(c) No basis for reinstating coverage. Coverage may not be reinstated if the enrollee

(1) Received timely and adequate notice but failed to pay within the grace period, for example because of insufficient income or resources; or

(2) Appealed the termination more than one month after the month in which SSA sent the termination notice.

§ 408.104 Reinstatement procedures.

(a) Request for payment. If the conditions of § 408.102(a) (1) and (2) are met, SSA sends written notice requesting the enrollee to pay, within 30 days, all premiums due through the month in which the enrollee appealed the termination.

(b) Reinstatement of coverage. If SSA receives the requested payment within 30 days, it sets aside the termination and reinstates the enrollee's coverage without interruption.

Subpart G-Collection of Unpaid Premiums; Refund of Excess Premiums After the Death of the Enrollee

8 408.110 Collection of unpaid premiums.

(a) Basis and scope-(1) Basis. Under the Federal Claims Collection Act of 1966 (31 U.S.C. 3711), HCFA is required to collect any debts due it but is authorized to suspend or terminate collection action on debts of less than $20,000 when certain conditions are met. (See 4 CFR, parts 101-105 for general rules implementing the Federal Claims Collection Act.) As indicated in § 408.4, unpaid premiums are debts owed the Federal government by the enrollee or the enrollee's estate.

(2) Scope. This section sets forth the methods of collection used by HCFA and the circumstances under which HCFA terminates or renews collection action. The regulations in this section apply to hospital insurance premiums as well as SMI premiums.

(b) Collection of unpaid premiums. Generally, HCFA will attempt to collect unpaid premiums by one of the following methods:

(1) By billing enrollees who pay the premiums directly to HCFA or to a

designated agent in accordance with § 408.60.

(2) By deduction from any benefits payable to the enrollee or the estate of a deceased enrollee under Title II or XVIII of the Social Security Act, the Railroad Retirement Act or any act administered by the Office of Personnel Management in accordance with § 408.4(b) and Subpart C of this part (Deduction from Monthly Benefits);

or

(3) By billing the estate of a deceased enrollee.

(c) Termination of collection action. HCFA terminates collection action on unpaid premiums under either of the following circumstances, if the cost of collection exceeds the amount of overdue premiums:

(1) The individual is not entitled to benefits under the Acts listed in paragraph (b)(2) of this section, is not currently enrolled for SMI or premium hospital insurance, and demonstrates, to HCFA's satisfaction, that he or she is unable to pay the debt within a reasonable time.

(2) The individual has been dead more than 27 months (the maximum time allowed for claiming SMI benefits), and the legal representative of his or her estate demonstrates, to HCFA's satisfaction, that the estate is unable to pay the debt within a reasonable time.

(d) Renewal of collection efforts. HCFA renews collection efforts in either of the following circumstances, if the cost of collection does not exceed the amount of the overdue premiums:

(1) The individual enrolls again for premium hospital insurance or SMI. (Payment of overdue premiums is not a prerequisite for reenrollment.)

(2) The individual becomes entitled or reentitled to social security or railroad retirement benefits or a Federal civil service annuity.

§ 408.112 Refund of excess premiums after the enrollee dies.

If HCFA has received premiums for months after the enrollee's death, HCFA refunds those premiums as follows:

(a) To the person or persons who paid the premiums or, if the premiums were paid by the enrollee, to the representative of the enrollee's estate, if any.

(b) If refund cannot be made under paragraph (a) of this section, HCFA refunds the premiums to the enrollee's survivors in the following order of priority:

(1) The surviving spouse, if he or she was either living in the same household with the deceased at the time of death, or was, for the month of death, entitled to monthly social security or railroad retirement benefits on the basis of the same earnings record as the deceased beneficiary;

(2) The child or children who were, for the month of death, entitled to monthly social security or railroad retirement benefits on the basis of the same earnings record as the deceased (and, if there is more than one child, in equal parts to each child);

(3) The parent or parents who were, for the month of death, entitled to monthly social security or railroad retirement benefits on the basis of the same earnings record as the deceased (and, if there is more than one parent, in equal parts to each parent);

(4) The surviving spouse who was not living in the same household with the deceased at the time of death and was not, for the month of death, entitled to monthly social security or railroad retirement benefits on the basis of the same earnings record as the deceased beneficiary;

(5) The child or children who were not entitled to monthly social security or railroad retirement benefits on the basis of the same earnings record as the deceased (and, if there is more than one child, in equal parts to each child);

(6) The parent or parents who were not entitled to monthly social security or railroad retirement benefits on the basis of the same earnings record as the deceased (and, if there is more than one parent, in equal parts to each parent).

