HI 00820.120 Establishing a Closed Period of Disability Entitlement

AUDIENCE: BA, BATA, CCDIPS, ER, LCC, RECOVR, EE, EHS, EIE, IES

The equitable relief provisions stated in HI 00830.020 A. apply in closed period DIB cases involving HI/SMI as far as offering the beneficiary the choice of accepting either no SMI coverage or fully retroactive SMI coverage. However, take no “equitable relief” action which would have the effect of allowing Medicare coverage after the actual disability has ceased to exist. In these situations, provide SMI coverage if the beneficiary wants SMI for the same period as the HI coverage, i.e., the 25th month of DIB through the month before the month of DIB cessation.

EXAMPLE:

An award is received with DIB entitlement retroactive to June, 1974. Entitlement to disability benefits ceases effective March, 1977. COM is May, 1977. If the beneficiary chooses retroactive SMI entitlement, the period that HI/SMI should be in effect is June, 1976 through February, 1977. See SM 00850.505 for HI/SMI coding in MADCAP.

This procedure only applies when initially establishing HI/SMI entitlement. Also, in the notice informing the beneficiary that he has a choice of having SMI fully retroactive or no SMI at all, he should be informed that if SMI is desired, he must remit payment of the amount of the premiums due with his request for SMI entitlement.

There will be instances in which a T claimant entitled under the Renal Disease provisions becomes entitled to a closed period of entitlement to disability benefits. These cases require two separate MADCAP actions and special handling as follows:

1. A. 

   Process a one-check-only award action through MADCAP showing a T to A entitlement conversion. Show the A in “S-9” status effective with the month following the last month of disability entitlement and continuing. Do not change the HENC/SENC of “K” previously established on the T claim.

2. B. 

   On the following day, terminate the A record (reason “T-8” ) and reinstate the T claim. (The HENC/SENC of “K” will ensure that the T record will be placed in LAF “U” status.)