TN 19 (03-93)

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

EXAMPLE: Mr. Schmitt, born 6/18/30, filed for and was awarded DIB effective 8/87. He would ordinarily be notified in 5/89 of his deemed enrollment effective 8/89. However, in 3/89 he submits notice that he is moving to an address in Austria effective 6/89. Even though he has an address in the U.S. in 5/89 (when the notice of deemed enrollment would ordinarily be mailed to him), the fact that he has shown that he 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. Nonbeneficiaries who want SMI must file a request during an enrollment period open to them as discussed in HI 00805.060ff.

2. Possibility of benefit disallowance

If a person files an application for HI (or for title II benefits and HI), which is disallowed, he/she 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 he/she wants SMI when filing for monthly benefits.

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

If he/she 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 he/ she files for, and establishes entitlement to, another monthly benefit.

EXAMPLE: Mrs. Simmons applied for and was awarded widow's benefits effective 9/88 at age 65, but refused enrollment in SMI. She subsequently filed an application for RIB in 11/92 and was awarded benefits retroactive to 5/92. She is not subject to automatic enrollment. If she wants SMI, she 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.