DI 28075.635 Premium Medicare for the Working Disabled
Social Security Act as Amended in 1989 and l990 - Sec. 1818A
P. L. 101-239, Enacted 12/19/89 -
Sec. 6012; P. L. 101-508,
Enacted 11/5 /90 - Sec. 4008 (m)(3)(C).
A. Policy - general
Section 1818A, established by Section 6012 of P.L 101-239, provides that disabled individuals who lose or have lost Medicare coverage solely due to their earnings from substantial gainful activity (SGA) may enroll in Medicare Part A Premium-Hospital Insurance (HI) when their premium-free HI ends. To be eligible for Premium-HI under this section, the individual must continue to have a disabling impairment. He or she must also apply for coverage during a proper enrollment period. These individuals may enroll in Medicare Part B Supplementary Medical Insurance because they are entitled to Part A. The first possible month of entitlement to Premium-HI for the Working Disabled is July 1990.
The Office of Disability and International Operations (ODIO) and the Program Service Centers (PSCs) review the claims folders of individuals who apply for coverage to verify that they meet the requirements for entitlement to Premium-HI (i.e., SGA cessation, timely enrollment, current disability). ODIO and the PSC prepare determinations on an SSA-831-U3.
Any case in which ODIO or the PSC cannot determine whether the individual continues to have a disabling impairment is sent to the DDS for a continuing disability review (CDR). The DDS prepares determinations on an SSA-833-U3.
The following process applies to potential Premium-HI enrollees:
Central Office, on an ongoing basis, identifies individuals who might be covered by the provisions of the law.
Individuals who are identified receive a notice advising them to contact their local field office (FO) if they believe they will benefit from the provisions of the law.
2. FO contact
Individuals who contact the FO file an HCFA-18 (Health Insurance application), and complete an SSA-454-BK, as well as SSA-827s or other local State medical releases. This package of materials is forwarded to ODIO or the PSCs.
3. Screening for Timely Enrollment
ODIO and the PSCs screen folders to verify whether the individual filed within the proper enrollment period. Individuals who do not meet this requirement receive a disallowance notice that explains the appropriate requirements.
4. Screening for SGA Cessation
For those individuals who are within the appropriate enrollment period, ODIO/ PSC screen folders to verify that disability was ceased due to SGA. If the cessation was for some other reason, ODIO/PSC prepares and releases a disallowance notice to that effect.
5. Screening for Current Disability
If the cessation was due to SGA, ODIO/PSC review the current SSA-454-BK (and any other evidence that was forwarded with it) to determine whether the individual may be assumed to still be under a disability. If ODIO/PSC is able to find the individual currently disabled after this medical folder review, a Medicare award notice is sent and enrollment action taken.
6. Request for Medical Evidence of Record (MER)
If the information in file does not permit ODIO/PSC to find that the individual is currently disabled, ODIO/PSC request medical evidence of record (MER) directly from the medical sources. If this evidence permits ODIO /PSC to find that the individual is currently disabled, a Medicare award notice is sent and enrollment action taken.
7. CDR necessary
If the MER does not permit ODIO/PSC to find that the individual is currently disabled, the folder is forwarded to the DDS for a CDR. The DDS conducts the CDR, and prepares a continuance or cessation determination following instructions in D. below.
NOTE: ODIO/PSC process a temporary award of Medicare coverage pending the outcome of the DDS review. The individual is notified to this effect.
C. Policy - evaluating current disability
The following policy applies when evaluating current disability:
1. Applicable Standard
Current disability is evaluated following the Medical Improvement Review Standard (MIRS) as described in DI 28005.000ff. However, the individual's work activity must not be considered in determining whether the individual continues to be disabled for purposes of Premium-HI. This means that:
the first step of the CDR sequential evaluation process for these cases considers whether the individual meets or equals listings severity, not whether the individual is engaging in SGA;
the SGA exception to the MIRS is not to be considered in the sequential evaluation process; and
the work that caused the individual to be ceased, as well as any subsequent work, cannot be considered “past work” for purposes of medical/ vocational evaluation (i.e., step 7 of the current CDR sequential evaluation process).
2. Disabling Impairment
The individual must continue to be under a disability. This means that an impairment of disabling severity must have existed from the time of the SGA cessation to the present. For purposes of this review, the DDS assumes that the impairment was continuously disabling, in the absence of evidence to the contrary, if the available evidence indicates a disabling impairment both at the time of the SGA cessation and at present.
Follow the instruction below in the completion of disability determinations:
Complete a current disability determination as follows:
Obtain MER from any source that has not already submitted it.
If MER is not sufficient to make a determination about continuing disability, purchase a consultative examination (CE).
Follow sequential evaluation process as defined in C. above.
Prepare a continuance or cessation determination on an SSA-833-U3, completing the following items:
Items 1A, 1B, 2, 3, 4, 7 (DDS Code), and 8.
Item 9 (Impairment severity) - Cross out “EPE,” enter “Section 6012,” and check A or B.
Items 10A, 11, 12, 13, 14, 20 (Enter “21”), 21, 22, 23 (if determination is continuance).
Item 24 - Enter one of the following remarks according to the action taken.
Items 25, 26, 27, 28, 29, and 35.
4. Personalized notice
Prepare a rationale, if appropriate, on an SSA-4268-U4 following usual instructions. Do not take further notice action. (ODIO/PSC will incorporate language from the SSA-4268-U4 in the notice.)
Forward folder to ODIO or PSC.