TN 26 (11-93)

HI 00801.170 Premium-HI for the Working Disabled

CITATIONS:

ACT AS AMENDED—SECTION 1818A

Regulations—42 CFR 406.20(c)

A. Policy — General

A disabled individual who loses premium-free D-HI solely because he/she is working may enroll in hospital insurance (and medical insurance) by paying monthly premiums for as long as he/she continues to have a disabling impairment. This provision is referred to as Premium-HI for the Working Disabled.

Although the first possible month of entitlement to Premium-HI for the Working Disabled is 7/90, any individual who lost premium-free D-HI prior to 7/90 solely because of work and has continuously been under a disabling impairment is eligible to enroll under the provision.

B. Policy — Eligibility requirements

To enroll in Premium-HI for the Working Disabled, an individual must be under age 65, and:

  • have lost entitlement to premium-free D-HI solely because he/she was engaging in substantial gainful activity (SGA);

  • continue to have a disabling physical or mental impairment; and

  • be ineligible for HI on any other basis.

An individual may not enroll in SMI under this provision unless he/ she also enrolls in Premium-HI.

NOTE: A re-entitled disability beneficiary who is required to serve a new 24-month D-HI qualifying period and who meets the above requirements is eligible to enroll in Premium-HI for the Working Disabled during a general enrollment period or special enrollment period (see C. below for a discussion of enrollment periods). Premium-HI eligibility continues until the individual becomes re-entitled to D-HI.

C. Policy — Enrollment periods

An individual may enroll in Premium-HI (and SMI) for the Working Disabled during the following enrollment periods:

  • Initial Enrollment Period (IEP): this is the 8-month period beginning with the month an individual is notified about the loss of premium-free HI

  • General Enrollment Period (GEP): GEPs occur during January through March of each year (for 1990, the GEP was extended through 7/2/90)

  • Special Enrollment Period (SEP): SEPs occur as described in HI 00805.265

D. Policy — When coverage begins

1. IEP enrollments

 

If the enrollment is filed:then coverage begins:
before the first month of
Premium-HI eligibility
the first month of Premium-HI eligibility
during the first month of
Premium-HI eligibility
the month after the first month of Premium-HI eligibility
during the second month of Premium-HI eligibilitythe second month after the month of enrollment
during the remainder of the IEPthe third month after the month of enrollment

2. GEP enrollment

Coverage begins July 1, following the GEP in which the
individual enrolls.

3. SEP enrollment

See HI 00805.275 for a discussion of the SEP provisions.

E. Policy—Premiums

1. General

Individuals who enroll in Premium-HI for the Working Disabled pay the same HI and SMI premium as aged Premium-HI enrollees. See HI 01005.005 and HI 01005.007 for HI premium amounts.

The HI premium for the Working Disabled is not subject to increase for late enrollment. This differs from the rule applicable to individuals who enroll in Premium-HI for the Aged and are subject to a 10 percent increase payable for twice the number of full twelve month periods they could have been but were not enrolled. The SMI premium under the Premium-HI for the Working Disabled provision is subject to increase for late enrollment following normal SMI premium increase rules. No months prior to 7/90 are counted in determining the number of months to assess for SMI premium increase purposes.

If an individual was paying an increased SMI premium during the last month of premium-free HI entitlement, but enrolls for SMI under the Working Disabled provision during his/her IEP, the SMI premium reverts to the standard rate.

States are required to pay HI (but not SMI) premiums for “qualified disabled and working individuals (QDWI).” QDWIs are individuals enrolled in Premium-HI for the Working Disabled who meet the requirements in SI 01715.005. States pay HI premiums throug