TN 22 (11-01)

HI 01001.055 Handling Supplementary Medical Insurance (SMI) Claims When Adjudication of Social Security or Railroad Retirement Claim is Delayed

There will be cases in which a person enrolling under Part B of Title XVIII (Health Insurance) will also be applying for Social Security benefits under Section 202 of the Social Security Act or for Railroad Retirement benefits. In many of these cases, it will be clear that the claimant is entitled to monthly benefits, as well as SMI, and a determination to this effect may be expected shortly. In these cases, the SMI enrollment will be processed simultaneously with his/her monthly benefit claim, and an enrollee to whom benefits are payable should be told his/her premiums will be deducted from benefits. However, if his/her monthly benefits will be subject to complete or indefinite suspension, he/she should be told to make payment upon receipt of a billing notice.

When the claimant is clearly eligible for SMI but there is any substantial question as to eligibility for monthly benefits (whether raised initially in the field office or during subsequent processing of the benefit claims), the SMI enrollment and an Hospital Insurance claim may have to be processed independently of the monthly benefit claim provided he/she is not a qualified railroad annuitant.

If the SMI enrollment is processed independently of the Social Security claim, the claimant will be treated for SMI premium purposes, in the same manner as a beneficiary in suspense, pending resolution of the retirement survivor insurance issue.

An award notice (SSA-L31-C1 with special paragraph) will be required. The notice will inform the claimant of his/her entitlement to SMI and (if appropriate) HI, and that his/her claim for monthly benefits is still pending. He/she will be notified as soon as a determination of entitlement is made.

If the monthly claim is denied before the end of the year and his/her premiums are then in arrears, he/she will be asked to pay all premiums due through the quarter (or month, for a monthly payer) following the month of the notice. If the Social Security claim is allowed, the person will be a beneficiary and the rules in HI 01001.040 and HI 01001.350 will apply.

The rules in this section do not apply to persons claiming only a special age 72 payment. With regard to these persons, see HI 01001.105.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0601001055
HI 01001.055 - Handling Supplementary Medical Insurance (SMI) Claims When Adjudication of Social Security or Railroad Retirement Claim is Delayed - 11/07/2001
Batch run: 01/27/2009
Rev:11/07/2001