Identification Number:
HI 00805 TN 49
Intended Audience:See Transmittal Sheet
Originating Office:Centers for Medicare & Medicaid Services (CMS)
Title:Supplementary Medical Insurance Entitlement
Type:POMS Transmittals
Program:Medicare
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. 49, 06/10/2022

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

These revisions incorporate changes brought forth by the Consolidations Appropriations Act.

Summary of Changes

HI 00805.055 Notice of Right to Refuse Deemed Enrollment

Subsection A – typo corrected

Subsection E – example corrected to reflect new effective date policy

HI 00805.080 Withdrawal of Enrollment Before It Goes Into Effect

Subsection 3 – policy and example corrected to reflect new CAA effective date policy

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

Subsection B.1-3 – policy and example corrected to reflect new CAA effective date policy. Question for SSA on example in B.2

HI 00805.165 Individual Enrollment - When A Coverage Period Begins

Subsections B, C, & D - policy and example corrected to reflect new CAA effective date policy

HI 00805.240 Other Situations Where Equitable Relief May Apply

Subsection B.7 - corrected to reflect new CAA effective date policy

HI 00805.270 General Eligibility Requirements for the Special Enrollment Period

Subsection A.3 - corrected to reflect new CAA effective date policy

HI 00805.275 Special Enrollment Period (SEP) Enrollments

Title – change to title “HI 00805.275 Special Enrollment Period (SEP) Enrollments – GROUP HEALTH PLAN

Subsection B.1-2 and C - corrected to reflect new CAA effective date policy

HI 00805.055 Notice of Right to Refuse Deemed Enrollment

A. Policy on who receives notice of automatic (deemed) enrollment in supplementary medical insurance (SMI)

Automatic (deemed) enrollment in SMI only occurs for beneficiaries who:

  • reside in the United States, the Northern Mariana islands, the Virgin Islands, Guam and American Samoa; and

  • receive retirement, survivor or disability insurance (RSDI) benefits at least four months prior to the start of their Medicare initial enrollment period (IEP).

For more information on automatic enrollment, see HI 00805.110A.1.

The Centers for Medicare & Medicaid Services (CMS) mails notices of automatic (deemed) SMI enrollment in the domestic initial enrollment period (IEP) package, at the beginning of the beneficiary’s IEP, which is:

  • the 22nd month of receiving benefits for disability insurance benefits (DIB), childhood disability benefits (CDB) or disabled widow(er)’s benefits (DWB); and

  • three months before the beneficiary’s month of attainment of age 65.

For a description of the contents of the domestic IEP package, see HI 00805.125B.

The Social Security Administration (SSA) mails notices of automatic (deemed) SMI to beneficiaries who obtain Medicare entitlement during or after their IEP, as outlined in HI 00805.110A.2. This may be due to a claim not processing timely or a DIB appeal.

For information regarding SMI enrollment for beneficiaries who are not automatically enrolled in SMI, see HI 00805.110B.

For information regarding SMI enrollment for beneficiaries who reside in Puerto Rico, see HI 00805.115B or a foreign country, see HI 00805.120B.

B. Policy for SMI refusal

Beneficiaries that we automatically enroll in SMI may refuse the coverage if they file a written notification by the specified deadline, as outlined in HI 00805.055B.1. in this section.

NOTE: If a State Buy-in is currently in effect, the beneficiary cannot refuse or terminate SMI, as outlined in HI 00815.001 and HI 00820.035B.5.

When a beneficiary states that he or she wants to refuse SMI, make all reasonable efforts to ensure that the beneficiary refusing or terminating SMI coverage understands the effect of their action, as explained in HI 00820.045 through HI 00820.075 and in TC 24001.070.

1. Opportunity to refuse SMI

All beneficiaries that we automatically enroll in SMI have an opportunity to refuse SMI. Beneficiaries receive written notice of their automatic SMI enrollment, as outlined in HI 0805.055A in this section. This notice:

  • provides the effective date of the SMI coverage; and

  • instructs the beneficiary to notify SSA in writing by a specified date if they want to refuse SMI.

