TN 20 (09-90)
DI 28055.001 Extended Period of Eligibility (EPE) and Related Medicare Provisions - General
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
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:
Title II (Disability Insurance)
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.)
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 as for EPE cases.
C. Policy - Medicare Buy-In for the Working Disabled
Effective July 1990, the Medicare buy-in provision allows the working disabled to purchase premium-HI Medicare coverage (during specified enrollment periods) after premium-free Medicare coverage ends. The state Medicaid program may pay the HI premiums for certain disabled workers with low income. Coverage ends with the earlier of medical recovery, a request for termination of coverage, or reentitlement to premium-free HI.
The first month no benefits are payable after the EPE. (Also referred to as the “disability benefit cessation” (DBC) date.)
2. Currently Disabled
Office of Disability and International Operations/Program Service Center-Disability Review Section (ODIO/PSC-DRS) decision that a person has a disabling impairment based on established review criteria.
3. Disabling Impairment
Requirement for entitlement to an EPE and extended Medicare eligibility.
Extended Period of Eligibility--the period beginning immediately following completion of the TWP and running up to the BTM.
5. EPE Medical Folder Review
A review usually performed just before or at the start of a person's EPE.
6. Extended Medicare Eligibility
Seventy-eight months of extended Medicare coverage which results in at least 93 months of continued coverage after the TWP is completed.
7. Impairment Severity
Medical Determination after disability ceased for SGA during the EPE.
8. Reinstatement Period
The 15 or 36-month period immediately following the TWP during which payments can be restarted if work is not at the SGA level. No new application, disability determination or waiting period is required during this period.
9. EPE Reinstatement
Resumption of cash benefits during the EPE.
10. EPE Suspension
Nonpayment of cash benefits during the EPE.
11. Medicare for the Working Disabled
Premium HI coverage for the working disabled after lose of premium-free coverage.