SSA's Policy Information Site

Subchapter List for Requirement for Entitlement and Termination

HI 008: Requirement for Entitlement and Termination

HI 00800: Requirement for Entitlement and Termination

HI 00800.000: Requirement for Entitlement and Termination - Table of Contents

HI 00801: Hospital Insurance Entitlement

HI 00801.000: Hospital Insurance Entitlement - Table of Contents

HI 00801.001: Introduction

HI 00801.002: Waiver of HI Entitlement by Monthly Beneficiary

HI 00801.006: Requirements for Entitlement - Regular Insured Provision

HI 00801.008: HI Entitlement for Aged Spouse of Age 62 Worker

HI 00801.011: Qualified Railroad Retirement Beneficiary (QRRB) Defined—Aged

HI 00801.012: Deemed QRRB

HI 00801.017: Proof of Age

HI 00801.022: Application Requirement and Effective Date for Hospital Insurance for Insured Beneficiaries

HI 00801.027: Taking the Claim

HI 00801.029: Special Development Considerations

HI 00801.032: Establishing Entitlement

HI 00801.034: Withdrawal Considerations

HI 00801.047: Requirements for Entitlement - Deemed Insured Provision

HI 00801.052: Application Requirement and Effective Date for Hospital Insurance for Deemed Insured Beneficiaries

HI 00801.056: Eligibility Under Regular Insured Provision

HI 00801.058: Proof of Age

HI 00801.061: Residence and Citizenship/Alien Status Requirements

HI 00801.066: QC Requirement

HI 00801.071: FEHBA eligibility preclusion

HI 00801.076: Coverage Under FEHBA

HI 00801.081: Establishing FEHBA Eligibility

HI 00801.086: Preclusion Because of Crimes Against U.S

HI 00801.091: Filing the Claim

HI 00801.096: Completion of Items on SSA-18F5

HI 00801.106: RR Involvement

HI 00801.111: Determining RR Status

HI 00801.116: HI Leads from RRB

HI 00801.121: FORM RR-80 (Report of Health Insurance Information — SSA Jurisdiction)

HI 00801.126: HI for the Uninsured

HI 00801.131: Eligibility for Premium-HI

HI 00801.133: Enrollment and Coverage Periods

HI 00801.134: HI Premium Reduction for Aged Individuals With At Least 30 Quarters of Coverage

HI 00801.135: HI Premium Reduction to Zero for Certain Public Retirees

HI 00801.137: Initial Interview

HI 00801.138: Application for Premium HI

HI 00801.139: QMB Provisions

HI 00801.140: Premium-Part A Enrollments for Qualified Medicare Beneficiaries (QMBs) – Part A Buy-In States and Group Payer States

HI 00801.142: Transfer Enrollment Period for Individuals Enrolled in Medicare Managed Care Plans

HI 00801.143: Evidence of Enrollment in A Medicare Managed Care Plan

HI 00801.144: Taking the Claim

HI 00801.145: Withdrawal of Application for Enrollment

HI 00801.146: Entitlement to HI for the Disabled

HI 00801.151: D-HI for QRRB Annuitants

HI 00801.152: Counting Months in Reentitlement Cases

HI 00801.153: D-HI Qualifying Period for Individuals Awarded DIB Under Section 332 of P.L. 98-21

HI 00801.154: SSI/SSP Credit for Disabled Deceased Spouse

HI 00801.155: Deemed Entitlement to DWB for Medicare

HI 00801.161: Medicare Continuation During Appeal of Title II Disability Cessation

HI 00801.163: Disability Cessation Affirmed or Reversed After Benefit Continuation

HI 00801.164: Medicare Entitlement During the Provisional Benefit Period – Expedited Reinstatement of Disability Benefits

HI 00801.165: Medicare Terminations When The Provisional Benefit Period Ends

HI 00801.166: Favorable Medical Decisions

HI 00801.167: Examples Of How Disability Determinations Affect Medicare Coverage During The Provisional Benefit Period

