TN 107 (06-24)

HI 00805.050 When Deemed Enrollment Does Not Apply

A. Policy - Residence in Puerto Rico or outside U.S.

1. No automatic enrollment

The law excludes from automatic enrollment persons (except R-HI beneficiaries) who reside in PR or outside the U.S.

Such individuals will be told about SMI and advised that, if the individual wishes to have such protection, the individual must file an enrollment request, see HI 00805.060.

NOTE: A high proportion of eligible individuals in PR receive medical care without payment on the basis of actual or presumed need. For them, as for persons living outside the U.S., automatic enrollment generally would not be advantageous.

2. Assumption about residence

In the absence of any indication to the contrary, any person whose address is in PR, or is outside the U.S., should be assumed not to reside in the U.S. and should not be automatically enrolled. Any person with an address in the U.S. should be assumed to reside in this country.

NOTE: If, within one year after coverage starts (or should have started), the individual submits evidence that the assumption was incorrect, the enrollment (or failure to enroll) is rectified.

EXAMPLE: Bill Conti, a fully insured worker born 6/12/26, files for monthly benefits 4/90, giving a bank in New York as Bill's mailing address. Bill is notified (via the bank address) that Bill is automatically enrolled in SMI beginning 6/91 unless Bill declines such coverage. If, however, in requesting that Bill's monthly benefits be sent to the bank, Bill mentioned that Bill intended to live outside the U.S., it would be assumed that Bill is not residing in the U.S., i.e., Bill would be treated as a nonresident.

EXAMPLE: Joe Schmitt, born 6/18/30, filed for and was awarded DIB effective 8/87. Joe would ordinarily be notified in 5/89 of the deemed enrollment effective 8/89. However, in 3/89 Joe submits notice that Joe is moving to an address in Austria effective 6/89. Even though Joe has an address in the U.S. in 5/89 (when the notice of deemed enrollment would ordinarily be mailed to Joe), the fact that Joe has shown that Joe will be living outside the U.S. precludes automatic enrollment.

B. Policy - Persons who are not entitled to HI

1. Must file for SMI

Automatic enrollment applies only to individuals eligible to enroll by reason of entitlement to HI. Non-beneficiaries who want SMI must file a request during an enrollment period open to the individual as discussed in HI 00805.060.

2. Possibility of benefit disallowance

If a person files an application for HI (or for title II benefits and HI), which is disallowed, the person does not qualify for automatic enrollment. That individual must file an enrollment request during an enrollment period.

Because of the possibility of disallowance, an individual who is age 64 or older should be asked whether or not the individual wants SMI when filing for monthly benefits.

If the disallowed individual elects “no,” the disallowed individual will not be enrolled for SMI under any circumstances.

If the disallowed individual elects “yes,” the individual will be enrolled if eligible for SMI and the application was filed during a prescribed enrollment period.

3. Refusal of SMI before IEP

A “no” election by an individual who is awarded monthly benefits precludes automatic enrollment if the benefit award notice is mailed no earlier than 3 months before the IEP begins.

C. Policy - Entitled on another record

A person who refused SMI when first eligible or had a period of SMI coverage which terminated, is not subject to automatic enrollment merely because the person files for, and establishes entitlement to, another monthly benefit.

EXAMPLE: Kate Simmons applied for and was awarded deceased spouse's benefits effective 9/88 at age 65, but refused enrollment in SMI. Kate subsequently filed an application for RIB in 11/92 and was awarded benefits retroactive to 5/92. Kate is not subject to automatic enrollment. If Kate wants SMI, Kate must file a written request for enrollment during a GEP.

D. Policy - New opportunity at age 65

As explained in HI 00805.085, an individual attaining age 65 who refused deemed enrollment in D-SMI or R-SMI or allowed D-SMI or R-SMI entitlement to terminate, is deemed to have enrolled in the 3 months prior to attainment of age 65.

To Link to this section - Use this URL:
HI 00805.050 - When Deemed Enrollment Does Not Apply - 06/03/2024
Batch run: 06/03/2024