TN 26 (11-14)
HI 00805.110 SMI Enrollment Processes
A. Process for automatic enrollment in Supplementary Medical Insurance (SMI)
SSA automatically enrolls beneficiaries in the following two types of cases:
1. Attainment cases
Each month the Regular Transcript Attainment and Selection Pass (RETAP) Operation identifies records for Medicare entitlement. Four months prior to attaining age 65 and four months prior to the 25th month a beneficiary has entitlement to disability benefits, RETAP establishes hospital insurance (HI) and supplementary medical insurance (SMI) entitlement on the master beneficiary record (MBR) for beneficiaries who reside in the United States, the Northern Mariana Islands, the Virgin Islands, Guam and American Samoa. RETAP establishes only HI for beneficiaries residing in Puerto Rico or foreign countries. The Social Security Administration (SSA) does not automatically enroll these beneficiaries in SMI. For more information, see HI 00805.115 and HI 00805.120.
SSA sends this entitlement information to the Centers for Medicare and Medicaid Services (CMS). CMS notifies these beneficiaries about their entitlement to HI and enrollment in SMI via the domestic initial enrollment period (IEP) package. CMS mails the domestic IEP package three months prior to the beneficiary’s age 65-attainment month or three months prior to the 25th month of disability benefit entitlement.
The domestic IEP package contains:
Welcome to Medicare letter;
Welcome to Medicare booklet that provides an overview of the Medicare Program;
Form CMS-40/CMS-1966 (Medicare card/SMI Refusal card) which is the beneficiary’s Medicare card showing the effective dates of HI and SMI entitlement (on the front) and the SMI refusal form (on the back); and
Return envelope to mail SMI refusals to the processing center (PC) of jurisdiction.
If we automatically enroll a beneficiary in SMI, he or she has the opportunity to refuse coverage. If the beneficiary does not want SMI coverage, he or she should follow the instructions on the Medicare card and in the Welcome to Medicare booklet to check the appropriate box on the card, sign, and return the card in the enclosed envelope before the effective date. Once we process the SMI refusal, CMS issues a new Medicare card showing the HI entitlement date only. Beneficiaries will receive the revised cards about four weeks after we process the refusal.
For a detailed description of the domestic IEP package, see HI 00805.125B.
2. New entitlement cases
For new entitlement cases, automatic enrollment in SMI occurs when we process an application for disability benefits and establish HI entitlement during or after the individual’s IEP.
We enroll (deem) these beneficiaries in SMI and establish the SMI entitlement in the MBR. They do not receive an IEP package. We provide information about HI and SMI entitlement in the SSA award notice. Each beneficiary automatically enrolled in SMI has until a specified date (at least two calendar months after the month in which we mail the notice of SMI coverage) to refuse SMI. For information about refusing SMI enrollment, see HI 00805.055.
Beneficiaries receive their Medicare cards approximately four weeks after we establish the Medicare entitlement. The card shows the effective dates of entitlement to HI and SMI. If the beneficiary refuses SMI, SSA processes the refusal, and CMS issues a new Medicare card showing the HI entitlement date only. Beneficiaries will receive the revised cards about four weeks after we process the refusal.
B. Voluntary enrollment in SMI
This subsection applies to enrollments that occur during the IEP and the general enrollment period (GEP). This section does not give information on special enrollment periods (SEP). You can find information on SEPs in HI 00805.265 through HI 00805.365.
1. New entitlement cases without automatic enrollment in SMI
Automatic enrollment in SMI does not occur when we establish HI entitlement under the following conditions:
an application for retirement benefits is filed three months before age 65 or later; or
an initial application for Medicare-only based on age is filed. (For information on the Medicare-only applications, see HI 00801.022C.)
We entitle these beneficiaries to premium-free HI; however, they must elect to enroll in SMI. The beneficiary can elect to enroll in SMI when he or she:
files an initial application for Social Security monthly benefits and Medicare;
files an initial application for Medicare-only; or
requests SMI enrollment during a subsequent valid enrollment period.
If the beneficiary elects SMI on their initial application, establish SMI entitlement as outlined in HI 00805.040.
These beneficiaries do not receive an IEP package. We send information about HI and SMI entitlement in the SSA award notice.
Beneficiaries receive their Medicare cards approximately four weeks after we process the initial application. The card shows the effective dates of entitlement to HI and SMI unless the beneficiary refused SMI during their application; in which case, the card shows HI coverage only.
Beneficiaries may cancel the SMI enrollment by requesting withdrawal any time before SMI coverage is effective. The PC processes these as a refusal of SMI coverage. For information about withdrawing the enrollment before it goes into effect, see HI 00805.080.
2. Beneficiary already entitled to Retirement, Survivor, Disability and Health Insurance (RSDHI)
Beneficiaries who are entitled to HI, and did not enroll in SMI during their initial application, must file a request for SMI during a prescribed enrollment period as explained in HI 00805.010. For the enrollment process, see HI 00805.110C of this section.
