TN 30 (08-01)

HI 00801.166 Favorable Medical Decisions

A favorable medical decision can result in up to one year's retroactivity for benefit reinstatement. A retroactive benefit reinstatement date may also result in an earlier D-HI entitlement date.

Note: The benefit reinstatement date can not be earlier than 01/01.

A favorable medical decision is considered a new period of benefit entitlement and results in a new IEP for SMI. SMI is affected by a favorable decision as follows:

  • If SMI is in effect at the time a favorable decision is made, the decision could result in an earlier date of entitlement if the benefit reinstatement date is retroactive. The SMI entitlement date should be changed to the earlier date except in equitable relief situations. If more than 5 months retroactive premiums are due, see HI 00805.195.

  • If the individual has HI only, SMI is awarded effective with the benefit reinstatement month, unless equitable relief applies. If more than 5 months retroactive premiums are due, see HI 00805.195.

The individual will also be given the right to refuse the SMI coverage. The notice of refusal is considered timely filed if it is filed within 2 months after the month notice of SMI coverage is mailed. Refusals received later will be treated as requests for voluntary termination of SMI. (See HI 00805.055.)


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0600801166
HI 00801.166 - Favorable Medical Decisions - 04/11/2011
Batch run: 04/11/2011
Rev:04/11/2011