TN 25 (09-93)

HI 00801.161 Medicare Continuation During Appeal of Title II Disability Cessation

A. Policy — General

The law permits a title II disability beneficiary who files an appeal of a medical cessation within 10 days of receipt of the cessation notice to continue receiving disability benefits (DIB, DWB, or CDB) until an ALJ hearing decision.

Under the provision, an individual who was entitled to D-HI prior to the termination may elect to continue his/her Medicare coverage during the appeal period with or without electing continuation of monthly cash benefits.

B. Policy— Effect of benefit continuation on medicare

1. Title II election

If an individual elects resumption of title II benefits during appeal, D-HI is affected as follows:

  • If D-HI was awarded prior to the termination date required by the disability cessation, D-HI is resumed effective with the first month for which title II benefit payments are resumed. (See example C.1.)

  • If an individual had not completed the 24 month D-HI qualifying period prior to the scheduled termination, months of benefit continuation during the appeal period count toward the Medicare qualifying period. D-HI is awarded with the 25th month for which the individual receives title II disability benefits. (See example C.2.)

2. Medicare only election

An individual may elect only Medicare reinstatement during the appeal period provided HI had been awarded prior to the scheduled title II benefit termination date. Where reinstatement of only Medicare is requested, HI is resumed effective with the month title II benefits would have been reinstated had title II benefit continuation been elected. (See example C.3.)

3. Effect on SMI

Where HI is resumed during appeal, SMI is affected as follows:

  • If the individual was entitled to SMI prior to termination, SMI is reinstated effective with the same month of the HI reinstatement, unless the individual requests that SMI not be reinstated. In that case, the request that SMI not be reinstated is treated as a request for termination, with coverage ending the end of the month after the month the request was filed.

  • If the individual was not entitled to SMI prior to termination because he/she had previously refused SMI or allowed coverage to lapse, he/ she may enroll for SMI only during a GEP or SEP which occurs while the appeal is pending.

  • If HI was not in effect at termination, but is awarded during the benefit continuation period, SMI is also awarded.

4. SMI premiums

Premium surcharges for SMI will apply only in the following situations:

  • A surcharge was in effect at the time of title II termination. The same percentage surcharge will apply during the benefit continuation period.

  • SMI was refused during the IEP or at the time of benefit election but later elected during a GEP or SEP occurring during the benefit continuation period. The months to be counted toward the surcharge will be those elapsing after the end of the IEP through the end of the enrollment period in which the individual enrolls.

  • If SMI was terminated earlier than HI (either voluntarily or for non-payment of premiums), months after the last month of SMI coverage will be counted for surcharge purposes where reenrollment occurs during a GEP or SEP in the benefit continuation period.

C. Examples

1. Medicare in effect prior to benefit continuation

Joe received DIB for more than 24 months and was entitled to Medicare prior to a determination his impairment was no longer disabling. If he files an appeal and makes a request for title II benefit continuation within 10 days of the cessation notice, HI is resumed effective with the same month title II disability benefits are resumed.

2. Medicare not in effect prior to benefit continuation

Mary received DIB from 7/91 through 10/92, a total of 16 months, when her DIB was terminated because of medical improvement. Although she requested reconsideration of the disability cessation in 11/92, she did not elect title II benefit continuation. The cessation was upheld at the reconsideration level and Mary requested an ALJ hearing and benefit continuation. Her DIB was reinstated beginning 2/93, the month of the reconsideration determination. If her appeal is still pending, she will be awarded D-HI beginning 10/1/ 93. That is, the 8 benefit continuation months 2/93 through 9/93 are added to the 16 months of DIB entitlement from 7/91 through 10/92 to complete the 24 mon