Effective Dates: 05/29/2024 - Present Previous | Next

TN 74 (05-24)

HI 00801.170 Premium-HI for the Working Disabled

Citations:

ACT as amended—Section 1818A

Regulations—42 CFR 406.20(c)

A. Policy — General

A disabled individual who loses premium-free D-HI solely because the individual is working may enroll in hospital insurance (and medical insurance) by paying monthly premiums as long as continues to have a disabling impairment. This provision is referred to as Premium-HI for the Working Disabled.

Although the first possible month of entitlement to Premium-HI for the Working Disabled is 7/90, any individual who lost premium-free D-HI prior to 7/90 solely because of work and has continuously been under a disabling impairment is eligible to enroll under the provision.

B. Policy — Eligibility requirements

To enroll in Premium-HI for the Working Disabled, an individual must be under age 65, and:

  • •

    have lost entitlement to premium-free D-HI solely because engaging in substantial gainful activity (SGA);

  • •

    continue to have a disabling physical or mental impairment; and

  • •

    be ineligible for HI on any other basis.

An individual may not enroll in SMI under this provision unless one also enrolls in Premium-HI.

NOTE: A re-entitled disability beneficiary who is required to serve a new 24-month D-HI qualifying period and who meets the above requirements is eligible to enroll in Premium-HI for the Working Disabled during a general enrollment period or special enrollment period (see C. below for a discussion of enrollment periods). Premium-HI eligibility continues until the individual becomes re-entitled to D-HI.

C. Policy — Enrollment periods

An individual may enroll in Premium-HI (and SMI) for the Working Disabled during the following enrollment periods:

  • •

    Initial Enrollment Period (IEP): this is the 8-month period beginning with the month an individual is notified about the loss of premium-free HI

  • •

    General Enrollment Period (GEP): GEPs occur during January through March of each year (for 1990, the GEP was extended through 7/2/90)

  • •

    Special Enrollment Period (SEP): SEPs occur as described in HI 00805.265

D. Policy — When coverage begins

1. IEP enrollments

 

If the enrollment is filed: then coverage begins:
before the first month of

Premium-HI eligibility 		the first month of Premium-HI eligibility
during the first month of

Premium-HI eligibility and all remaining months in the IEP 		the first day of the month following the month of enrollment

2. GEP enrollment

Coverage begins the first day of the month following the month of enrollment.

3. SEP enrollment

For a discussion of the SEP provisions, see HI 00805.275.

E. Policy—Premiums

1. General

Individuals who enroll in Premium-HI for the Working Disabled pay the same HI and SMI premium as aged Premium-HI enrollees. For HI premium amounts, see HI 01005.005 and HI 01005.007.

The HI premium for the Working Disabled is not subject to increase for late enrollment. This differs from the rule applicable to individuals who enroll in Premium-HI for the Aged and are subject to a 10 percent increase payable for twice the number of full twelve month periods they could have been but were not enrolled. The SMI premium under the Premium-HI for the Working Disabled provision is subject to increase for late enrollment following normal SMI premium increase rules. No months prior to 7/90 are counted in determining the number of months to assess for SMI premium increase purposes.

If an individual was paying an increased SMI premium during the last month of premium-free HI entitlement, but enrolls for SMI under the Working Disabled provision during IEP, the SMI premium reverts to the standard rate.

States are required to pay HI (but not SMI) premiums for “qualified disabled and working individuals (QDWI).” QDWIs are individuals enrolled in Premium-HI for the Working Disabled who meet the requirements in SI 01715.005. States pay HI premiums through the Part A Group Payer System.

2. Premium reduction

Beginning 1/1/94, a disabled Premium-HI enrollee may qualify for a reduction in the amount of HI premium. A disabled Premium-HI enrollee (including a disabled worker, a disabled surviving spouse or a disabled adult child) is eligible for HI premium reduction if:

  • •

    Has 30 or more QCs on own E/R;

  • •

    Has been married for at least 1 year to a number holder (NH) with 30 or more QCs;

  • •

    Was married for at least 1 year to a deceased NH with 30 or more QCs;

  • •

    Is divorced, after at least 10 years of marriage, from a NH who had acquired 30 or more QCs at the time the divorce became final.

NOTE: Although a disabled adult child can qualify for HI premium reduction based on own earnings or on the earnings of a spouse (including a divorced spouse), a disabled adult child cannot qualify for premium reduction based on the earnings of their parent (including the NH on whose earnings the child's premium-free HI entitlement was based).

F. Examples of HI premium reduction

1. Disabled worker

John lost entitlement to premium-free HI solely because of working. John enrolls in Premium-HI for the Working Disabled during IEP. John has 26 QCs on own record. The spouse, to whom John has been married for 8 years, has 32 QCs. John is eligible for HI premium reduction since John is married to a NH with at least 30 QCs.

2. Disabled adult child

Amy is a disabled adult child who returned to work and lost premium-free HI entitlement. Disability benefit and premium-free HI entitlement was based on the claimant's 67 year old parent's earnings. Amy enrolls for Premium-HI for the Working Disabled during IEP. Amy has 20 QCs on own record. The parents each have more than 40 QCs. Amy is not eligible for HI premium reduction. However, if Amy continues to work and subsequently acquires 30 QCs, will be eligible for HI premium reduction at that time. Also, if marries a NH with 30 or more QCs, will be eligible for HI premium reduction after married to the NH for 1 year.

3. Disabled Surviving Spouse

Tom is a disabled surviving spouse who loses premium-free HI solely because of work. Tom's deceased spouse had a total of 28 QCs. Tom has 31 QCs on own E/ R. Tom is eligible for HI premium reduction.

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0600801170
HI 00801.170 - Premium-HI for the Working Disabled - 05/29/2024
Batch run: 10/10/2024
Rev:05/29/2024