Identification Number:
HI 00801 TN 48
Intended Audience:See Transmittal Sheet
Originating Office:Centers for Medicare & Medicaid Services (CMS)
Title:Hospital Insurance Entitlement
Type:POMS Transmittals
Program:Medicare,Medicaid
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part HI – Health Insurance
Chapter 008 – Requirement for Entitlement and Termination
Subchapter 01 – Hospital Insurance Entitlement
Transmittal No. 48, 05/17/2022

Audience

PSC: BA, CA, CS, DS, IES, ILPDS, IPDS, ISRA, PETE, RECONR, SCPS, TSA, TST;
OCO-OEIO: BET, CR, CTE, EIE, ERE, FCR, FDE, PETL, RECONE, RECONR;
OCO-ODO: BET, BTE, CCE, CR, CST, CTE, CTE TE, DEC, PAS, PETE, PETL;
FO/TSC: CS, CS TII, CSR, CTE, DRT, FR, OA, OS, RR, TA, TSC-CSR;

Originating Component

CMS

Effective Date

Upon Receipt

Background

This is a full transmittal we updated the policy and procedures in sections HI 00801.133. The changes were to improve the readability, tone and content of the policies.

Summary of Changes

HI 00801.133 Enrollment and Coverage Periods

 

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

 

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

 

HI 00801.170 Premium-HI for the Working Disabled

 

HI 00801.251 SMI Enrollment

 

HI 00801.133 Enrollment and Coverage Periods

A. Policy — Basic rules

An individual who is not subject to Part A buy-in as discussed in HI 00801.140 may only enroll for Premium-HI during the
following periods:

  • Initial Enrollment Period (IEP): the IEP begins 3 months before the first month of eligibility (generally, the month of attainment of age 65; see HI 00801.131 C. for exceptions) and continues for 7 months. Coverage based on an IEP enrollment begins as provided for in HI 00805.165. The IEP for Premium-HI is generally the same as the IEP for SMI.

  • General Enrollment Period (GEP): the GEP is January through March of each year. Coverage based on a GEP enrollment begins the first day of the month following the month of enrollment.

  • Special Enrollment Period (SEP): the SEP is an enrollment opportunity for individuals whose employer group health plan coverage based on current employment has ended. (See HI 00805.265ff. for a complete discussion of the SEP provisions.)

  • Transfer Enrollment Period: This is a special enrollment opportunity for Medicare beneficiaries who are also Health Maintenance Organization (HMO) or Competitive Medical Plan (CMP) enrollees and whose HMO or CMP enrollment is terminated either on a voluntary basis or because of termination of the HMO or CMP contract. (See HI 00801.143 for further discussion.)

B. Policy — Additional considerations

The following provisions which apply to SMI enrollment also apply to Premium-HI enrollment for the Aged:

  • Deemed IEP (see HI 00805.150ff.);

  • Equitable Relief (see HI 00805.170ff.);

  • Group Premium Payer (see HI 01001.230).

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

A. Introduction

Prior to 01/01/99, uninsured enrollees were only required to have SMI coverage when joining a Medicare Managed Care Plan (MMCP) with a Medicare contract. Thus, individuals who enrolled in an MMCP prior to 01/01/99, and do not have HI coverage because they are uninsured, may be offered hospital insurance coverage by the plan.

A contract with an MMCP can be terminated either by the plan or by Medicare. In addition, Medicare beneficiaries may voluntarily terminate their enrollment in an MMCP the month after they request such disenrollment. However, when enrollment in the MMCP ends, these individuals are left without the possibility of HI coverage for as many as 15 months, depending on the date of disenrollment.

B. Background

To alleviate the hardship that contract termination or voluntary disenrollment can cause uninsured individuals who are enrolled in an MMCP, as defined in HI 00208.066C.2. and D., the law was amended beginning 2/1/91, to provide an additional opportunity to enroll in Premium-HI and relief from the HI premium surcharge for late enrollment.

NOTE: This provision has absolutely no effect on SMI enrollment or SMI premium computation.

C. Policy

1. Who can enroll

The transfer enrollment period is for individuals age 65 or over, who meet the requirements in HI 00801.131 for entitlement to Premium-HI for the Aged.

NOTE: There is no requirement as to how long the individual must have been enrolled in a Medicare Managed Care Plan to qualify for the transfer enrollment period. In addition, enrollment in the MMCP need not be ending in order for the beneficiary to utilize the transfer enrollment period.

