When the Contractor Does Not Take Recovery Action in Beneficiary

110.10 - When the Contractor Does Not Take Recovery Action in Beneficiary Cases but Considers Whether Waiver of Recovery is Applicable (Rev. 13183; Issued: 04-24-25; Effective: 05-27-25; Implementation: 05-27-25) The contractor shall consider whether waiver of recovery from the beneficiary is applicable. If the beneficiary is liable and the criteria for waiver of recovery from the beneficiary are likely to be met, i.e., it appears from the circumstances that the beneficiary was without fault and that recovery is against equity and good conscience or defeats the purpose of the Medicare program (i.e., would cause the individual financial hardship), the contractor makes a waiver determination. The contractor shall first determine if the beneficiary was without fault see §70.3. If it appears that the beneficiary was without fault the contractor shall then determine if recovery would be against equity and good conscience or if recovery would defeat the purpose of title II or title XVIII of the Social Security Act. • For recovery to be against equity and good conscience an individual must have changed his or her position for the worse or relinquished a valuable right because of reliance upon a notice that a payment would be made or because of the overpayment itself. (See 20 CFR §404.509) • For recovery to defeat the purpose of title II or title XVIII of the Social Security Act the beneficiary must need all his or her current income to meet ordinary and necessary living expenses. (See 20 CFR §405.508) The contractor shall make waiver of recovery determinations for individual non-MSP overpayments up to $20,000. If an individual non-MSP overpayment is greater than $20,000, and the contractor believes that the waiver of recovery is appropriate the contractor shall make a recommendation to the regional office for approval to waive the recovery. If there is a situation that involves several beneficiaries where the aggregate total of all waiver determinations exceeds $40,000, the regional office shall be notified. The regional office shall provide guidance as to who shall approve the waiver of recovery determinations. If the contractor decides that the information available does not justify waiver, it proceeds with normal recovery efforts from the beneficiary. NOTE: If a beneficiary requests an appeal or a waiver after the overpayment has been referred to the SSA for collection from Title II benefits, the SSA processing center will return the overpayment to the Medicare contractor to review the waiver and/or appeal.