HI 00801.170: Premium-HI for the Working Disabled

HI 00801.172: Taking Premium-HI Claims for the Working Disabled

HI 00801.174: Withdrawal of Enrollment

HI 00801.186: HI Based on End Stage Renal Disease

HI 00801.191: Requirements for Entitlement to R-HI

HI 00801.196: ESRD Medicare Application Requirement

HI 00801.197: Withdrawal of Application

HI 00801.201: R-HI Insured Status

HI 00801.206: Course of Dialysis

HI 00801.211: Kidney Transplant - Definition

HI 00801.215: ESRD Medicare Date of Entitlement - General Policy

HI 00801.216: ESRD Medicare Date of Entitlement - Dialysis

HI 00801.221: ESRD Medicare Date of Entitlement - Transplant

HI 00801.226: Date of ESRD Medicare Entitlement Based on Self-Dialysis Training

HI 00801.233: Medical Evidence of ESRD - Form CMS-2728-U3

HI 00801.235: Development of Claims (ESRD)

HI 00801.246: R-HI and R-SMI Benefits - Policy

HI 00801.247: Medicare as Secondary Payer of ESRD Benefits

HI 00801.248: Effect of Immunosuppressive Drug Coverage on Filing for R-HI and R-SMI

HI 00801.251: Renal SMI Enrollment

HI 00801.256: SMI Premiums

HI 00801.257: State Buy-In Considerations

HI 00801.258: Relationship Between R-HI, D-HI, and Age 65 HI

HI 00801.261: HI Freeze

HI 00801.300: District Office Final Authorization (DOFA) of ESRD Medicare Awards and Disallowances

HI 00801.302: Medical Review of ESRD Claims

HI 00801.308: Form SSA-892-U2 (End-Stage Renal Disease (ESRD) Medicare Determination)

HI 00801.309: SSA-892-U2 (End-Stage Renal Disease (ESRD) Medicare Determination) — Exhibit

HI 00801.325: Notice to RRB: ESRD Medicare Award — LAF Code on MBR is E-Exhibit

HI 00801.400: Medicare Qualified Government Employment (MQGE)

HI 00801.405: HI Entitlement for Auxiliaries and Survivors Based on MQGE

HI 00801.410: Insured Status Based on MQGE

HI 00801.415: Evidence of MQGE — Earned GEQCs

HI 00801.420: Deemed GEQCs for Federal Employees — Employee Status During 1/83

HI 00801.425: Deemed GEQCs for Federal Employees — Pre-1983 Earnings

HI 00801.430: Using CS DATA Element to Determine Fully Insured Status

HI 00801.435: Taking the Claim

HI 00801.440: Special Rules Applicable to MQGE Claims

HI 00801.901: RR-80;Report of Health Insurance Information, SSA Jurisdiction

HI 00801.902: CMS 2728-U3, End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration - Exhibit

HI 00803: Medicare Entitlement for Individuals Exposed to Environmental Health Hazards (EHH)

HI 00803.000: Medicare Entitlement for Individuals Exposed to Environmental Health Hazards (EHH) - Table of Contents

HI 00803.001: Hospital Insurance (HI) Entitlement for Individuals Exposed to Environmental Health Hazards (EHH)

HI 00803.010: EHH Beneficiary Entitled to HI Based on Age, Disability, or End Stage Renal Disease (ESRD)

HI 00803.020: Protective Filing and Leads for EHH Medicare

HI 00803.030: EHH Medicare Application

HI 00803.040: Developing Presence in Lincoln County, Montana, for Entitlement to EHH Medicare

HI 00803.050: Developing Medical Requirement for Entitlement to EHH Medicare

HI 00803.080: Withdrawal of EHH Medicare Application

HI 00803.090: Termination of HI and SMI for Individuals Exposed to Environmental Health Hazards (EHH)

HI 00803.100: EHH Medicare Entitlement Appeals

HI 00803.200: Medicare Pilot Program for Asbestos-Related Disease

HI 00803.210: Special Enrollment Period for Medicare Pilot Program for Asbestos-Related Disease (July 1, 2011 to June 30, 2012)

HI 00803.220: Special Enrollment Period for Expanded Medicare Pilot Program for Asbestos Related Disease (April 1, 2014 to March 31, 2015)

HI 00805: Supplementary Medical Insurance Entitlement

HI 00805.000: Supplementary Medical Insurance Entitlement - Table of Contents

HI 00805.001: Supplementary Medical Insurance (Part B)

