A POD participant in treatment group 2 who has their SSDI benefit reduced to zero
for 12 consecutive months will have their SSDI entitlement terminated. If the participant
is entitled to Medicare and has entitlement terminated due to 12 consecutive months
of zero benefit, the POD will provide 93 months of EPMC from the month of termination
as long as the participant continues to have the same disabling impairment(s) that
provided the basis for the prior SSDI entitlement and meets the other SSDI entitlement
requirements. The automatic 93 months of EPMC applies only to participants who terminate
due to POD offset rules.
To calculate the Medicare end date for a beneficiary that completes POD participation
and terminates under regular SSDI SGA rules, follow these steps:
determine the POD start date;
determine the date of the last work CDR decision prior to the POD start date;
determine the POD end date;
use steps outlined in HI 00820.025A.4 to determine the Medicare end date; and
exclude all months from the date of the last work CDR decision to the POD end date
in the EPMC calculation.
DIB LINE information provided for termination:
DDO-05/11/2010 DIG-3890 DIB DOED-11/2010 MEDICARE DOED-11/2010 ADC-04/16 CDR-E DBC-10/2021
According to the HISTDEMO on the Master Beneficiary Record (MBR), John Doe participated
in the POD from 01/2018 to 06/2021. The last work CDR decision prior to the start
of his POD participation was 05/10/2017. In 10/2023, a post-POD work CDR was completed
and it determined that his benefits terminate 08/2023 due to SGA.
According to the DIB LINE on the MBR, John Doe's extended period of eligibility (EPE)
begin date (EBD) is 04/2016. His cessation date (ADC) is also 04/2016, which is prior
to the 14th month of the EPE. To determine his Medicare end date, we must determine if he worked
in the 16th month of the EPE.
Since the POD does not evaluate the period from John Doe’s pre-POD work CDR to the
end of POD participation under regular SGA rules, the period from 06/2017 to 06/2021
does not apply when calculating the Medicare end date.
To determine the 16th month of the EPE, count from the first month of the EPE through the month of the
last work CDR decision prior to POD. That is 04/2016 to 05/2017, which is 14 months.
Then, exclude the period starting 06/2017 through 06/2021. Begin counting the EPE
again starting the month after POD participation ends. The 16th month of the EPE is 08/2021.
Use HI 00820.025A.4 to determine the Medicare end date. If John Doe worked above SGA in the 16th month of the EPE (08/2021), his Medicare ends the last day of the 57th month (01/2028) following the end of the 36-month EPE (04/2023). If he did not work
above SGA in the 16th month of his EPE (08/2021), Medicare ends the last day of the 77th month following the first month SGA occurs.