TN 52 (02-12)

DI 11010.261 Field Office Applying Prior Entitlement Months to the Medicare Waiting Period

Citations:

Public Law 100-203, Section 4033

A. When to apply prior entitlement months to the Medicare waiting period

This section provides field office (FO) processing instructions when a claimant has a prior period of disability entitlement. Prior months of disability benefit entitlement may count towards the 24-month Medicare waiting period for the current entitlement. For details about counting months in reentitlement cases, see HI 00801.152.

B. Review and document the new claim

If a claimant was previously entitled to DIB benefits and files a new claim, determine if the prior period of disability ended more or less than five years ago (seven years for DWB or CDB) before the current potential onset date (POD).

If the prior period ended more than (or close to) five years before the current POD, document the SSA-3367 Disability Report - Field Office with the prior diagnosis code. (See DI 11010.261D.1.). This will alert the DDS to determine if the current impairment is the same as, or directly related to, the prior impairment.

EXAMPLE 1: Claimant’s entitlement terminated 10/2005 due to work. He re-filed 02/2011 because substantial gainful activity (SGA) ended 01/2011. Since there is no possibility of earlier entitlement, we need the DDS to determine if the impairment is the same as, or related to, the prior impairment because it has been more than five years since we terminated benefits.

EXAMPLE 2: Claimant’s entitlement terminated 10/2005 for medical recovery. There is no SGA work since termination. He files again in 02/2009 for a new impairment. If DDS allows his claim, we can count his prior months of entitlement because he became disabled again before five years passed since termination.

EXAMPLE 3: Claimant entitlement terminated 10/2005 due to work. He worked through 10/2009 and had no SGA work after that time. He re-filed in 02/2011 with an alleged onset date (AOD) of 02/2010. Since it is possible that DDS will not find the claimant disabled within five years of the prior termination, we need DDS to document if the impairment is the same, or related to, the prior impairment.

Additional examples are in HI 00801.152C.

C. Onset less than five years (seven years for DWB or CDB) after prior termination

Process the current claim using existing instructions. See MSOM MCS 009.007 to complete the Health Insurance-Supp Medical Insurance (HICL) screen with the prior entitlement information. In order to process these claims using Non-Medical completion (NMC), complete the HICL screen.

D. Onset more than five years (seven years for DWB or CDB) after prior termination

You cannot process these claims via NMC.

1. FO claims processing

  1. Process the current claim using existing instructions.

  2. On the SSA-3367, annotate the Remarks section with:

    • “Medicare Waiting Period Determination Needed;” and

    • Diagnosis Code (DIG) from prior folder, Master Beneficiary Record (MBR), Disability Determination Services Query (DDSQ), or Disability Control File (DCF); and

    • Month of prior termination.

  3. Annotate EDCS (Electronic Disability Collect System) if you are sending a paper folder from a prior filing.

NOTE: If the MBR shows the most recent termination date before March 1, 1988, the procedures in this subsection DO NOT apply.

2. Process the DDS favorable allowance

When DDS returns the case, review Item 34 (Remarks) on the SSA-831, Disability Determination and Transmittal.

a. Fully favorable allowance

If the SSA-831 states: “Count prior months of benefit entitlement toward Medicare waiting period,” this is a fully favorable determination. Then,

  • Process the case via A101 or EF101 per SM 00850.535.

  • Complete the HI/SMI screens per SM 00850.535B.

  • Include the remark “Medicare DIB Re-entitlement Case” on the BCRN (BCF/Remarks/Notice) screen.

  • Route the claims folder to the appropriate processing center for follow-up awards processing.

  • Follow appropriate procedures for processing of the electronic folder.

b. Partially favorable allowance

If the SSA-831 states: “Do not count prio