HI 00805.005: Eligibility for SMI

HI 00805.006: Enrollee Ceases to Meet Eligibility Requirements

HI 00805.007: SMI Eligibility for Foreign Residents

HI 00805.010: Rules on Enrollment Periods

HI 00805.015: Initial Enrollment Period

HI 00805.020: Determining the IEP for Aged Alien Non-Beneficiaries

HI 00805.025: General Enrollment Period (GEP)

HI 00805.030: Relationship Between Initial and General Enrollment Periods

HI 00805.035: Nature and Purpose of Automatic Enrollment

HI 00805.040: Automatic (Deemed) Enrollment - Aged and Disabled Individuals

HI 00805.045: Deemed Enrollment - R-HI Beneficiaries

HI 00805.050: When Deemed Enrollment Does Not Apply

HI 00805.055: Notice of Right to Refuse Deemed Enrollment

HI 00805.060: Voluntary Request for Supplementary Medical Insurance (SMI) Enrollment

HI 00805.065: Enrollment Form Not in File

HI 00805.070: Who May Execute a Valid Request for SMI Enrollment

HI 00805.075: Prescribed SMI Enrollment Forms

HI 00805.080: Withdrawal of Enrollment Before It Goes Into Effect

HI 00805.085: Effect of Reentitlement to HI After Termination

HI 00805.090: SMI Enrollment of Reentitled Disability Beneficiaries

HI 00805.095: What Constitutes an Effective Enrollment

HI 00805.100: Individual Incapacitated During IEP, GEP, or SEP

HI 00805.105: Enrollee Needs Help in Paying Premiums or Claiming Reimbursement

HI 00805.110: SMI Enrollment Processes

HI 00805.115: Enrolling Beneficiaries in SMI who Reside in Puerto Rico

HI 00805.120: Enrolling Beneficiaries in SMI who Reside in a Foreign Country

HI 00805.125: Description of CMS Medicare Initial Enrollment Period Package Information Sent to Beneficiaries

HI 00805.126: Exhibits of Medicare Initial Enrollment Period Packages

HI 00805.130: When an Enrollment Received by Mail Is Considered Filed

HI 00805.135: Extending the Enrollment Period

HI 00805.140: Enrollment Action - Claim for Entitlement Pending When IEP or GEP Begins

HI 00805.150: Deemed IEP Based on Alleged Date of Attainment of Age 65

HI 00805.151: The Date of Birth to Be Established

HI 00805.152: Examples of Deemed IEP

HI 00805.153: Prior Month Attainment Rule

HI 00805.154: Use of the Deemed IEP

HI 00805.155: Enrollment Request Filed After Age 65 But Before Deemed Date of Attainment

HI 00805.160: Coverage Period Defined

HI 00805.165: Individual Enrollment - When A Coverage Period Begins

HI 00805.170: Conditions for Providing Equitable Relief

HI 00805.175: Evidence of Government Error or Delay

HI 00805.180: Payment of Premium Arrearage

HI 00805.185: Processing Equitable Relief Cases

HI 00805.190: Common Situations Involving Equitable Relief

HI 00805.195: Enrollment Not Processed Timely

HI 00805.200: SMI Awarded on Later of 2 Timely Enrollment Requests

HI 00805.205: Delayed or Incorrect Advice Frustrated Enrollment or Termination Rights

HI 00805.210: SMI Awarded Erroneously

HI 00805.215: SMI Terminated Erroneously

HI 00805.220: Inadvertent Failure to Bill for or Deduct Premiums - Non-Buy-In Cases

HI 00805.230: Delayed Deletion from State Buy-In Rolls Prejudices Termination Rights

HI 00805.235: Special Considerations for Premium-HI

HI 00805.236: Current Equitable Relief Considerations Involving CHAMPUS

HI 00805.240: Other Situations Where Equitable Relief May Apply

HI 00805.245: Development for SMI Enrollment of Civil Service Annuitants and Their Spouses

HI 00805.250: SMI Enrollment for Qualified Railroad Retirement Beneficiary

HI 00805.255: SMI Enrollment of Holocaust Survivors

HI 00805.260: Medicare Entitlement for Residents of the Northern Mariana Islands

HI 00805.265: The Special Enrollment Period -- Definition - Group Health Plans

HI 00805.266: Description of Terms Used in the Special Enrollment Period and Premium Surcharge Rollback Provisions - Group Health Plans

