TN 30 (08-01)

HI 00801.164 Medicare Entitlement During the Provisional Benefit Period – Expedited Reinstatement of Disability Benefits

A. Policy – General

Effective 1/1/01, individuals whose entitlement to disability benefits terminated due to work (i.e., engaged in substantial gainful activity (SGA) after the extended period of eligibility), and who again become unable to perform SGA because of their disabling impairment(s), may request benefit reinstatement within 60 consecutive months of the benefit termination month.

These individuals may receive up to 6 months of provisional cash benefits while SSA conducts a medical review to determine whether the disability continues and benefit reinstatement applies. Provisional cash benefits can be paid beginning with the month the individual files the reinstatement request, but no earlier than 1/1/01.

B. Policy – Medicare coverage during the provisional benefit period

A disabled individual who requests benefit reinstatement will also receive Medicare coverage during the provisional benefit period.

Note: Although a disabled individual who was previously entitled to Medicare based on Medicare Qualified Government Employment is not eligible for cash benefits during the provisional benefit period, he or she can request reinstatement of Medicare coverage. These individuals must meet the same requirements as individuals requesting reinstatement of cash benefits.

1. Individual currently in extended period of Medicare

a. Entitled to Disability Hospital Insurance (D-HI) only

The individual will continue to have D-HI coverage during the provisional benefit period.

The individual can elect SMI coverage during a general enrollment period (GEP) or special enrollment period (SEP) that occurs during the provisional benefit period. Normal rules apply for GEP or SEP enrollments.

Note: The provisional benefit period does not begin a new initial

enrollment period (IEP).

b. Entitled to Disability Hospital Insurance (D-HI) and Supplementary Medical Insurance (SMI)

The individual will continue to have HI and SMI coverage. If he or she is currently paying a premium surcharge, then the surcharge will continue to apply during the provisional benefit period. Any premium arrearages will be deducted from the provisional benefits.

c. Extended period of Medicare coverage ends during the provisional benefit period

If an individual's extended period of Medicare coverage ends during

the provisional benefit period, then Medicare will continue until

the end of the provisional benefit period (see HI 00801.165).

d. Extended period of Medicare coverage ends after the provisional benefit period

If the extended period of Medicare coverage ends after the provisional benefit period, then Medicare coverage will continue unless the provisional benefit period ended because the individual is no longer under a disability.

When the provisional benefit period ends due to a determination that the person is no longer under a disability, Medicare coverage will terminate at the end of the month following the month the notice of the unfavorable decision is mailed.

2. Extended period of Medicare coverage ended prior to request for expedited reinstatement

If the individual's extended period of Medicare coverage ended prior to

the request for expedited reinstatement, then Medicare coverage will be reinstated during the provisional benefit period as follows:

a. Individual had D-HI coverage only

If the individual had D-HI coverage only in the month prior to the Medicare termination month, then he or she will have D-HI coverage during the provisional benefit period.

The individual may enroll in SMI during a GEP. If the provisional benefit period ends before July, the individual will not be entitled to SMI.

The individual may also enroll in SMI under the SEP provisions.

Note: The provisional benefit period does not create a new IEP.

b. Individual had D-HI and SMI coverage

If the individual had both D-HI and SMI coverage in the month prior to the Medicare termination month, he or she will have D-HI coverage during the provisional benefit period. The individual must sign a statement to elect SMI. If SMI is not elected, then only D-HI coverage will be reinstated.

If the individual was previously paying a premium surcharge, then the surcharge will apply during the provisional benefit period.

c. When coverage begins

If Medicare entitlement ended prior to the request for benefit reinstatement, reinstate Medicare as follows:

  • No break in D-HI entitlement

If the first month of the provisional benefit period is the same as the D-HI termination month, then Medicare coverage will be reinstated effective with the prior entitlement dates.

  • Break in Medicare entitlement

If the D-HI termination date is earlier than the first month of the provisional benefit period, then Medicare coverage will be reinstated effective with the first month of the provisional benefit period.

3. Individual entitled to Premium-HI for disabled working individuals

Disabled working individuals with premium-HI coverage will be entitled to premium-free HI during the provisional benefit period.

If the individual is currently paying a premium surcharge for SMI, then the surcharge will continue to apply during the provisional benefit period. Any premium arrearages will be deducted from the provisional benefits.

The provisional benefit period does not begin a new IEP. If the individual does not currently have SMI coverage, he or she can apply for SMI during a general enrollment period (GEP) or special enrollment period (SEP) that occurs during the provisional benefit period. Normal rules apply for GEP or SEP enrollments.

