TN 19 (03-93)

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

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

Mr. Smith's SMI coverage is terminated effective 12/31/92 based on a request for termination filed in 11/92. He reenrolls for SMI during the 1994 GEP. In computing the premium Mr. Smith must pay beginning 7/94, all months of non-coverage in SMI following expiration of his 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, Mr. Jones enrolled in SMI and presented documentary evidence supporting his allegation that he attained age 65 in 8/83. The FO's development established that Mr. Jones actually attained age 65 as of 8/10/ 80. Since the claimant was mistaken as to his true age and his request for enrollment on 1/10/85 was filed during a GEP, his request is accepted and coverage begins 7/1/85. Of course, Mr. 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, Mrs. Jones (who had no EGHP coverage) telephoned a DO concerning her right to HI and SMI, and stated that she would be age 65 in 8/91. Since she was working steadily and did not want reduced RIB, the FO advised her to file for RIB, HI and SMI in 5/91, and to bring proof of age at the time. Mrs. Jones then wrote for and obtained a birth certificate which showed she was born in 1923.

She immediately filed a claim for RIB, HI, and SMI alleging she was born 8/15 /23. Her DB was established 8/15/23. She was advised by the FO that she would be awarded RIB and HI effective 11/90, but that her SMI could not start until 7/92 since her SMI election had not been filed during an enrollment period open to her. She objected to the SMI delay because