HI 00805.270: General Eligibility Requirements for the Special Enrollment Period - Group Health Plans

HI 00805.275: Special Enrollment Period (SEP) Enrollments - Group Health Plans

HI 00805.276: SMI Effective Date for SEP Enrollments - Group Health Plans

HI 00805.277: Processing Special Enrollment Period (SEP) Enrollments

HI 00805.278: SEP Enrollments for Aged Beneficiaries with Hours’ Bank Arrangements - Group Health Plans

HI 00805.280: Premium Surcharge Rollback for Individuals With GHP/LGHP Coverage

HI 00805.281: Examples of the Elimination or Rollback of Premium Surcharges for Individuals With GHP/LGHP Coverage

HI 00805.285: The SEP and Premium Surcharge Rollback for Individuals Eligible for Premium-HI - Group Health Plans

HI 00805.290: SEP Requirements for Self-employed Beneficiaries - Group Health Plans

HI 00805.295: Evidence of GHP or LGHP Coverage Based on Current Employment Status

HI 00805.300: Disability SEP for Beneficiaries for Whom Medicare is Now the Primary Payer - Group Health Plans

HI 00805.310: Disability SEP Enrollments - Group Health Plans

HI 00805.315: GEP Enrollment For Disabled Beneficiaries Who Do Not Enroll During The D-SEP - Group Health Plans

HI 00805.320: Equitable Relief for Disabled Individuals Covered Under a GHP/LGHP

HI 00805.322: Equitable Relief for Domestic (Or Life) Partners Covered Under a GHP

HI 00805.324: Equitable Relief for Enrollment Request Affected by Major Disasters

HI 00805.325: GHP Coverage Under TRICARE (Formerly CHAMPUS)

HI 00805.330: Individuals with GHP Coverage Under COBRA

HI 00805.340: Exhibit of Form CMS (L564 Request for Employment Information)

HI 00805.345: CMS Regional Office MSP Coordinators

HI 00805.346: Special Enrollment Period (SEP) for Eligible Postal Annuitants and Eligible Family Members to Enroll in Medicare Part B

HI 00805.350: Special Enrollment Period for International Volunteers

HI 00805.355: Evidentiary Requirements for the SEP or Premium-Surcharge Rollback for International Volunteers

HI 00805.365: Premium Surcharge Rollback for International Volunteers

HI 00805.370: Processing Requests for SMI and/or Premium - HI Termination

HI 00805.382: Special Enrollment Period (SEP) for Exceptional Conditions

HI 00805.383: Exceptional Conditions Special Enrollment Period (SEP) for Individuals Impacted by an Emergency or Disaster Declared by Federal, State or Local Government Entities

HI 00805.384: Exceptional Conditions Special Enrollment Period (SEP) for Group Health Plan (GHP) or Employer Misrepresentation

HI 00805.385: Exceptional Conditions Special Enrollment Period (SEP) for Termination of Medicaid Eligibility

HI 00805.386: Exceptional Conditions Special Enrollment Period (SEP) for Formerly Incarcerated

HI 00805.387: Special Enrollment Period (SEP) for Other Exceptional Conditions

HI 00805.400: Medicare Part B Immunosuppressive Drug Coverage (Part B-ID)

HI 00805.700: Outmoded Rules on Enrollment Periods and Coverage

HI 00805.705: Supreme Court Decision Affecting the Alien Residence Requirement for SMI ( Mathews v. Diaz )

HI 00805.721: Equitable Relief for Certain Individuals Dually Enrolled in Both Medicare and a Marketplace Plan

HI 00805.725: Equitable Relief for Certain CHAMPVA Beneficiaries

HI 00805.730: Certain Military Retirees and Dependents Receiving Health Care at Military Hospitals

HI 00805.731: Change in CHAMPUS Law Required Relief in 1992

HI 00805.735: Cuban Refugees Whose Status Was Adjusted Under P.L. 89-732

HI 00805.740: SEP and Premium Surcharge Provisions for the Ages Prior to the 1986 Amendments

HI 00805.750: SEP and Premium Surcharge Requirements in Effect for the Aged Prior to August 1986

