TN 65 (12-22)

HI 00805.154 Use of the Deemed IEP

A. Policy

1. General

The date of birth used for the deemed IEP is the person's date of birth for SMI (or Premium-HI) entitlement purposes. All provisions in the law and instructions relating to enrollment (including automatic enrollment (see HI 00805.035), premiums, and coverage periods), are applied as if the person's date of attainment of age 65 based on deemed IEP rules was the actual date of attainment.

2. If automatic enrollment does not apply

If an individual for whom a deemed IEP may be established is not subject to automatic enrollment and has not elected SMI, the individual should be contacted about the advantages of filing for SMI and given the opportunity to enroll.

3. Refuses SMI

In some cases, an individual who is otherwise eligible for enrollment on the basis of the deemed IEP provision may decline SMI enrollment (e.g., because the individual prefers other insurance, etc.). If that individual seeks to enroll for coverage at a later date, the deemed IEP protection no longer applies.

Similarly, if an individual was enrolled in SMI on the basis of a deemed IEP but that person allows coverage to lapse (either through non-payment of premiums or based on a request for termination), the premium protection afforded by the deemed IEP provision is not applicable should the person reenroll for coverage at a later date.

In determining the amount of the individual's SMI premium surcharge for late enrollment, months of non-coverage will be counted beginning with the month following the end of the person's actual IEP, keeping in mind that some months of non-coverage may not be countable because of the working aged provision (see HI 00805.295).

EXCEPTION: If an individual would be eligible for an SEP and/or premium surcharge rollback because of coverage under an employer group health plan (EGHP), the deemed IEP protection continues for that person. All determinations for SEP and/or premium rollback purposes will be based on the deemed date of birth and deemed IEP.

B. Examples

1. Reenrollment in SMI

In 8/91, Bill Smith, a fully insured worker, files for RIB and HI. Bill alleges, and has documentary evidence indicating, that Bill attained age 65 in 8 /91. FO development of proof of age shows Bill actually attained age 65 in 8/ 89, and that Bill could have enrolled during the 7-month period 5/89-11/89. Nevertheless, Bill's deemed IEP will be 5/91-11/91 based on the evidence Bill submitted.

Bill Smith's SMI coverage begins 9/91 in accordance with HI 00805.165 B.2., although Bill's entitlement to RIB and HI may be effective as early as 2/91. There is no increase in premiums since Bill is considered to have enrolled in the deemed IEP for both enrollment and premium purposes.

Bill Smith's SMI coverage is terminated effective 12/31/92 based on a request for termination filed in 11/92. Bill reenrolls for SMI during the 1994 GEP. In computing the premium Bill Smith must pay beginning 7/94, all months of non-coverage in SMI following expiration of Bill's actual IEP (5/89 - 11/ 89) through the end of the 1994 GEP must be counted, a total of 36 months. Thus, a 30% premium increase is applicable beginning 7/94.

2. Premium penalty

On 1/10/85, Joe Jones enrolled in SMI and presented documentary evidence supporting Joe's allegation that Joe attained age 65 in 8/83. The FO's development established that Joe Jones actually attained age 65 as of 8/10/ 80. Since the claimant was mistaken as to the claimant's true age and Joe's request for enrollment on 1/10/85 was filed during a GEP, Joe's request is accepted and coverage begins 7/1/85. Of course, Joe Jones' premium is increased by 10 percent because there are 16 elapsed months in the period 12/1/83-3/31/ 85 (see HI 01001.010 for rules concerning computation of premium increases).

3. Late evidence

In 3/91, Carol Jones (who had no EGHP coverage) telephoned a DO concerning Carol's right to HI and SMI, and stated that Carol would be age 65 in 8/91. Since Carol was working steadily and did not want reduced RIB, the FO advised Carol to file for RIB, HI and SMI in 5/91, and to bring proof of age at the time. Carol Jones then wrote for and obtained a birth certificate which showed Carol was born in 1923.

Carol immediately filed a claim for RIB, HI, and SMI alleging Carol was born 8/15 /23. Carol's DB was established 8/15/23. Carol was advised by the FO that Carol would be awarded RIB and HI effective 11/90, but that Carol's SMI could not start until 7/92 since Carol's SMI election had not been filed during an enrollment period open to Carol. Carol objected to the SMI delay because Carol had thought for many years that Carol would attain age 65 in 8/91 and had not known of the earlier DB until shortly before filing. Upon being asked to do so, Carol submitted documentary evidence indicating an 8/26 DB, and that Carol had been using this date of birth. On the basis of this evidence and Carol's 5/ 91 enrollment request, a deemed IEP is established and SMI allowed with entitlement effective 8/91.

4. Automatic enrollment

In 7/85, Dan Green, a fully insured worker, came to the FO and applied for RIB and HI. Dan presented documentary evidence supporting Dan's allegation that Dan would attain age 65 in 8/85. However, FO development of age showed that Dan had attained age 65 in 8/84, and could have enrolled in SMI during the 7-month period 5/84-11/84.

Because the documentary evidence shows that the claimant was mistaken as to the claimant's true age, Dan's deemed IEP is 5/85-11/85 and, since automatic enrollment applies, the claimant will be deemed to have enrolled for SMI during the first 3 months of Dan's deemed IEP, with entitlement effective August 1985.

If Dan Green's application establishing HI entitlement had been filed in 12/ 85, Dan would be deemed to have enrolled for SMI during the 1986 GEP and Dan's SMI coverage would begin 7/86. Dan's premium, because of the deemed IEP, would be at the standard (unincreased) rate.

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HI 00805.154 - Use of the Deemed IEP - 12/02/2022
Batch run: 12/02/2022