2. When can enrollment occur

An individual who meets the requirements in HI 00801.142C.1. may enroll:

  • during any of the 8 consecutive months following the last month during any part of which the individual was enrolled in the MMCP.

 

3. Transfer Enrollment Period and General Enrollment Period overlap

An individual who enrolls in a transfer enrollment period (TEP) month that occurs in January, February or March can elect to have the enrollment processed as either a GEP enrollment or as a TEP enrollment (see HI 00801.144).

If the individual chooses a GEP enrollment, coverage begins the first day of the month following the month of enrollment. The premium surcharge is calculated using the months through the end month of enrollment. However, all months of enrollment in an MMCP meeting the definition in HI 00208.066C.2. and HI 00208.066D. are subtracted from the calculation.

4. Coverage beginning date

If the individual enrolls in Premium-HI while still enrolled in an MMCP, or during the first full month when not enrolled in an MMCP, Premium-HI begins with either:

  • the first day of the month of Premium-HI enrollment, or

  • at the individual's option, with the first day of any of the following 3 months.

If the individual enrolls in Premium-HI during any of the remaining 7 months of this transfer enrollment period, Premium-HI coverage begins with the first day of the month after the month of Premium-HI enrollment.

5. Premium surcharge relief

The HI premium surcharge is determined by following the instructions in HI 01005.010. This means that all months after the end of the IEP through the end of the transfer enrollment period must be considered. However, in determining if there will be a Premium-HI surcharge and how long it will be payable, the following months are excluded.

  • Months in the remainder of the transfer enrollment period during which the individual is covered under Premium-HI.

Months of MMCP enrollment are excluded even if the individual is already enrolled in Premium-HI or is enrolling under GEP procedures.

6. Effective date

The transfer enrollment period provisions (including relief from a premium surcharge for months of MMCP enrollment) were effective beginning 2/1/91.

D. Examples

1. Enrollment in MMCP is ending

Jenny, who is uninsured, is entitled to SMI effective 6/16, the month she attained age 65. In 4/18, she enrolled in a Medicare Managed Care Plan. In 9/21, she is notified that the managed care plan is terminating its Medicare contract effective 12/31/21. If Jenny enrolls in Premium-HI at any time between 9/1/21 and 1/31/22, she can elect Premium-HI with the month of enrollment or any of the following 3 months.

If she enrolls between 2/1/22 and 8/31/22, she will have Premium-HI effective with the month after the month of enrollment.

2. Premium surcharge only

Will, who was age 65 in 4/95, did not enroll in SMI until 3/97. He was assessed a 10% premium surcharge when SMI became effective in 7/97. He also enrolled in an MMCP in 7/97. He terminated his MMCP enrollment effective with 12/31/98 and enrolled in during the 1999 GEP. His Premium-HI premium was increased by 10%, payable for 6 years because there were 44 months (3 full years) that elapsed between the end of his IEP and the GEP in which he enrolled (8/95-3/99)

In 6/00, he applied for a premium surcharge rollback because of his enrollment in the MMCP. His Premium-HI surcharge remains at 10 percent, but the period of time for which it is payable is reduced to 4 years. The 18 months from 7/97 through 12 /98, during which he was enrolled in an MMCP, were subtracted from the 44 months that elapsed after his IEP and through the end of the 1999 GEP , leaving 26 chargeable months (2 full years, instead of 3 full years).

3. No premium surcharge

Carl was entitled to SMI effective 12/16 when he attained age 65. He enrolled in an MMCP with coverage effective 4/17. The MMCP went out of business in 12/21, and Carl enrolled in Premium-HI in 6/22. Premium-HI entitlement begins 7/22. There is no penalty for late enrollment because the only months after the end of Carl’s IEP which are chargeable for premium surcharge purposes are the 6 months he was not covered by the MMCP (01/22 – 06/22).

4. Premium-HI enrollment while still in MMCP

Pam, who is uninsured, has been enrolled in SMI and an MMCP since 3/18, the month she attained age 65. Although she is still enrolled in the MMCP, Pam files for Premium-HI in 9/21, and based on her request, coverage begins 12/21.

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

A. Policy – General

 

Effective 1/1/01, individuals whose entitlement to disability benefits terminated due to work (i.e., engaged in substantial gainful activity (SGA) after the extended period of eligibility), and who again become unable to perform SGA because of their disabling impairment(s), may request benefit reinstatement within 60 consecutive months of the benefit termination month.

 

These individuals may receive up to 6 months of provisional cash benefits while SSA conducts a medical review to determine whether the disability continues and benefit reinstatement applies. Provisional cash benefits can be paid beginning with the month the individual files the reinstatement request, but no earlier than 1/1/01.

