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:

  • The individual is still in the extended period of Medicare, or

  • The individual is entitled to Medicare on the basis of age or ESRD, or

  • The individual has requested reinstatement of premium-HI under the Disabled Working Individual provisions.

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:

  • The end of the month following the month the notice that provisional benefits will end due to SGA is mailed, or

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

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).


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0600801165
HI 00801.165 - Medicare Terminations When The Provisional Benefit Period Ends - 04/20/2015
Batch run: 04/20/2015
Rev:04/20/2015