TN 30 (08-01)

HI 00801.167 Examples Of How Disability Determinations Affect Medicare Coverage During The Provisional Benefit Period

1. Favorable medical decision – equitable relief not involved

Lamont was entitled to Medicare from 1/99 – 6/05. His request for reinstatement period was 1/01 – 12/05. Lamont requests benefit reinstatement in 11/05. Provisional payments and Medicare coverage begin effective 11/05. A favorable decision is made in 2/06 with benefit reinstatement effective 8/05. The Medicare entitlement dates are changed to 8/05.

2. Favorable medical decision – equitable relief applies

Mary was entitled to Medicare effective 3/95. Her request for reinstatement period was 8/01 – 7/06. Mary had HI coverage until 3/06 (the end of the extended Medicare period), but SMI coverage ended 5/02 due to non-payment of premiums. Mary requested benefit reinstatement in 3/06 and filed for SMI under the GEP provisions. Provisional payments and HI coverage were effective 3/06. A favorable decision is made in 5/06 with benefit reinstatement effective 6/05.

The HI START date is changed to 3/95. Mary is enrolled in SMI beginning 5/06 since the favorable decision results in a new IEP.

The notice advises Mary that she may elect SMI coverage effective 6/05 if she files a written request within 30 days of the notice. She is also given the option of refusing SMI coverage.

3. Unfavorable medical decision – extended period of Medicare coverage ended prior to provisional benefit period

Lonnie's extended period of Medicare coverage ended 11/05. He requested provisional benefits in 1/06. An unfavorable decision is made in 03/06 but not processed until COM 5/06. Medicare coverage ends the last day of 6/06.

4. Unfavorable medical decision – beneficiary is still in extended period of Medicare

Shirley's extended period of Medicare coverage ends 8/04. She requests provisional benefits in 11/03. An unfavorable disability determination is made in 4/04, however the notice is not released until 6/04. Medicare coverage ends the last day of 7/04.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0600801167
HI 00801.167 - Examples Of How Disability Determinations Affect Medicare Coverage During The Provisional Benefit Period - 08/14/2001
Batch run: 01/27/2009
Rev:08/14/2001