 

B. Policy – Medicare coverage during the provisional benefit period

 

A disabled individual who requests benefit reinstatement will also receive Medicare coverage during the provisional benefit period.

Note: Although a disabled individual who was previously entitled to Medicare based on Medicare Qualified Government Employment is not eligible for cash benefits during the provisional benefit period, he or she can request reinstatement of Medicare coverage. These individuals must meet the same requirements as individuals requesting reinstatement of cash benefits.

 

1. Individual currently in extended period of Medicare

 

a. Entitled to Disability Hospital Insurance (D-HI) only

 

The individual will continue to have D-HI coverage during the provisional benefit period.

 

The individual can elect SMI coverage during a general enrollment period (GEP) or special enrollment period (SEP) that occurs during the provisional benefit period. Normal rules apply for GEP or SEP enrollments.

Note: The provisional benefit period does not begin a new initial

enrollment period (IEP).

 

b. Entitled to Disability Hospital Insurance (D-HI) and Supplementary Medical Insurance (SMI)

 

The individual will continue to have HI and SMI coverage. If he or she is currently paying a premium surcharge, then the surcharge will continue to apply during the provisional benefit period. Any premium arrearage s will be deducted from the provisional benefits.

 

c. Extended period of Medicare coverage ends during the provisional benefit period

 

If an individual's extended period of Medicare coverage ends during

the provisional benefit period, then Medicare will continue until

the end of the provisional benefit period (see HI 00801.165).

 

d. Extended period of Medicare coverage ends after the provisional benefit period

If the extended period of Medicare coverage ends after the provisional benefit period, then Medicare coverage will continue unless the provisional benefit period ended because the individual is no longer under a disability.

 

When the provisional benefit period ends due to a determination that the person is no longer under a disability, Medicare coverage will terminate at the end of the month following the month the notice of the unfavorable decision is mailed.

 

 

2. Extended period of Medicare coverage ended prior to request for expedited reinstatement

 

If the individual's extended period of Medicare coverage ended prior to

the request for expedited reinstatement, then Medicare coverage will be reinstated during the provisional benefit period as follows:

 

a. Individual had D-HI coverage only

 

If the individual had D-HI coverage only in the month prior to the Medicare termination month, then he or she will have D-HI coverage during the provisional benefit period.

The individual may enroll in SMI during a GEP.

The individual may also enroll in SMI under the SEP provisions.

 

Note: The provisional benefit period does not create a new IEP.

 

b. Individual had D-HI and SMI coverage

 

If the individual had both D-HI and SMI coverage in the month prior to the Medicare termination month, he or she will have D-HI coverage during the provisional benefit period. The individual must sign a statement to elect SMI. If SMI is not elected, then only D-HI coverage will be reinstated.

 

If the individual was previously paying a premium surcharge, then the surcharge will apply during the provisional benefit period.

 

c. When coverage begins

 

If Medicare entitlement ended prior to the request for benefit reinstatement, reinstate Medicare as follows:

 

  • No break in D-HI entitlement

 

If the first month of the provisional benefit period is the same as the D-HI termination month, then Medicare coverage will be reinstated effective with the prior entitlement dates.

 

  • Break in Medicare entitlement

 

If the D-HI termination date is earlier than the first month of the provisional benefit period, then Medicare coverage will be reinstated effective with the first month of the provisional benefit period.

 

3. Individual entitled to Premium-HI for disabled working individuals

 

Disabled working individuals with premium-HI coverage will be entitled to premium-free HI during the provisional benefit period.

If the individual is currently paying a premium surcharge for SMI, then the surcharge will continue to apply during the provisional benefit period. Any premium arrearage s will be deducted from the provisional benefits.

 

The provisional benefit period does not begin a new IEP. If the individual does not currently have SMI coverage, he or she can apply for SMI during a general enrollment period (GEP) or special enrollment period (SEP) that occurs during the provisional benefit period. Normal rules apply for GEP or SEP enrollments.

 

Premium-HI (and SMI, if applicable) can continue after the provisional benefit period ends only if the field office obtains a statement from the individual requesting premium-HI coverage to be reinstated and he or she is still eligible for the coverage.

 

4. Individual currently has Medicare based on end stage renal disease (ESRD)

 

a. Entitled to renal HI only

 

In these situations, the individual will also have HI coverage based on disability during the provisional benefit period. The individual can enroll in SMI only during the GEP.

