Identification Number:
HI 00805 TN 48
Intended Audience:See Transmittal Sheet
Originating Office:Centers for Medicare & Medicaid Services (CMS)
Title:Supplementary Medical 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 05 – Supplementary Medical Insurance Entitlement
Transmittal No. 48, 05/24/2022

Audience

PSC: BET, BTE, CR, CST, CTE, DEC, EHI, LCC, PAS, PCS, PETL, RECONR;
OCO-OEIO: BET, BIES, CCRE, CR, CTE, EIE, ERE, FCR, PETL, RECONE, RECONR;
OCO-ODO: BET, BTE, 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

CMS made updates to improve the readability, tone and policy.

Summary of Changes

HI 00805.010 Rules on Enrollment Periods

Improved language in this section by doing the following:

Added this phrase to the initial enrollment paragraph under section 1 "month after the month of enrollment"

Updated language under the heading "Exception" with this phrase" Further, individuals may be eligible for an Exceptional Circumstance SEP if they meet the requirements of HIXXXXXX.

HI 00805.030 Relationship Between Initial and General Enrollment Periods

Updated section with enrollment period dates and language

HI 00805.010 Rules on Enrollment Periods

CITATIONS:

Section 1837 of the Social Security Act
Social Security Act

Social Security Amendments of 1965 - Section 103(b)

P.L. 89-732, P.L. 90-97, P.L. 90-248, P.L. 92-603, P.L. 96-499, P.L. 116-260

Policy

1. Specific times for enrollment

The law provides specific times for an individual to enroll (or to be deemed enrolled) in SMI.

The initial enrollment period (IEP) is explained in HI 00805.015. If the individual does not enroll in the IEP, or if SMI enrollment is terminated, he /she can only enroll in a GEP (See HI 00805.025), with coverage beginning the month after the month of enrollment.

EXCEPTION: Individuals with employer group health plan coverage may be eligible for an SEP if they meet the requirements of HI 00805.265ff. Further, individuals may be eligible for an Exceptional Circumstance SEP if they meet the requirements of HIXXXXXX.

If coverage under a State buy-in agreement terminates, SMI coverage continues on an individual basis as though the individual had enrolled in the IEP, i.e., with no penalty.

2. Filing occurs outside enrollment period

Unless automatic enrollment applies (see HI 00805.040), an enrollment request filed outside an applicable enrollment period is not valid and must be denied.

If an individual files an enrollment request shortly before an enrollment period and the request has not been denied by the beginning of the period, the individual should be asked to file again as soon as the enrollment period begins. The premature request need not be formally denied if he/she files in the enrollment period.

If an individual's request for enrollment will be denied because it is not filed in an IEP or GEP, he/she should be advised that he/she may enroll during a subsequent GEP.

NOTE: See HI 00805.205 where there is failure to advise the individual to file a valid enrollment request during a prescribed enrollment period.

3. SMI rights for those with HI who develop ESRD

A beneficiary on Medicare when he/she contracts ESRD has a second IEP, beginning 3 months before and ending 3 months after the first month of R-HI eligibility. (See HI 00801.258 C.)

HI 00805.030 Relationship Between Initial and General Enrollment Periods

A. Policy - IEP overlaps GEP

An individual's IEP may overlap a GEP in whole or in part. In such a case, the following considerations apply.

1. GEP ends with or before end of IEP

When the GEP ends with or before the end of an individual's IEP, the GEP has no effect on either the individual's enrollment or date of coverage. That is, the enrollment is based on the IEP.

2. IEP ends prior to end of GEP

If the IEP extends into, but ends prior to, the end of the GEP, the individual has the benefit of the additional time remaining in the current GEP in which to enroll, with a effective date for SMI being the first of the month after the month of enrollment.

REMINDER: Months that elapse between the end of the IEP and the end of the GEP may count against the individual for premium penalty purposes if the period of SMI coverage terminates and the individual subsequently re-enrolls. See HI 01001.010 for information on premium surcharges for late enrollment or re-enrollment.

B. Example

Mrs. Benton was born 11/4/58. Her IEP is 8/1/23 through 2/29/24. If she enrolls in SMI during January or February 2024, it is considered an IEP enrollment. If she enrolls during March 2024, it is a GEP enrollment and coverage begins with April 1, 2024.


HI 00805 TN 48 - Supplementary Medical Insurance Entitlement - 5/25/2022