TN 22 (05-95)

GN 00303.800 Eligibility Under the HI/SMI Program for Uninsured Individuals

Citations:

Social Security Act, Sections 1818 and 1836;

42 C.F.R. 406.11, 406.20, 407.10-407.25.

A. Policy - Uninsured HI/SMI Eligibility

1. Definition - U.S.

“U.S. Under HI/SMI Program for Uninsured Persons” is defined as the 50 States, District of Columbia, Commonwealth of Puerto Rico, the Northern Mariana Islands, Virgin Islands of the U.S., Guam and American Samoa (including Swain's Island).

2. Requirements Uninsured HI/SMI Eligibility

To be eligible for uninsured HI/SMI or for deemed insured HI, an individual must be a U.S. resident and either a U.S. citizen or a LAPR who has continuously resided in the U.S. for the 5 years immediately before the first month of eligibility.

A beneficiary can become eligible for insured HI/SMI before the 5-year residency requirement is met because of a change in status under the law. For example, eligibility for spouse's benefits can be established after one year of marriage to an insured number holder.

REMEMBER: End-stage-renal disease HI (R-HI) has no residency, citizenship or alien status requirements. (See HI 00801.201 for insured status requirements which must be met.) (See GN 00303.300 for determining and documenting U.S. citizenship.) (See HI 00801.006 for HI regular insured status requirements and HI 00801.201 for R-HI insured status requirements.)

3. LAPR Status

Follow GN 00303.610 to GN 00303.640 to verify all immigration documents submitted to establish LAPR status.

When the individual attains age 65 before acquiring LAPR status, the first month of eligibility cannot be earlier than the month in which LAPR status is acquired. The ADM/ADJ DATE field on the I-551 identifies the date the alien was admitted for permanent residence.

If the I-551 does not have an entry in the ADM/ADJ date field or if the I-151 does not show a date of entry, contact DHS to determine the date.

(See GN 00303.440 for determining and documenting LAPR status.)

CAUTION: While other sources can be used to determine an alien's date of entry to the U.S., only DHS can provide the beginning LAPR date or date of adjustment in status.

4. 5-Year U.S. Residency

In addition to establishing U.S. residency, the alien must have continuously resided in the U.S. for the 5-year period immediately preceding the month of effective enrollment (or effective filing for deemed HI). The alien need not have had LAPR status during this 5-year period.

The 5-year period of U.S. residency begins the day the NH arrives in the U.S. with the intention of establishing a home. Arrival as a visitor or tourist does not begin a period of residence.

REMINDER: The period of residence continues so long as the NH continues to maintain a U.S. residence, and is physically present for a significant part of the 5-year period. (See GN 00303.740 for procedure on establishing U.S. residency.)

B. Procedure - Establishing 5-Year U.S. Residency

The ADM/ADJ field and date of entry on the I-551 generally reflect the alien's lawful date of entry to the U.S. Follow the procedure below to establish the 5-year U.S. residency requirement.

NOTE: The claimant does not need to be in LAPR status for the entire 5 years immediately before the first month of eligibility. The claimant just needs to establish continuous residency in the U.S. for the 5 years immediately before the first month of eligibility.

1. ADM/ADJ Date or Entry Date 5 Years Earlier

If the date of entry on the I-551 is at least 5 years earlier than the first month of eligibility, use the date shown as the date of entry to the U.S.

2. No Date of Entry Shown

  1. If the I-151 does not show the date of entry into the U.S., generally accept the residency statements on the application for Hospital or Medical Insurance.

  2. If there is evidence to the contrary or if the residency statements for the current claim do not agree with either the residency statements or date of entry to the U.S. allegation in a prior claim, request evidence of the date of entry to the U.S.

3. ADM/ADJ Date or Entry Date Less Than 5 Years

Under certain circumstances the alien may have entered the U.S. in refugee or some other status before acquiring LAPR status.

  1. If the I-551 shows an ADM/ADJ date or the I-151 shows a date of entry which is not 5 years earlier than the first month of eligibility and the individual alleges an earlier date of entry by which the 5-year U.S. residency period would