 

Note: Individuals with ESRD are not eligible for the SEP or premium surcharge rollback.

 

HI coverage based on ESRD will continue after the provisional benefit period even if a medical review finds the individual is no longer disabled.

 

b. Entitled to renal HI and SMI

 

The individual will also have HI and SMI coverage based on disability during the provisional benefit period. If he or she is currently paying a premium surcharge, it will continue to apply during the provisional benefit period.

 

Medicare coverage based on ESRD will continue after the provisional benefit period even if a medical review finds the individual is no longer disabled.

 

5. Individual attains age 65 during the provisional benefit period

 

If an individual attains age 65 during the provisional benefit period or during the extended Medicare period, Medicare will convert to Aged Medicare.

 

The attainment of age 65 begins a new IEP. Normal processing rules apply; i.e., if the individual does not currently have SMI coverage, he or she will be automatically enrolled and an IEP package will be mailed.

 

 

C. Policy – SMI withdrawals during the provisional benefit period

 

If the individual files a voluntary request for termination of SMI during the provisional benefit period, coverage will end the earliest of:

 

  • The end of the month following the month the termination request is filed; or

 

  • The end of the month following the month in which either an unfavorable decision or a notice of termination due to SGA is mailed; or

  • The last day of the six month provisional benefit period.

D. Examples of Medicare reinstatement during the provisional benefit period

 

1. Extended period of Medicare coverage terminated prior to request for provisional benefits

 

Nora's 60 month request for reinstatement period is 6/01 – 5/06. Medicare coverage terminated effective 12/05 (the end of the extended period of Medicare). Nora requests benefit reinstatement in 4/06. Provisional payments and Medicare coverage begin effective 4/06.

 

2. Extended period of Medicare coverage terminated prior to request for provisional benefits – SMI not elected

 

Joan's Medicare coverage ended 4/03 (the end of the extended period of Medicare). She requests benefit reinstatement in 6/03, but does not elect SMI coverage. Provisional payments and D-HI coverage begin effective 6/03.

 

3. Extended period of Medicare coverage terminated prior to request for provisional benefits – SMI terminated prior to D-HI

 

Eric's request for reinstatement period is 1/01– 12/05. His D-HI coverage terminated effective 7/05 (the end of the extended period of Medicare). SMI was terminated effective 12/01 due to non-payment of premiums. Eric requests benefit reinstatement in 8/05. Based on his request, provisional payments and D-HI begin effective 8/05. SMI cannot be reinstated unless Eric qualifies under the SEP provisions. Any premium arrearage will be deducted from the provisional payments.

 

4. Extended period of Medicare coverage terminated prior to request for provisional benefits – premium surcharge involved

 

Mary requests provisional payments in 10/01. She was paying a 20% premium surcharge when her Medicare coverage ended 8/01. Mary receives provisional payments and Medicare coverage beginning 10/01. A 20% premium surcharge is applied to SMI premiums.

 

5. Extended period of Medicare coverage terminated prior to request for provisional benefits – GEP and premium surcharge involved

Leroy refused SMI coverage when first eligible in 12/98. His D-HI coverage ended 11/05 (the end of the extended period of Medicare). In 3/06, Leroy requests provisional payments and enrolls in SMI. Provisional payments and D-HI coverage begin in 3/06. SMI is effective 7/06 with a 60% premium surcharge. The surcharge is calculated based on the number of months from the end of the IEP (4/99) through the last month of HI coverage (10/05).

Johnny refused SMI coverage when first eligible in 12/16. His D-HI coverage ended 11/23 (the end of the extended period of Medicare). In 3/24, Johnny requests provisional payments and enrolls in SMI. Provisional payments and D-HI coverage begin in 3/24. SMI is effective 4/24 with a 60% premium surcharge. The surcharge is calculated based on the number of months from the end of the IEP (4/17) through the last month of HI coverage (10/23).

 

6. Extended period of Medicare ends during the provisional benefit period

Doris' extended period of Medicare coverage ends 3/05. She requests provisional payments in 12/04. The provisional payments begin effective 12/04 and the Medicare termination date is changed to 6/05.

 

E. References

  • SM 00856.000 - Expedited Reinstatement (EXR) - Provisional Benefits

  • DI 13050.000ff – Expedited Reinstatement & Provisional Payments

HI 00801.170 Premium-HI for the Working Disabled

CITATIONS:

ACT AS AMENDED—SECTION 1818A

Regulations—42 CFR 406.20(c)

A. Policy — General

A disabled individual who loses premium-free D-HI solely because he/she is working may enroll in hospital insurance (and medical insurance) by paying monthly premiums for as long as he/she continues to have a disabling impairment. This provision is referred to as Premium-HI for the Working Disabled.

