TN 20 (09-90)

DI 28055.001 Extended Period of Eligibility (EPE) and Related Medicare Provisions - General

Citations:

Social Security Act--Sections 202(d)(1), 202(e)(1), 202(f)(1), and 223(a)(1);

20 CFR 404.316, 404.321, 404.325, 404.337, 404.352, 404.1511, and 404.1592a.

A. Policy - EPE

1. General

This 1980 amendment permits the reinstatement of payments to a person whose disability previously ceased due to SGA, for any month(s) his or her earnings fall below SGA within a specific period.  During this period, a new application, Disability Determination Services (DDS) determination, or waiting period is not required to have benefits reinstated. Payments are withheld for month(s) of SGA earnings.

The reinstatement period, plus any subsequent month(s) of payment up to the benefit termination month (BTM) is called the extended period of eligibility (EPE). (See DI 28055.005A.2. for a description of the reinstatement period and the BTM.)

2. Who Is Entitled to An EPE

An individual who completes a 9-month trial work period (TWP) and continues to have a disabling impairment is entitled to an EPE. (See DI 28050.001 for who is not entitled to a TWP, and, therefore, is not entitled to an EPE.)

3. The 15-Month Reinstatement Period

The 15-month reinstatement period is effective December 1980 for individuals whose disability had not ceased as of December 1980 and applies to:

  1. Title II (Disability Insurance)

  2. Title XVI (Supplemental Security Income)-Through June 30, 1987. Effective July 1, 1987, the TWP and EPE provisions no longer apply. (See DI 28075.600.)

  3. Title XVIII (Medicare Coverage)-Claims in which disability is
    established for Medicare purposes such as Medicare Only-Disabled Widows Benefit (DWB) and Medicare For Qualified Government Employment ( MQGE) claims.

4. The 36-Month Reinstatement Period

The 36-month reinstatement period is effective January 1988 (based on 1987 Amendments) and applies to title II and title XVIII disabled persons described in A.2. above who are entitled to benefits:

  • for any month after December 1987, or

  • before January 1988 and whose EPE under the prior law had not elapsed as of January 1988,i.e., a BTM of February 1988 or later.

B. Policy - Extended Medicare Eligibility

Extended Medicare coverage, effective October 2000 provides 78 months of extended Medicare eligibility to persons whose disability ceased due to SGA and continue to have a disabling impairment.

Counting the first 15 months of the EPE, this provision allows for continued premium-free hospital insurance (HI), and supplemental medical insurance, for at least 93 months after the TWP. (In extending the reinstatement period from 15 to 36 months, Congress stipulated that, for Medicare purposes, we must treat the reinstatement period as though it was still 15 months. That is, the beginning date of extended Medicare coverage did not change along with the lengthening of the reinstatement period. As a result, the start of the Medicare extension often occurs before the BTM). Generally, coverage ends 78 months after the first month of SGA occuring after the 15th month of the EPE, but never before the BTM.

The policies and procedures for determining whether a person continues to have a disabling impairment for Medicare purposes are essentially the same