TN 25 (09-93)

HI 00801.163 Disability Cessation Affirmed or Reversed After Benefit Continuation

A. Policy - Cessation affirmed

If the disability cessation is affirmed, Medicare terminates with the end of the month after the month in which the notice affirming the cessation is sent.

Months of Medicare entitlement during the benefit continuation period may not be used to meet the 24-month D-HI qualifying period during any subsequent period of disability established.

B. Policy- Cessation reversed

1. HI

If the cessation is reversed on appeal, HI is reinstated fully retroactively. If HI was awarded during the benefit continuation period, a reversal will cause HI to begin earlier if there were months of nonpayment between the original termination and benefit reinstatement. (See examples C.1. and C.2.)

2. SMI

SMI is affected by reversal of the cessation as follows:

  • If SMI was in effect at the time of termination and during the entire benefit continuation period (or if HI and SMI are initially awarded during the benefit continuation period), SMI is reinstated effective with the month of HI reinstatement, unless the reinstatement results in more than 5 months retroactive premiums. If there are more than 5 months retroactive premiums, see HI 00805.215.

  • If HI, but not SMI, was in effect at the time of termination (or if HI was in effect but SMI continuation is not elected) and SMI was not elected during the benefit continuation period, SMI is not awarded either currently or retroactively because of the reversal.

  • If HI, but not SMI, was in effect at the time of termination and SMI was elected during a GEP or SEP in the benefit continuation period, SMI continues on the basis of the GEP or SEP enrollment. There is no offer of retroactive SMI.

  • If HI was initially awarded during the benefit continuation period but SMI was refused (or elected and allowed to lapse during the benefit continuation period), upon reversal, the beneficiary may only enroll in a GEP or SEP occurring after the reversal.

C. Examples

1. Retroactive HI/SMI eligibility following disability cessation

Gil was entitled to D-HI and D-SMI when his DIB terminated 3/31/92. Although he requested reconsideration of the disability cessation, he did not request benefit continuation at that time. In 1/93, he was advised that there was no basis for reversing the cessation. However, he immediately appealed the reconsideration determination and requested continuation of both DIB and Medicare. DIB, D-HI and D-SMI were reinstated effective 1/1/93. The ALJ reversed the cessation and both DIB and D-HI are reinstated effective 4 /1/92. Since more than 5 months SMI premiums would be due if D-SMI were also reinstated effective 4/1/92, Gil is advised that if he wishes D-SMI for the period 4/92-12/92, he must file a written request within 60 days of the notice and authorize deduction of the retroactive premiums from his monthly benefits.

2. SMI in effect during benefit continuation

Fred's last benefit check was for 1/92, his 20th month of DIB entitlement. He received benefit continuation from 9/92 through 9/93 when the termination was reversed. He had been awarded D-HI and D-SMI as of 1/1/93, the 25th month of combined “actual” and “continuation” benefit entitlement. The revised award will show D-HI beginning retroactively with 6/ 92, the 25th month of DIB entitlement. D-SMI will continue. However, the revised notice will advise him that he may have D-SMI beginning 6/92, as well, if he notifies SSA within 60 days and authorizes deduction of the retroactive premiums from his monthly benefits.

3. HI elected, SMI refused

May was awarded D-HI and D-SMI prior to disability cessation. When contacted about benefit continuation, she elected only D-HI; she refused D-SMI continuation and D-SMI coverage ended with the last day of the month after the month of her refusal of D-SMI continuation. If the cessation is reversed, she will not be awarded D-SMI along with the D-HI reinstatement.

4. SMI not in effect at cessation

Evelyn refused D-SMI when she became entitled to D-HI prior to cessation of disability. She enrolled for D-SMI during a GEP occurring during her benefit continuation period. If the termination is reversed, her D-SMI will continue; there will be no retroactive award of D-SMI.