TN 49 (11-22)
HI 01001.055 Handling Supplementary Medical Insurance (SMI) Claims When Adjudication of Social
Security or Railroad Retirement Claim is Delayed
There will be cases in which a person enrolling under Part B of Title XVIII (Health
Insurance) will also be applying for Social Security benefits under Section 202 of
the Social Security Act or for Railroad Retirement benefits. In many of these cases,
it will be clear that the claimant is entitled to monthly benefits, as well as SMI,
and a determination to this effect may be expected shortly. In these cases, the SMI
enrollment will be processed simultaneously with their monthly benefit claim, and
an enrollee to whom benefits are payable should be told that their premiums will be
deducted from benefits. However, if the enrollee's monthly benefits will be subject
to complete or indefinite suspension, they should be told to make payment upon receipt
of a billing notice.
When the claimant is clearly eligible for SMI but there is any substantial question
as to eligibility for monthly benefits (whether raised initially in the field office
or during subsequent processing of the benefit claims), the SMI enrollment and an
Hospital Insurance claim may have to be processed independently of the monthly benefit
claim provided the claimant is not a qualified railroad annuitant.
If the SMI enrollment is processed independently of the Social Security claim, the
claimant will be treated for SMI premium purposes, in the same manner as a beneficiary
in suspense, pending resolution of the retirement survivor insurance issue.
An award notice (SSA-L31-C1 with special paragraph) will be required. The notice will
inform the claimant of their entitlement to SMI and (if appropriate) HI, and that
their claim for monthly benefits is still pending. The claimant will be notified as
soon as a determination of entitlement is made.
If the monthly claim is denied before the end of the year and the claimant's premiums
are then in arrears, the claimant will be asked to pay all premiums due through the
quarter (or month, for a monthly payer) following the month of the notice. If the
Social Security claim is allowed, the person will be a beneficiary and the rules in
HI 01001.040 and HI 01001.350 will apply.
The rules in this section do not apply to persons claiming only a special age 72 payment.
With regard to these persons, see HI 01001.105.