If none of the listed relatives survives, no refund can be made.

Sec.

409.42 Requirements and conditions for home health services.

409.43 Home health service visit.. 409.44 Home health services under Medi

care Part B.

409.46 Coinsurance for durable medical equipment (DME) furnished as a home health service.

Subpart F-Scope of Hospital Insurance
Benefits

409.60 Benefit periods.

409.61 General limitations on amounts of benefits.

409.62 Lifetime maximum on inpatient psychiatric care.

409.63 Reduction of inpatient psychiatric benefit days available in the initial benefit period.

409.64 Services that are counted toward allowable amounts.

409.65 Lifetime reserve days. 409.66

Revocation of election not to use lifetime reserve days.

409.68 Guarantee of payment for inpatient hospital services furnished before notification of exhaustion of benefits.

Subpart G-Hospital Insurance Deductibles and Coinsurance

409.80 Inpatient deductibles and coinsurance: General provisions

409.82 Inpatient hospital deductible. 409.83 Inpatient hospital coinsurance. 409.85 Skilled nursing facility (SNF) care coinsurance.

409.87 Blood deductible.

409.89 Exemption of kidney donors from deductible and coinsurance requirements.

Subpart H-Payments of Hospital Insurance Benefits

409.100 To whom payment is made. 409.102 Amounts of payment.

AUTHORITY: Secs. 1102, 1812, 1813, 1861, 1862(h), 1871, and 1881 of the Social Security Act (42 U.S.C. 1302, 1395d, 1395e, 1395x, 1395y(h), 1395hh, and 1395rr).

SOURCE: 48 FR 12541, Mar. 25, 1983, unless otherwise noted.

Subpart A-Hospital Insurance
Benefits: General Provisions

§ 409.1 Statutory basis.

Sections 1812 and 1813 of the Social Security Act establish the scope of benefits of the hospital insurance program under Medicare Part A and set

forth the deductible and coinsurance requirements.

§ 409.2 Scope.

Subparts A through G of this part describe the benefits available under Medicare Part A and set forth the limitations on those benefits, including certain amounts of payment for which beneficiaries are responsible.

[48 FR 12541, Mar. 25, 1983, as amended at 50 FR 33033, Aug. 16, 1985]

§ 409.3 Definitions.

As used in this part, unless the context indicates otherwise

Arrangements means arrangements which provide that Medicare payment made to the provider that arranged for the services discharges the liability of the beneficiary or any other person to pay for those services.

Covered refers to services for which the law and the regulations authorize Medicare payment.

Nominal charge provider means a provider that furnishes services free of charge or at a nominal charge and is either a public provider, or another provider that (1) demonstrates to HCFA's satisfaction that a significant portion of its patients are low-income, and (2) requests that payment for its services be determined accordingly.

Participating refers to a hospital or other facility that meets the conditions of participation and has in effect a Medicare provider agreement.

Qualified hospital means a facility that

(a) Is primarily engaged in providing, by or under the supervision of doctors of medicine or osteopathy, inpatient services for the diagnosis, treatment, and care or rehabilitation of persons who are sick, injured, or disabled;

(b) Is not primarily engaged in providing skilled nursing care and related services for inpatients who require medical or nursing care;

(c) Provides 24-hour nursing service in accordance with Sec. 1861(e)(5) of the Act;

(d) If it is a U.S. hospital, is licensed, or approved as meeting the standards for licensing, by the State or local licensing agency; and

(a) To the person or persons who paid the premiums or, if the premiums were paid by the enrollee, to the representative of the enrollee's estate, if

any.

