TN 14 (08-92)

DI 40510.140 Premium Medicare for the Working Disabled - General

Citations:

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. Introduction

This subchapter provides the Office of Disability and International Operations (ODIO) and the Program Service Centers (PSCs) with instructions on how to process those cases where  an individual has filed for Premium Medicare for the Working Disabled.

B. Policy -- General

Section 1818A of the Social Security Act, established by Section 6012 of P. L. 101-239, provides that disabled individuals who lose Medicare coverage solely because of substantial gainful work 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. These individuals may also enroll in Medicare Part B, Supplementary Medical Insurance (SMI) because they are entitled to Part A. In addition, the application for Premium-HI must be filed during an appropriate enrollment period. This provision also applies to individuals who lost premium-free HI prior to enactment of P.L. 101-239, provided their disabling impairment continues.

C. Policy -- Entitlement

1. Month of entitlement

The first possible month of entitlement to Premium-HI for the Working Disabled is July l990.

2. Cessation based on work

The period of disability must have ended because of substantial gainful activity (SGA) rather than medical improvement, regardless of whether the individual was eligible for an extended period of eligibility (EPE) and extended Medicare coverage. The provision applies to DIB, DWB, CDB and MQGE cases.

3. Disabling impairment

To be entitled to Premium Medicare the individual must continue to have a disabling mental or physical impairment.

4. Enrollment

The field office (FO) obtains an HCFA-18, an SSA-454-BK and SSA-827s or local State medical releases from the individual at the time of enrollment. Refer to HI 00801.170C. for detailed information on FO enrollment procedures, effective date of coverage, etc.

For purposes of enrollment in Premium-HI, the individual is “deemed disabled” prior to verification of continuing disability, provided that a review of the claim folder shows that SGA was the basis for the cessation.

Enrollment must not be delayed pending verification of continuing disability, per DI 40510.150B. and DI 40510.155.

5. New claim filed

If an individual entitled to Premium-HI stops working and files a new claim for benefits, the claim is subject to normal FO development and requires an initial DDS disability determination (DI 11005.001 and DI 20101.001.). GLPSC-DRS is responsible for processing railroad cases.

D. Process

Claims are processed as follows:

  • First, the folders are reviewed to determine whether the individual filed in a proper enrollment period.

  • Disability examiners (DEs) then review the claims folders to verify that benefits were ceased because of work activity.

  • Next, the DEs determine whether or not the individual continues to have a disabling impairment, using the updated SSA-454-BK information along with evidence already in the claim folder.

  • If the individual cannot be found currently disabled, the DE initiates a continuing disability review (CDR).

  • Any case in which medical improvement is likely, or  in which the original impairment is no longer disabling but a new impairment has been alleged is forwarded to the disability determination service (DDS) for a decision.

  • An interim award is prepared and notice sent to the individual before the case goes to the DDS.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0440510140