Identification Number:
HI 00805 TN 72
Intended Audience:
Originating Office:Centers for Medicare & Medicaid Services (CMS)
Title:Supplementary Medical Insurance Entitlement
Type:POMS Full Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part HI – Health Insurance
Chapter 008 – Requirement for Entitlement and Termination
Subchapter 05 – Supplementary Medical Insurance Entitlement
Transmittal No. 72, 01/05/2023

Originating Component

CMS

Effective Date

Upon Receipt

Background

The POMS updates are required to support the legislative changes mandated in the Consolidated Appropriations Act 2021 (CAA)

Summary of Changes

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

Adding Example 3 to HI 00805.040A2 to illustrates deemed rules during a GEP.

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

A. Policy

Subject to the exceptions in HI 00805.050, a person who first becomes entitled to HI after 6/73 is deemed to have enrolled (is “automatically” enrolled) for SMI in accordance with the following rules.

NOTE: Automatic enrollment does not occur if the individual files with SSA a timely refusal of SMI (see HI 00805.055 B.2.).

1. During first 3 months of IEP

An individual is deemed enrolled for SMI in the third month of the IEP if the individual:

  • qualifies for HI without an application by attaining age 65 while on the benefit rolls; or

  • qualifies for HI without an application by being entitled for more than 24 months to a disability benefit (DIB, CDB, or DWB); or

  • files during or before the first 3 months of the IEP an SSA or RRB application which establishes entitlement to HI.

The individual becomes entitled to SMI beginning with the first month in which the individual is entitled to HI.

EXAMPLE: James Bennett established entitlement to DIB beginning 7/89 and is entitled to D-HI (HI based on disability) beginning 7/91, James' 25th month of DIB entitlement. James is deemed enrolled in D-SMI in the third month of James' IEP which began 4/1/91, and will be entitled to D-SMI beginning 7/91, the first month of D-HI entitlement.

2. After first 3 months of IEP

If a person files the application establishing entitlement to HI in the last 4 months of the IEP or during a GEP, the person is deemed to have enrolled for SMI at the time the HI application is filed.

If the application establishing entitlement to HI is filed after the IEP, but not during a GEP or SEP, the individual is deemed to have filed the enrollment request on the first day of next GEP.

EXAMPLE 1 (Before 1/1/2023): Mary Hanover did not file for monthly benefits and Medicare when Mary attained age 65 in 9/90. In 11/91, Mary filed and was awarded monthly benefits and HI. Mary did not refuse SMI. Because filing occurred after Mary's IEP, but not during a GEP, Mary is deemed to have enrolled in SMI on the first day of the next GEP (1/01/92) with coverage beginning 7/1/92.

EXAMPLE 2 (After 1/1/2023): Maggie Winston did not file for monthly benefits and Medicare when Maggie attained age 65 in 5/23. In 7/24, Maggie filed and was awarded monthly benefits and HI. Maggie did not refuse SMI. Because filing occurred after Maggie's IEP, but not during a GEP, Maggie is deemed to have enrolled in SMI on the first day of the next GEP (1/01/25) with coverage beginning 2/1/25.

EXAMPLE 3 (After 1/1/2023): Bobby Smith attained age 65 in 1/2022 but did not file for monthly benefits and Medicare. In 3/2023, Bobby filed for and was awarded monthly retirement benefits and HI. Bobby did not refuse SMI. Because filing occurred after Bobby's IEP, but during a GEP, Bobby is deemed to have enrolled in SMI on the first day of the current GEP (1/1/2023). Bobby will have SMI coverage beginning 02/1/2023.

B. Reference

  • Application filed with a hospital protects automatic enrollment in SMI, HI 00801.027 B.4.

  • Automatic enrollment in R-HI claims, HI 00805.045.

  • Reentitled disability beneficiaries, HI 00805.090.

  • Automatic enrollment is refused but, during the balance of the IEP, the individual submits a request for enrollment, HI 00805.055 B.4.


HI 00805 TN 72 - Supplementary Medical Insurance Entitlement - 1/05/2023