS), SM 03040.090.