Although the first possible month of entitlement to Premium-HI for the Working Disabled is 7/90, any individual who lost premium-free D-HI prior to 7/90 solely because of work and has continuously been under a disabling impairment is eligible to enroll under the provision.

B. Policy — Eligibility requirements

To enroll in Premium-HI for the Working Disabled, an individual must be under age 65, and:

  • have lost entitlement to premium-free D-HI solely because he/she was engaging in substantial gainful activity (SGA);

  • continue to have a disabling physical or mental impairment; and

  • be ineligible for HI on any other basis.

An individual may not enroll in SMI under this provision unless he/ she also enrolls in Premium-HI.

NOTE: A re-entitled disability beneficiary who is required to serve a new 24-month D-HI qualifying period and who meets the above requirements is eligible to enroll in Premium-HI for the Working Disabled during a general enrollment period or special enrollment period (see C. below for a discussion of enrollment periods). Premium-HI eligibility continues until the individual becomes re-entitled to D-HI.

C. Policy — Enrollment periods

An individual may enroll in Premium-HI (and SMI) for the Working Disabled during the following enrollment periods:

  • Initial Enrollment Period (IEP): this is the 8-month period beginning with the month an individual is notified about the loss of premium-free HI

  • General Enrollment Period (GEP): GEPs occur during January through March of each year (for 1990, the GEP was extended through 7/2/90)

  • Special Enrollment Period (SEP): SEPs occur as described in HI 00805.265

D. Policy — When coverage begins

1. IEP enrollments

 

If the enrollment is filed: then coverage begins:
before the first month of
Premium-HI eligibility
the first month of Premium-HI eligibility
during the first month of
Premium-HI eligibility and all remaining months in the IEP
the first day of the month following the month of enrollment

2. GEP enrollment

Coverage begins the first day of the month following the month of enrollment.

3. SEP enrollment

See HI 00805.275 for a discussion of the SEP provisions.

E. Policy—Premiums

1. General

Individuals who enroll in Premium-HI for the Working Disabled pay the same HI and SMI premium as aged Premium-HI enrollees. See HI 01005.005 and HI 01005.007 for HI premium amounts.

The HI premium for the Working Disabled is not subject to increase for late enrollment. This differs from the rule applicable to individuals who enroll in Premium-HI for the Aged and are subject to a 10 percent increase payable for twice the number of full twelve month periods they could have been but were not enrolled. The SMI premium under the Premium-HI for the Working Disabled provision is subject to increase for late enrollment following normal SMI premium increase rules. No months prior to 7/90 are counted in determining the number of months to assess for SMI premium increase purposes.

If an individual was paying an increased SMI premium during the last month of premium-free HI entitlement, but enrolls for SMI under the Working Disabled provision during his/her IEP, the SMI premium reverts to the standard rate.

States are required to pay HI (but not SMI) premiums for “qualified disabled and working individuals (QDWI).” QDWIs are individuals enrolled in Premium-HI for the Working Disabled who meet the requirements in SI 01715.005. States pay HI premiums through the Part A Group Payer System.

2. Premium reduction

Beginning 1/1/94, a disabled Premium-HI enrollee may qualify for a reduction in the amount of his/her HI premium. A disabled Premium-HI enrollee (including a disabled worker, a disabled widow(er) or a disabled adult child) is eligible for HI premium reduction if he /she:

  • Has 30 or more QCs on his/her own E/R;

  • Has been married for at least 1 year to a number holder (NH) with 30 or more QCs;

  • Was married for at least 1 year to a deceased NH with 30 or more QCs;

  • Is divorced, after at least 10 years of marriage, from a NH who had acquired 30 or more QCs at the time the divorce became final.

NOTE: Although a disabled adult child can qualify for HI premium reduction based on his/her own earnings or on the earnings of a spouse (including a divorced spouse), a disabled adult child cannot qualify for premium reduction based on the earnings of his/her parent (including the NH on whose earnings the child's premium-free HI entitlement was based).

F. Examples of HI premium reduction

1. Disabled worker

John lost his entitlement to premium-free HI solely because he was working. He enrolls in Premium-HI for the Working Disabled during his IEP. John has 26 QCs on his own record. His wife, to whom John has been married for 8 years, has 32 QCs. John is eligible for HI premium reduction since he is married to a NH with at least 30 QCs.

