TN 30 (08-01)
HI 00801.165 Medicare Terminations When The Provisional Benefit Period Ends
A. Policy – Individual received provisional benefits for six months
If the provisional benefit period ends because an individual received cash payments for six months, but a decision has not been made regarding whether he/she meets the disability criteria for reinstatement of benefits, Medicare coverage will end the last day of the last month of the provisional benefit period except in the following situations:
B. Policy - Individual returns to SGA
If the provisional benefit period ends because an individual returns to work and has earnings at the SGA level, Medicare coverage will end the earliest of:
Exception: Medicare coverage will continue for an individual who is still in the extended period of Medicare.
C. Policy – Individual receives an unfavorable medical decision
When the Disability Determination Section determines that a reinstatement request must be denied because an individual is no longer under a disability, Medicare coverage will terminate as follows unless the beneficiary is also entitled based on age or ESRD (see HI 00801.164B.4 and 5).
1. If the individual's extended period of Medicare coverage ended prior to the provisional benefit period or he or she was in an extended period of Medicare that ended during the provisional benefit period, then Medicare will end the earliest of:
The last day of the month following the month the notice of the unfavorable decision is mailed, or
The last day of the six month provisional benefit period.
2. If the individual is in the extended period of Medicare, coverage will end the last day of the month following the month the notice of the unfavorable decision is mailed.
An individual can file an appeal for the disability determination, but Medicare coverage will end as stated above. He or she is not eligible for cash benefits or Medicare continuation during the appeal.
D. Policy - Retroactive terminations
For any situation (other than those given above) that involves a retroactive termination, Medicare coverage will terminate at the end of the month following the month the notice is mailed (unless fraud is involved).