HI 00805.751: SEP and Premium Surcharge Requirements for the Aged Effective 8/86

HI 00805.752: SEP Enrollment Requirements for Disabled Beneficiaries Covered Under an LGHP Prior to the 1994 Amendments (Disabled Active Individuals)

HI 00810: Medicare Processes

HI 00810.000: Medicare Processes - Table of Contents

HI 00810.010: How the Medicare Attainments and Leads Process Works

HI 00815: State Enrollment of Eligible Individuals

HI 00815.000: State Enrollment of Eligible Individuals - Table of Contents

HI 00815.001: State Payment of Medicare Premiums (Buy-In Program)

HI 00815.006: Establishing State Payment of Medicare Part B Premiums (State Buy-In)

HI 00815.018: When State Payment of Medicare Premiums (State Buy-In) Begins

HI 00815.021: The End of State Payment of Medicare Premiums Under a Buy-in Agreement

HI 00815.023: Medicare Savings Programs Income Limits

HI 00815.024: SSA’s Role in Medicare Savings Programs (MSP) Applications

HI 00815.025: SSA Outreach to Low-Income Medicare Beneficiaries – Extra Help and Medicare Savings Programs

HI 00815.030: Establishing State Buy-in for Medicare Part B through The Public Welfare Accretion Process

HI DAL00815.030: Establishing State Buy-In For SMI In Initial Claims through the Public Welfare (PW) Accretion Process (RTN 05, 10/2015)

HI 00815.033: SSA/CMS Processing of PW Accretion

HI 00815.036: State Response to Public Welfare (PW) Accretion

HI 00815.039: Effect of Buy-In on the Individual

HI 00815.042: Implications and Options for Beneficiaries When State Payment of Medicare Premiums (State Buy-in) Ends

HI 00815.045: Establishing Buy-In Eligibility for Persons Who Refuse to Cooperate — State Accretions

HI 00815.048: Establishing Buy-In Eligibility for Persons Who Refuse to Cooperate — CMS Accretions Under SSI Program

HI 00815.051: Establishing Buy-In Eligibility for Deceased Individuals

HI 00815.055: Establishing State Buy-In Eligibility for Railroad Retirement Board (RRB) Annuitants

HI 00815.060: Centers for Medicare & Medicaid Services (CMS) State Buy-In Data Processing

HI 00815.063: Systems Processing of State Responsibility Items

HI 00815.066: Systems Processing of CMS Responsibility Items

HI 00815.070: State/Carrier/Intermediary/CMS/SSA Coordination on Problem Cases Involving HI Query Codes 42, 44, or 56

HI 00815.073: SSA DO/BO Assistance to States

HI DAL00815.073: Field Office (FO) Assistance to the Texas Health and Human Services Commission

HI 00815.076: Social Security Administration (SSA) DO/BO Action Upon Receipt of HI/MBR Status Query (HMQ) Reply

HI 00815.079: Reconciliation of SSI Master Record and the SID (Supplemental Income Data) Line on the MBR

HI 00815.082: Social Security Administration Field Office (FO) Procedures for Resolving Individual State Buy-In Problem Cases Due to Problem with SSR-MBR Interface

HI 00815.085: SSA DO/BO Procedures for Resolving Individual Buy-In Problem Cases Not Involving SSR-MBR Interface

HI 00815.088: Servicing DO/BO Processing of CMS-1957

HI 00815.091: State Agency and Parallel DO Processing of CMS-1957

HI 00815.094: CMS Central Office Procedures for Resolving Buy-In Problem Cases

HI 00815.204: Form CMS-1957 (SSO Report of State Buy-In Problem)

HI 00815.208: Buy-In Form for Railroad Annuitants - Sample

HI 00820: Terminations and Withdrawals

HI 00820.000: Terminations and Withdrawals - Table of Contents

HI 00820.001: Introduction - Terminations and Withdrawals

HI 00820.005: Regular Insured Termination

HI 00820.010: Termination Under the Deemed Insured Provision

HI 00820.015: Termination of Premium-HI for the Aged

HI 00820.025: Termination of Disability HI (D-HI)