Premium-HI (and SMI, if applicable) can continue after the provisional benefit period ends only if the field office obtains a statement from the individual requesting premium-HI coverage to be reinstated and he or she is still eligible for the coverage.

4. Individual currently has Medicare based on end stage renal disease (ESRD)

a. Entitled to renal HI only

In these situations, the individual will also have HI coverage based on disability during the provisional benefit period. The individual can enroll in SMI only during the GEP.

Note: Individuals with ESRD are not eligible for the SEP or premium surcharge rollback.

HI coverage based on ESRD will continue after the provisional benefit period even if a medical review finds the individual is no longer disabled.

b. Entitled to renal HI and SMI

The individual will also have HI and SMI coverage based on disability during the provisional benefit period. If he or she is currently paying a premium surcharge, it will continue to apply during the provisional benefit period.

Medicare coverage based on ESRD will continue after the provisional benefit period even if a medical review finds the individual is no longer disabled.

5. Individual attains age 65 during the provisional benefit period

If an individual attains age 65 during the provisional benefit period or during the extended Medicare period, Medicare will convert to Aged Medicare.

The attainment of age 65 begins a new IEP. Normal processing rules apply; i.e., if the individual does not currently have SMI coverage, he or she will be automatically enrolled and an IEP package will be mailed.

C. Policy – SMI withdrawals during the provisional benefit period

If the individual files a voluntary request for termination of SMI during the provisional benefit period, coverage will end the earliest of:

  • The end of the month following the month the termination request is filed; or

  • The end of the month following the month in which either an unfavorable decision or a notice of termination due to SGA is mailed; or

  • The last day of the six month provisional benefit period.

D. Examples of medicare reinstatement during the provisional benefit period

1. Extended period of Medicare coverage terminated prior to request for provisional benefits

Nora's 60 month request for reinstatement period is 6/01 – 5/06. Medicare coverage terminated effective 12/05 (the end of the extended period of Medicare). Nora requests benefit reinstatement in 4/06. Provisional payments and Medicare coverage begin effective 4/06.

2. Extended period of Medicare coverage terminated prior to request for provisional benefits – SMI not elected

Joan's Medicare coverage ended 4/03 (the end of the extended period of Medicare). She requests benefit reinstatement in 6/03, but does not elect SMI coverage. Provisional payments and D-HI coverage begin effective 6/03.

3. Extended period of Medicare coverage terminated prior to request for provisional benefits – SMI terminated prior to D-HI

Eric's request for reinstatement period is 1/01– 12/05. His D-HI coverage terminated effective 7/05 (the end of the extended period of Medicare). SMI was terminated effective 12/01 due to non-payment of premiums. Eric requests benefit reinstatement in 8/05. Based on his request, provisional payments and D-HI begin effective 8/05. SMI cannot be reinstated unless Eric qualifies under the SEP provisions. Any premium arrearage will be deducted from the provisional payments.

4. Extended period of Medicare coverage terminated prior to request for provisional benefits – premium surcharge involved

Mary requests provisional payments in 10/01. She was paying a 20% premium surcharge when her Medicare coverage ended 8/01. Mary receives provisional payments and Medicare coverage beginning 10/01. A 20% premium surcharge is applied to SMI premiums.

5. Extended period of Medicare coverage terminated prior to request for provisional benefits – GEP and premium surcharge involved

Leroy refused SMI coverage when first eligible in 12/98. His D-HI coverage ended 11/05 (the end of the extended period of Medicare). In 3/06, Leroy requests provisional payments and enrolls in SMI. Provisional payments and D-HI coverage begin in 3/06. SMI is effective 7/06 with a 60% premium surcharge. The surcharge is calculated based on the number of months from the end of the IEP (4/99) through the last month of HI coverage (10/05).

6. Extended period of Medicare ends during the provisional benefit period

Doris' extended period of Medicare coverage ends 3/05. She requests provisional payments in 12/04. The provisional payments begin effective 12/04 and the Medicare termination date is changed to 6/05.

E. References

  • SM 00856.000 - Expedited Reinstatement (EXR) - Provisional Benefits

  • DI 13050.000ff – Expedited Reinstatement & Provisional Payments


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0600801164
HI 00801.164 - Medicare Entitlement During the Provisional Benefit Period - Expedited Reinstatement of Disability Benefits - 04/22/2015
Batch run: 04/22/2015
Rev:04/22/2015