TN 97 (02-24)

HI 00805.090 SMI Enrollment of Reentitled Disability Beneficiaries

A. Policy - General

Section 103 of P.L. 96-265 modified section 226 of the Social Security Act effective December 1, 1980, to provide that the 24 months in the D-HI qualifying period no longer needed to be consecutive.

1. 24 Months in prior period of entitlement

An individual may establish immediate entitlement to both HI and SMI if the individual:

  • becomes reentitled to title II disability benefits within the time limits specified in HI 00801.152; and

  • received disability benefits for at least 24 months during the earlier period of entitlement.

2. Less than 24 months in prior entitlement

An individual who becomes reentitled within the time limits specified in HI 00801.152 (with less than 24 months prior disability benefit entitlement) may have such prior months counted toward the 24-month qualifying period during a subsequent period of entitlement to disability benefits.

3. Retroactive SMI award

Medicare eligibility in reentitlement cases may begin before the month the award notice is sent to the individual.

If limited to a choice of paying for retroactive coverage they did not know they had, or refusing SMI altogether, many individuals may refuse SMI.

NOTE: To prevent hardship and inequity that can arise from retroactive SMI awards, SMI enrollments for reentitled disability beneficiaries are processed in accordance with the instructions in HI 00805.090B. or HI 00805.090D.

B. Policy - Automatic enrollment applies

1. General

An individual is deemed to have enrolled for SMI in the third month of the IEP if the individual:

  • files an application for disability benefit reentitlement;

  • is eligible without a waiting period (or has a shortened waiting period) for HI; and

  • is subject to automatic enrollment in SMI.

The individual is awarded coverage beginning with the first month of D-HI entitlement.

2. Premium arrearage

At the time of final processing, if more than 5 months' retroactive premiums must be withheld from the initial monthly benefit check, the individual is awarded SMI effective with the month in which final action is taken to process the award.

NOTE: The award notice advises of the option to have SMI begin with the first month of D-HI entitlement provided that, within 60 days, the enrollee requests the earlier date and authorizes the deduction of the accrued premiums from monthly benefits.

3. Right to refuse SMI

The individual is also sent a form giving the individual the right to refuse SMI. If the individual refuses SMI by the end of the second month following the month the award notice is mailed, the individual is deemed not to have enrolled and does not incur any premium liability. Any refusal received later than that is treated as a voluntary termination request. (See HI 00805.080 and HI 00820.050.)

C. Example - Arrearage/refusal

Carl Davis was previously entitled to DIB for the period 6/84-12/87 and was entitled to D-HI and D-SMI on the basis of 24 months DIB entitlement. Carl files an SSA-16 on 4/12/91 alleging Carl became disabled on 11/15/90. When the claim is adjudicated in 8/91, Carl Davis is found eligible for DIB and HI beginning 12/90.

Because more than 5 months' SMI premiums have accrued, Carl is awarded SMI effective 8/91. Carl is advised in the award notice that Carl may have coverage beginning 12/90, provided Carl notifies us in 30 days and authorizes deduction of all retroactive premiums.

If Carl decides instead to refuse enrollment, and does so by 10/31/91, Carl will be deemed never to have enrolled. The SMI award of 8/91 will be deleted and any SMI premiums that were withheld will be refunded to Carl.

D. Policy - Automatic enrollment does not apply

1. Who cannot be deemed enrolled

Individuals residing in Puerto Rico or outside the U.S. are not subject to automatic enrollment. If such individuals desire SMI coverage, they must specifically request enrollment at the time they file their application for reentitlement to monthly disability benefits.

If the FO fails to secure a SMI election, the PSC should obtain it before the reentitlement award.

2. How to enroll

The SMI election should preferably be recorded on a CMS-40B, but any written request for enrollment will suffice. If a claim is received which:

  • does not include the claimant's SMI enrollment or refusal, and

  • it is likely at the time of processing that the individual would not otherwise be selected for enrollment solicitation as discussed in HI 00805.115 and HI 00805.120,

an election should immediately be secured from the claimant by the FO.

3. Deemed date of enrollment

Individuals alleging a specified onset date are often found to be disabled earlier or later than that date. Because of the uncertainty involved in determining the IEP for an individual filing for reentitlement to disability benefits, the SMI enrollment request is deemed to have been filed in the third month of the IEP. This assures that the enrollee has the opportunity for coverage at the earliest possible date.

4. Additional instructions

In all other respects, the claim is handled in the same way as a claim filed by an individual who is subject to automatic enrollment as described in HI 00805.090B.2. and HI 00805.090B.3.

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HI 00805.090 - SMI Enrollment of Reentitled Disability Beneficiaries - 02/01/2024
Batch run: 02/01/2024