BASIC (07-11)

HI 00803.060 Supplementary Medical Insurance (SMI) Enrollment for Individuals Exposed to Environmental Health Hazards (EHH)

A. Initial Enrollment Period (IEP) for EHH SMI

The following are IEP rules for EHH SMI:

  • The first month of EHH Hospital Insurance (HI) entitlement is the first month of EHH Supplementary Medical Insurance (SMI) eligibility. Deem a beneficiary entitled to HI under this provision to have enrolled in SMI during the first 3 months of the IEP. The IEP is the 7-month period that begins 3 months prior to the month of HI entitlement.

  • SMI entitlement begins with the first month of HI entitlement unless the beneficiary refuses SMI.

  • The beneficiary has 2 calendar months after receipt of the notice of SMI enrollment to refuse coverage timely. A person is not liable for Part B premiums if refusal is timely.

  • If the beneficiary declines SMI enrollment, he or she may enroll during the remainder of the IEP or during the general enrollment period (GEP) or a special enrollment period (SEP). For the effective date of SMI coverage when enrollment occurs during the IEP, see HI 00805.165. For additional information on GEP and SEP see HI 00803.060B. and HI 00803.060C.

B. GEP

If the beneficiary enrolls or re-enrolls during a GEP, SMI coverage begins July 1 of that year of enrollment.

C. SEP for the working aged and working disabled

Beneficiaries entitled to HI based solely on EHH are eligible to enroll in a SEP if they have group health plan (GHP) coverage based on their own, a spouse’s, or a parent’s current employment status and meet one of the following requirements. If the beneficiary:

  1. did not enroll during the IEP, he or she had to be covered under a GHP in the first month of SMI eligibility (the month of EHH HI entitlement) and for all months thereafter;

  2. enrolled during an IEP or GEP and SMI coverage was terminated later (e.g. for nonpayment), he or she had to be covered under a GHP the month of SMI termination and all months thereafter; or

  3. enrolled in SMI during an SEP and SMI coverage terminated, he or she had to be covered under a GHP at the time of SMI termination and all months thereafter.

Beneficiaries entitled to HI based on age or disability and EHH may enroll in SMI under these SEP rules if they meet one of the requirements in HI 00805.275.

D. SMI enrollments after initial eligibility

If beneficiary is enrolling in SMI after initial eligibility, he or she must submit a CMS-40B (Application for Enrollment in SMI). If the beneficiary is enrolling in SMI during an SEP because of GHP coverage based on current employment status, he or she must also submit form CMS-L564 (Request for Employment Application) after having it completed by the employer.

Upon receipt of the necessary form(s) from the beneficiary, any FO may process the SMI enrollment by taking the following actions:

  1. scan the CMS-40B form (and the CMS-L564 when appropriate) and email to ^Libby Cases NEPSC ; and

  2. fax the required form(s) into the Non-Disability Repository for Evidentiary Documents (NDRed).

    NOTE: Do not do a Post Entitlement On-Line System (POS) input. Upon receipt of the fax, NEPSC (PC1), will process the SMI enrollment. NEPSC processes all EHH SMI enrollments for beneficiaries already entitled to EHH HI.

E. Collection of SMI premiums

The SMI premium for beneficiaries enrolled under this provision is the same as all other enrollees. An Income-Related Monthly Adjustment Amount (IRMAA) will apply if the beneficiary meets IRMAA criteria. For description of IRMAA, see HI 01101.001

SSA deducts SMI premiums from monthly Social Security benefits. The Office of Personnel Management deducts SMI premiums from civil service annuities. If the monthly benefit payment is less than the SMI premium, see HI 01001.041. If monthly benefits are not otherwise payable, the beneficiary must pay the SMI premium by direct remittance. For information on collection of premiums, see HI 01001.020.

If the EHH beneficiary is a Railroad Retirement Board (RRB) beneficiary and is not entitled to Medicare based on age or disability, RRB will not withhold the Part B premium from the RRB benefit. CMS quarterly billing applies.

F. SMI premium billing options

1. Claimant is unable or unwilling to make quarterly payments due to lack of funds

Consider taking applications for Supplemental Security Income (SSI) and Medicare Part D Extra Help if the claimant mentions during the initial interview that he or she is unable or unwilling to make quarterly payments due to a lack of funds. In addition, make a referral to the state for the Medicare Savings Programs since qualifying for any of these programs will pay for the Part B premiums.

2. Monthly premium payment option

Offer the beneficiary the option of monthly premium payments if monthly billing is acceptable but quarterly billing is not. For information about monthly and quarterly billing, see HI 01001.070, HI 01001.075, and HI 01001.080.

If the beneficiary elects

  1. monthly billing during the initial interview, take the following actions:

    • annotate the A101 BCRN screen with the remark that the claimant elects to have monthly billing for SMI premiums, and

    • send an email message to ^Libby Cases NEPSC indicating election of monthly billing for SMI premiums.

  2. to change from quarterly to monthly billing after coverage begins, send an email message to ^Libby Cases NEPSC indicating election of monthly billing for SMI premiums.

3. Medicare Easy Pay

Offer the beneficiary the opportunity for Medicare Easy Pay that permits automatic monthly deductions from a checking or savings account. To start Medicare Easy Pay, advise the beneficiary to:

  • contact 1-800-MEDICARE when he or she receives the first quarterly or monthly bill to request Medicare Easy Pay; and

  • pay the premium bill until he or she receives a notice that his or her bank will deduct premiums from his or her account.

NOTE: A technician at 1-800-MEDICARE will review the billing status and answer Medicare Easy Pay questions before sending a Medicare Easy Pay package to a Medicare beneficiary.

For more information about the Medicare Easy Pay process, see HI 01001.025D.

4. Post entitlement requests for monthly billing

Any FO may initiate a post entitlement request for monthly billing. The FO technician should send post entitlement requests for monthly instead of quarterly billing via email to ^Libby Cases NEPSC for processing.

5. Direct-bill beneficiary requires assistance

If a direct-bill beneficiary appears to require assistance with the payment of SMI premiums or handling of correspondence or both, the FO develops for a “Premium Payer.” For developing and processing requests for third party premium billing, see HI 01001.225 and HI 01005.810.

G. References

  • HI 00805.165, Individual Enrollment – When Coverage Period Begins

  • HI 00805.275, SEP Enrollments

  • HI 01001.020, Collection of Premiums

  • HI 01001.025, Payment by Remittance

  • HI 01001.041, Collection from Beneficiaries When the Amount of the Benefit Payment is Less than the Amount of the Premium

  • HI 01001.070, Quarterly and Monthly Premium Payments

  • HI 01001.075, Information Regarding Monthly Payments

  • HI 01001.080, Enrollee Changes From Quarterly to Monthly Pay Plan after Coverage Begins

  • HI 01001.225, When Premium Notices May Be Sent to an Individual Other Than An Enrollee

  • HI 01005.810, CMS-2384, Third Party Billing Request

  • HI 01101.001, Description of the Medicare Income-Related Monthly Adjustment Amount (IRMAA)


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HI 00803.060 - Supplementary Medical Insurance (SMI) Enrollment for Individuals Exposed to Environmental Health Hazards (EHH) - 04/23/2015
Batch run: 04/23/2015
Rev:04/23/2015