TN 10 (08-20)

SL 30001.395 Voluntary Medicare Hospital Insurance Coverage for Pre-1986 Hires


Social Security Act, Section 218(n); Public Law 99-272, ยง 13205

States may execute a Section 218 Agreement with the Social Security Administration (SSA) to provide Medicare Hospital Insurance (HI) coverage voluntarily to employees who both (1) are not already subject to mandatory Medicare coverage due to continuous employment since before April 1, 1986, and (2) do not receive Medicare coverage through participation in Social Security through either voluntary Section 218 coverage or under the mandatory coverage rules (see SL 50001.000), SSA generally refers to Modifications for voluntary Medicare coverage as "HI-only Agreements." HI-only Agreements are part of a State's Section 218 Agreement.

The purpose of a HI-only Agreement is generally to provide HI coverage to non-covered employees who cannot obtain Medicare coverage because they were hired before April 1, 1986, and have been in continuous employment since that time (see SL 50001.510).

A. Coverage

States may obtain Medicare HI-only coverage for State and local government employees who were hired before April 1, 1986, and are not covered mandatorily for Medicare. Most employees of State and local governments hired on or after April 1, 1986, are covered mandatorily for Medicare as described in POMS SL 50001.510. There is no provision for granting retroactive HI wage credits for State or local government employment prior to 1986. Medicare HI-only coverage under a Section 218 Agreement cannot begin before April 1, 1986.

B. Referendum rules

The same referendum and Modification rules for Social Security and Medicare coverage under Section 218 apply to HI-only Agreements. For example, if the State is authorized to conduct a divided-vote retirement system referendum, the State may use the divided- vote procedure to provide HI coverage.

If a State or local government employee is covered mandatorily for Medicare when a referendum is conducted for a HI-only Agreement for other employees of the same employing entity, the employee is not eligible to vote in the referendum.

The required exclusions from Medicare coverage (see SL 50001.510B) also apply to HI-only Agreements. The State may elect Section 218 optional exclusions (see SL 30001.357).


Medicare HI-only Agreements extend HI coverage to the individual employees and not the position. Medicare coverage is otherwise mandatory for all employees hired on or after April 1, 1986, regardless of their positions.

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SL 30001.395 - Voluntary Medicare Hospital Insurance Coverage for Pre-1986 Hires - 08/27/2020
Batch run: 08/27/2020