HI 00820.027: Termination of Premium-HI for the Working Disabled

HI 00820.030: Termination of R-HI

HI 00820.035: Termination of SMI Entitlement

HI 00820.045: Voluntary Termination of SMI

HI 00820.050: Effective Date of Voluntary Termination

HI 00820.055: Cancellation of Voluntary Termination Request

HI 00820.060: Voluntary Termination Interview

HI 00820.065: Tailoring Interview to the Individual Situation

HI 00820.070: Field Office Handling of Requests for Termination

HI 00820.075: Processing Center Processing of Termination

HI 00820.100: Cessation of Disability

HI 00820.105: Cessation of Renal Disease (RD)

HI 00820.110: Life Terminations for Disabled or Deemed Disabled Beneficiaries

HI 00820.115: Life Terminations for Aged Auxiliary Beneficiaries

HI 00820.120: Establishing a Closed Period of Disability Entitlement

HI 00820.130: Manual Processing of Withdrawals

HI 00820.140: Reversing an Erroneous Termination

HI 00820.901: Exhibit 1: CMS-1763 (Request for Termination of Premium Hospital and/or Supplementary Medical Insurance)

HI 00820.904: Exhibit 4: Notice to R-HI Beneficiary About Termination Because of Transplant

HI 00825: Inquiries and Referrals for HI/SMI

HI 00825.000: Inquiries and Referrals for HI/SMI - Table of Contents

HI 00825.001: HI/SMI Inquiries Received from Beneficiaries

HI 00825.005: Determining Enrollment Status

HI 00825.015: Premium Inquiries

HI 00825.020: Correspondence Pertaining to State Buy-In, Group Payers, Civil Service, or RRB

HI 00825.055: Undeliverable HI/SMI Letters and Forms

HI 00825.060: HI/SMI Notices and Forms HCFA-40B, HCFA-40D

HI 00825.065: Forms CMS-1966, Medicare Health Insurance Card

HI 00825.070: Undeliverable SMI Premium Notice

HI 00825.075: Processing Returned SMI Refund Checks

HI 00825.080: Establishing a SMI Premium Payer for Uninsured (T, M, J, or K) Enrollee

HI 00825.095: FormCMS-2178-U2, HIB/SMIB Entitlement Problem — Priority

HI 00825.100: Entitlement Issue

HI 00825.105: Miscellaneous Issue

HI 00825.110: Interpretation of Combined HIM and MBR Query Replies

HI 00825.115: CMS-1725 (Program Service Center Referral)

HI 00825.120: Telephone Calls

HI 00825.125: Disclosure of Information

HI 00825.130: Disposition of Completed Correspondence

HI 00825.905: Phone Call Record of Critical HI/SMI Issue — Sample

HI 00825.906: Sample MBR Reply to Combined MBR/HIM Query

HI 00825.907: Sample HIM Reply to Combined MBR/HIM Query

HI 00825.908: Form SSA-3339-U2, Interim Reply to HIB/SMIB Referrals

HI 00825.909: Transmittal Used by OCRO to Forward Earnings Statements to PSC

HI 00825.910: HCFA-1778 HIMEXC PSC Request Card

HI 00825.912: Form CMS-1725 (Program Service Center Referral)

HI 00825.913: Health Insurance Printout (HIPO)

HI 00830: Processing Equitable Relief Inquiries

HI 00830.000: Processing Equitable Relief Inquiries - Table of Contents

HI 00830.001: Granting Equitable Relief

HI 00830.005: When to Consider Relief

HI 00830.010: Evidence Required

HI 00830.015: Premium Waiver Determinations

HI 00830.020: Enrollment/Disenrollment Determination

HI 00830.025: Erroneous Entitlement to Hospital Insurance (HI) and Supplementary Medical Insurance (SMI) Coverage

HI 00830.030: Incorrect SMI Termination

HI 00830.035: Failure to Bill or Deduct Premiums

HI 00830.040: Premium—HI Cases

HI 00830.045: Delayed Deletions from State Buy-In

HI 00830.050: Erroneous Premium Refund

HI 00830.055: Delayed Terminations

HI 00830.060: Installment Payments for Retroactive Premiums

HI 00830.065: Exhibit—Summary Sheet, Installment Payments for Retroactive Premium Due Amounts

Program Operations Manual System (POMS)

Subchapter List for Requirement for Entitlement and Termination