2. Disabled adult child

Amy is a disabled adult child who returned to work and lost her premium-free HI entitlement. Her disability benefit and premium-free HI entitlement was based on her 67 year old father's earnings. Amy enrolls for Premium-HI for the Working Disabled during her IEP. She has 20 QCs on her own record. Her father and mother each have more than 40 QCs. Amy is not eligible for HI premium reduction. However, if she continues to work and subsequently acquires 30 QCs, she will be eligible for HI premium reduction at that time. Also, if she marries a NH with 30 or more QCs, she will be eligible for HI premium reduction after she has been married to the NH for 1 year.

3. Disabled widow(er)

Tom is a disabled widower who loses his premium-free HI solely because of work. Tom's deceased wife had a total of 28 QCs. Tom has 31 QCs on his own E/ R. Tom is eligible for HI premium reduction.

HI 00801.251 SMI Enrollment

A. Policy - General

1. Need for SMI

The first month of R-HI entitlement is the first month of R-SMI eligibility. As explained in HI 00801.246, most of the dialysis expenses incurred by ESRD patients are covered by SMI rather than by HI. Practically all R-HI beneficiaries use very costly health care services from the time they first become entitled to R-HI and rarely gain anything by refusing R-SMI entitlement.

(If something is to be gained by refusing R-SMI, the beneficiary should probably postpone filing for R-HI, as discussed in HI 00801.191 B.2.)

R-HI claimants are deemed to have enrolled in R-SMI in the first 3 months of their initial enrollment period (IEP) except as provided in B. Therefore, unless R-SMI is refused, R-SMI entitlement generally begins with the first month of R-HI entitlement.

2. Automatic enrollment

Claimants are notified of their deemed enrollment and its effective date. They are also given at least 2 full calendar months from the date of notice to refuse deemed SMI enrollment. If the individual declines SMI enrollment, he or she may later enroll by filing a request for SMI during the remainder of the IEP or during a GEP, with coverage based on the month of filing (see HI 00805.165). If the claimant files a voluntary request for termination of SMI coverage effective with any month after the end of the IEP, he/she can re-enroll only during a GEP with coverage the first of the month after the month enrollment.

Puerto Rican residents and persons outside the U.S. who qualify for R-HI, like other

R-HI beneficiaries, have SMI beginning immediately after the qualifying period, under the terms of the ESRD provision, unless they refuse SMI timely.

3. Refusal of SMI

Only the beneficiary (or, if he/she is unable to transact business, his/ her representative) can refuse SMI. If an R-HI beneficiary wants to decline SMI before being awarded HI, explain the effect of such a decision. Document when SMI is refused to show that the beneficiary understands the consequences of his/her action.

4. State Buy-in

If, during the enrollment process, there is an indication of welfare involvement, develop possible State buy-in coverage per HI 00815.030.

5. SMI termination

R-SMI is subject to termination under the same general rules that govern termination of D-SMI. These are:

  • for nonpayment of premiums;

  • by voluntary request;

  • termination of the enrollee's HI; and

  • upon the enrollee's death.

B. Policy - Premium arrearage of 6 months or more involved

Many people would have difficulty in paying a large premium arrearage, and might either refuse SMI or lose their SMI due to the inability to pay their premiums on time.

When talking with the claimant or his/her responsible representative and there appears to be 6 or more months of premium arrearage, tell him/her that SMI coverage is prospective only (i.e., coverage begins with the month in which the enrollment is processed). If the claimant is willing and able to pay all premiums for coverage beginning with the earliest possible (specified) month, or prefers to have SMI begin with the month of filing, he/she may choose to have coverage begin with either of those months.

Unless there is a statement in file showing that the claimant wants to have SMI retroactive to the specified month or the month of filing, SMI should be awarded prospectively, and the claimant notified of his/her right to have earlier coverage. The SMI award can be amended to give retroactive coverage if a timely request and payment are received.

C. Example

Mr. Henderson, born 12/50, begins a course of renal dialysis for ESRD 9/8/00. The first month of Medicare eligibility is 12/00, but he delays filing until 8/01. His award is processed in 10/01. He is entitled to R-HI retroactive to 12/1/00 and R-SMI effective 10/01 (unless the file shows he did not want R-SMI, or wanted it effective 12/00 or 8/01). He will be billed for premiums from that date. If, when notified of the award, he states that he wants retroactive SMI and encloses the necessary payment, coverage will be made effective 12/00 or 08/01 as requested.


HI 00801 TN 48 - Hospital Insurance Entitlement - 5/17/2022