Process the enrollment request via the Post-entitlement Online System (POS) for a beneficiary in his or her IEP as discussed in SM 03040.010D or for a beneficiary in the GEP in SM 03040.055. Approved requests will generate an automated notice to the beneficiary, providing the SMI entitlement date, premium amount if applicable, and a reconsideration paragraph.
If the beneficiary files the enrollment request outside of a prescribed enrollment period as described in HI 00805.010, the POS input will result in a denial. Denied requests generate an automated notice that tells the beneficiary that we denied the request and provides options for filing a request for SMI during a prescribed enrollment period.
3. Beneficiary not eligible for RSDHI
If a beneficiary is currently applying for SMI only and is not eligible for HI or monthly benefits, develop for eligibility and adjudicate the claim as outlined in in GN 01010.008. The beneficiary uses Form CMS-4040 (Request for Enrollment in Supplementary Medical Insurance) to enroll in SMI, as outlined in HI 00805.075B.1.
C. SMI enrollment for beneficiaries entitled to premium-free HI
Beneficiaries that we automatically enroll in SMI do not need to submit a separate SMI enrollment request, unless they refused SMI and subsequently want to re-enroll in SMI. Beneficiaries not automatically enrolled in SMI must elect to enroll in SMI as outlined in HI 00805.110B.
If a beneficiary refuses SMI or does not elect to enroll in SMI on their initial application, he or she may submit a separate SMI enrollment request using Form CMS-40B (Application for Enrollment in Medicare Part B (Medical Insurance)) as outlined in HI 00805.075B.2.
Form CMS-40B is available in English and Spanish. Beneficiaries obtain the form by contacting their local field office (FO), by calling the SSA toll-free line, or by downloading the form. For exhibits of the Form CMS-40B in English and Spanish, see SM 00706.265.
NOTE: Beneficiaries who receive a GEP mailing from CMS may use Form CMS-L40D (Application for Medicare Part B) to enroll in SMI during that GEP, as outlined in HI 00805.075B.3.
D. FO, Teleservice Center (TSC) and PC instructions for processing SMI enrollment requests using Form CMS-40B
Beneficiaries may contact the FO and TSC about enrolling in SMI or submit SMI enrollment requests (Form CMS-40B) without prior contact.
1. When the individual contacts the FO or TSC about enrolling in SMI
Take the following actions:
Determine if the beneficiary is eligible to enroll in SMI (see HI 00805.005).
Offer the option to have the Form CMS-40B mailed to them or to visit Medicare.gov to get the form by clicking on the tab “Forms, Help & Resources” and selecting “Forms.” This tab is located on the top of the screen at the far right. (Medicare.gov/forms-help-and-resources/forms/medicare-forms.html). This is where the beneficiary can find the Form CMS-40B to complete.
If the beneficiary wants to have the form mailed, send the form and include a FO return envelope in the mailing.
Explain to the beneficiary that he or she should mail or take the completed form to their local FO for processing.
2. When a FO or PC receives a request for SMI enrollment (Form CMS-40B)
Take the following actions:
Review the Form CMS-40B for completion and possible notes related to the enrollment application. Follow up with the beneficiary if any information is missing as outlined in SM 00706.022.
Determine if the beneficiary is eligible to enroll in SMI. For information on SMI eligibility, see HI 00805.005 and for date of filing for a SMI enrollment, see HI 00805.130.
Process the SMI enrollment request using procedures in SM 03040.010.
NOTE: The revised Form CMS-40B includes additional pages with information to help the individual complete the form. Only the official request for enrollment (page 2 of Form CMS-40B) and any pertinent notes made on any other page of the request needs to be scanned or maintained for documentation of the enrollment request.
GN 01010.008 Field Office (FO) Adjudicative Responsibilities
HI 00801.022 Application Requirement and Effective Date for Hospital Insurance for Insured Beneficiaries
HI 00805.005 Eligibility for SMI
HI 00805.010 Rules on Enrollment Periods
HI 00805.035 Nature and Purpose of Automatic Enrollment
HI 00805.040 Automatic (Deemed) Enrollment - Aged and Disabled Individuals
HI 00805.050 When Deemed Enrollment Does Not Apply
HI 00805.055 Notice of Right to Refuse Deemed Enrollment
HI 00805.075 Prescribed Enrollment Forms
HI 00805.080 Withdrawal of Enrollment Before It Goes Into Effect
HI 00805.115 Enrolling Beneficiaries Who Reside in Puerto Rico
HI 00805.120 Enrolling Beneficiaries in SMI who reside in a Foreign Country
HI 00805.125 Description of CMS Medicare Initial Enrollment Period Package Information Sent to Individuals
HI 00805.130 When an Enrollment Received by Mail Is Considered Filed
SM 00706.022 Preparing the Form CMS-40B
SM 00706.265 Exhibits of Form CMS-40B
SM 03040.055 General Enrollment Period (GEP) Processing Via MCS and POS
SM 03040.100 Description of Enrollment Automated Actions
TC 24001.040 Initial Enrollment Period (IEP)
TC 24001.060 General Enrollment Period (GEP)