(b) If refund cannot be made under paragraph (a) of this section, HCFA refunds the premiums to the enrollee's survivors in the following order of priority:

(1) The surviving spouse, if he or she was either living in the same household with the deceased at the time of death, or was, for the month of death, entitled to monthly social security or railroad retirement benefits on the basis of the same earnings record as the deceased beneficiary;

(2) The child or children who were, for the month of death, entitled to monthly social security or railroad retirement benefits on the basis of the same earnings record as the deceased (and, if there is more than one child, in equal parts to each child);

(3) The parent or parents who were, for the month of death, entitled to monthly social security or railroad retirement benefits on the basis of the same earnings record as the deceased (and, if there is more than one parent, in equal parts to each parent);

(4) The surviving spouse who was not living in the same household with the deceased at the time of death and was not, for the month of death, entitled to monthly social security or railroad retirement benefits on the basis of the same earnings record as the deceased beneficiary;

(5) The child or children who were not entitled to monthly social security or railroad retirement benefits on the basis of the same earnings record as the deceased (and, if there is more than one child, in equal parts to each child);

(6) The parent or parents who were not entitled to monthly social security or railroad retirement benefits on the basis of the same earnings record as the deceased (and, if there is more than one parent, in equal parts to each parent).

If none of the listed relatives survives, no refund can be made.

Sec.

409.42 Requirements and conditions for home health services.

409.43 Home health service visit.. 409.44 Home health services under Medi

care Part B.

409.46 Coinsurance for durable medical equipment (DME) furnished as a home health service.

Subpart F-Scope of Hospital Insurance Benefits

409.60 Benefit periods.

409.61 General limitations on amounts of

benefits.

409.62 Lifetime maximum on inpatient psychiatric care.

409.63 Reduction of inpatient psychiatric benefit days available in the initial benefit period.

409.64 Services that are counted toward allowable amounts.

409.65 Lifetime reserve days.

409.66 Revocation of election not to use lifetime reserve days.

409.68 Guarantee of payment for inpatient hospital services furnished before notification of exhaustion of benefits.

Subpart G-Hospital Insurance Deductibles and Coinsurance

409.80 Inpatient deductibles and coinsurance: General provisions

409.82 Inpatient hospital deductible. 409.83 Inpatient hospital coinsurance. 409.85 Skilled nursing facility (SNF) care coinsurance.

409.87 Blood deductible.

409.89 Exemption of kidney donors from deductible and coinsurance requirements.

Subpart H-Payments of Hospital Insurance Benefits

409.100 To whom payment is made. 409.102 Amounts of payment.

AUTHORITY: Secs. 1102, 1812, 1813, 1861, 1862(h), 1871, and 1881 of the Social Security Act (42 U.S.C. 1302, 1395d, 1395e, 1395x, 1395y(h), 1395hh, and 1395rr).

SOURCE: 48 FR 12541, Mar. 25, 1983, unless otherwise noted.

Subpart A-Hospital Insurance Benefits: General Provisions

8 409.1 Statutory basis.

Sections 1812 and 1813 of the Social Security Act establish the scope of benefits of the hospital insurance program under Medicare Part A and set

forth the deductible and coinsurance requirements.

§ 409.2 Scope.

Subparts A through G of this part describe the benefits available under Medicare Part A and set forth the limitations on those benefits, including certain amounts of payment for which beneficiaries are responsible.

[48 FR 12541, Mar. 25, 1983, as amended at 50 FR 33033, Aug. 16, 1985]

§ 409.3 Definitions.

As used in this part, unless the context indicates otherwise

Arrangements means arrangements which provide that Medicare payment made to the provider that arranged for the services discharges the liability of the beneficiary or any other person to pay for those services.

Covered refers to services for which the law and the regulations authorize Medicare payment.

Nominal charge provider means a provider that furnishes services free of charge or at a nominal charge and is either a public provider, or another provider that (1) demonstrates to HCFA's satisfaction that a significant portion of its patients are low-income, and (2) requests that payment for its services be determined accordingly.

Participating refers to a hospital or other facility that meets the conditions of participation and has in effect a Medicare provider agreement.

Qualified hospital means a facility that

(a) Is primarily engaged in providing, by or under the supervision of doctors of medicine or osteopathy, inpatient services for the diagnosis, treatment, and care or rehabilitation of persons who are sick, injured, or disabled;

(b) Is not primarily engaged in providing skilled nursing care and related services for inpatients who require medical or nursing care;

(c) Provides 24-hour nursing service in accordance with Sec. 1861(e)(5) of the Act;

(d) If it is a U.S. hospital, is licensed, or approved as meeting the standards for licensing, by the State or local licensing agency; and