TN 19 (03-93)

HI 00805.045 Deemed Enrollment - R-HI Beneficiaries

A. Policy

1. Month of R-SMI eligibility

The first month of R-HI entitlement (HI based on ESRD) is the first month of R- SMI eligibility. Therefore, the IEP begins with the third month prior to the month of R-HI entitlement. R-HI claimants are deemed enrolled in R-SMI in the first 3 months of their IEP (unless such an award results in a premium arrearage of 6 months or more (see 2. below)).

R-SMI entitlement generally begins with the first month of R-HI entitlement. As in all automatic enrollment cases, R-HI claimants have the right to refuse R-SMI.

CAUTION: Since the cost of dialysis is so high, claimants who refuse R-SMI will be questioned closely to see if they are making a sound decision. See HI 00801.191 C. and HI 00801.251.

IMPORTANT: Puerto Rican residents and persons outside the U.S. who are not subject to automatic enrollment, as explained in HI 00805.050, nevertheless have R-SMI beginning at the same time as R-HI, under the terms of the ESRD provision, unless they refuse SMI timely.

2. Premium arrearage is 6 months or more

When there are 6 months or more of premium arrearage, the enrollee or his/ her representative will be notified that SMI is prospective only.

That is, SMI begins with the month in which the enrollment is processed, unless the individual will pay all premiums for coverage beginning with the earliest possible (specified) month.

NOTE: The enrollee may also choose to have SMI begin with the month of filing (e.g., if a Medicare secondary payer coordination period is involved).

Unless there is a statement in file showing the claimant chooses an earlier month, the award of SMI is prospective, and the individual will be notified of the right to have the earlier coverage. The SMI award can be amended to give retroactive coverage if a timely request and payment are received.

B. Example

Mr. Henderson, born 12/50, begins a course of renal dialysis for ESRD 9/8 /91, but because he delays filing until 8/92, his award is not processed until 10/92.

He is awarded R-HI retroactive to 12/1/91 (the third month after the month maintenance dialysis began), and R-SMI effective 10/92 (unless the file shows he did not want R-SMI, or wanted it effective with the month of first eligibility (12/91) or the filing month of 8/92). He will be billed for premiums from that date. However, when notified of the award, if he states that he wants retroactive SMI and encloses the necessary payment, coverage will be made effective 8/92 or 12/91, whichever he requests.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0600805045
HI 00805.045 - Deemed Enrollment - R-HI Beneficiaries - 04/23/2015