BASIC (07-11)

HI 00803.001 Hospital Insurance (HI) Entitlement for Individuals Exposed to Environmental Health Hazards (EHH)

Citations:

Section 1881A of the Social Security Act

A. Background for EHH Medicare

Section 10323 of the Affordable Care Act added section 1881A of the Social Security Act effective March 23, 2010. This section extends entitlement to Medicare Hospital Insurance (HI) and eligibility to enroll in Supplementary Medical Insurance (SMI) to certain individuals exposed to environmental health hazards (EHH) and diagnosed with a medical condition caused by such exposure.

Currently, the only individuals eligible for Medicare under this provision are those who were present in Lincoln County, Montana and have an asbestos- related disease diagnosis. April 2010 is the earliest possible effective date of entitlement based on a March 2010 filing date.

B. Policy for EHH HI entitlement

1. Requirements for HI entitlement

An individual is entitled to HI based on exposure to EHH if he or she meets all of the following criteria:

  • diagnosed with an asbestos-related disease (ARD) established by certain diagnostic methods. For instructions on developing this medical requirement, see HI 00803.050; and

  • present in Lincoln County, Montana, for a total of at least 6 months (need not be consecutive) in the period ending 10 years or more before diagnosis of an ARD and prior to the implementation of all the remedial and removal actions specified by the Environmental Protection Agency in Records of Decision for Libby and Troy, Montana. Since all remedial and removal actions have not been completed, there is no end date to establishing presence at this time. For instructions on developing this presence requirement, see HI 00803.040; and

  • filed an application for HI.

2. Age and insured status requirements

There are no age or insured status requirements.

3. Effective date of HI coverage

If the claimant meets both the presence and medical requirements as of the date of filing (DOF), or by the end of the month of filing, HI will be effective the first day of the month following the month of filing. If a physician has not diagnosed the claimant with a qualifying ARD as of the DOF or by the end of the month of filing, the effective date of HI will be the first day of the month after the month the claimant is diagnosed with a qualifying ARD if the claimant also meets the presence requirement in HI 00803.001B.1. second bullet in this section.

Example 1:

Ms. Jackson applied for EHH Medicare on May 12, 2010. A completed EHH Checklist confirmed Ms. Jackson received an ARD diagnosis established by a diagnostic method specified in the law on April 4, 2010, and that she met the presence requirement. Ms. Jackson's HI entitlement began June 1, 2010.

Example 2:

Mr. James applied for EHH Medicare on July 12, 2010. As of the filing date, he had not received an ARD diagnosis. In the same month, on July 22, Mr. James received an ARD diagnosis established by a diagnostic method specified in the law. A completed EHH Checklist confirmed the diagnosis and that Mr. James met the presence requirement. Mr. James' HI entitlement began August 1, 2010.

Example 3:

Mr. Brown applied for EHH Medicare on May 12, 2010. As of the filing date, he had not received an ARD diagnosis. On June 1, Mr. Brown received an ARD diagnosis established by a diagnostic method specified in the law. A completed EHH Checklist confirmed the diagnosis and that Mr. Brown met the presence requirement. Mr. Brown's HI entitlement began July 1, 2010.

4. Retroactivity for Medicare eligibility

There is no retroactivity for Medicare eligibility under this provision.

5. Protective filing for EHH Medicare claims

Normal protective filing rules apply to EHH Medicare claims but cannot extend before March 23, 2010. For more information on protective filing and leads for EHH Medicare refer to HI 00803.020.

C. References