The notice may be in the form of an IEP package or a Medicare award notice.

a. Deadline for SMI refusal in IEP package

A beneficiary who receives an IEP package must refuse SMI enrollment before the coverage begins.

b. Deadline for SMI refusal in Medicare award notice

A beneficiary has two full calendar months following the date of the Medicare award notice to refuse SMI enrollment.

When we mail the Medicare award notice in the first month of the beneficiary’s IEP, he or she must refuse SMI enrollment before coverage begins.

Example of deadline for refusal based on automatic enrollment during a beneficiary’s IEP :

Ms. Grey files for DIB in March 2012, and we deny her claim. She appeals the denial and receives a favorable decision. We establish her entitlement retroactively, starting in April 2012. Ms. Grey’s Medicare entitlement begins in April 2014. SSA notifies Ms. Grey of her automatic enrollment into SMI on January 10, 2014 (during the first month of her IEP). Because her SMI coverage begins April 2014, Ms. Grey has until March 30, 2014 to refuse SMI enrollment. (The timeframe offered Ms. Grey provides her with two full calendar months following the date of her Medicare award notice.)

When we mail the Medicare award notice any time after the first month of the beneficiary’s IEP, he or she must refuse SMI within two full calendar months following the date of the Medicare award notice.

Example of deadline for refusal based on automatic enrollment after a beneficiary’s IEP :

Mr. Fuller files for DIB in June 2010, and we deny his claim. He appeals the denial and receives a favorable decision. We establish his entitlement retroactively, starting in July 2010. Mr. Fuller’s Medicare Part A entitlement begins in July 2012 and his Medicare Part B begins October 2014. SSA notified Mr. Fuller of his automatic enrollment into SMI on October 20, 2014 (after his IEP). Because he is notified after his IEP, Mr. Fuller has until December 31, 2014 to refuse SMI enrollment.

c. Deadline for SMI refusal when notice is not sent timely

In some instances, the beneficiary may not receive the automatic enrollment notice timely. These beneficiaries may learn they have SMI coverage through a SMI premium bill, a reduced benefit payment, or another benefit notification informing them of the SMI premium deduction. When this occurs, the beneficiary must refuse SMI within two full calendar months after either:

  • the month the beneficiary says that they received the notice; or

  • the month the beneficiary receives their first SMI premium bill,

whichever occurs first.

d. Other considerations to determine if refusal is filed by the deadline

CMS does not accept SMI refusals or protect filing dates for SMI refusals.

We must receive the written refusal for SMI by the specified date for it to be timely. If a beneficiary calls the field office (FO) or Teleservice Center (TSC), or visits the FO, to refuse SMI, he or she must still file a written refusal for SMI by the deadline. We do not protect filing dates for SMI refusals.

For information on the 7-day tolerance test for mailed SMI refusals, see SM 03040.080C.

2. Form CMS-2690 (Request for Cancellation of Medicare Part B (Medical Insurance))

The Medicare award notice includes a Form CMS-2690 in cases where we send the notice less than two months before SMI coverage begins or after SMI coverage begins. If the individual requested SMI coverage, the Medicare award notice does not include Form CMS-2690.

Beneficiaries who want to refuse SMI may complete Form CMS-2690 and return it to SSA before the date specified on the form.

NOTES:

  • Beneficiaries may provide other written notification to SSA to refuse the SMI coverage instead of using Form CMS-2690.

  • Form CMS-2690 advises TRICARE beneficiaries that they must keep both HI and SMI to remain eligible for TRICARE benefits.

To view Form CMS-2690, see OS 15060.073.

3. Timely SMI refusal

If the beneficiary files before SMI coverage starts, we always consider this a timely SMI refusal timely.

We consider a SMI refusal timely if we receive it by the deadline indicated in HI 00805.055B.1. in this section.

If the beneficiary files a written refusal for SMI timely, we determine that he or she legally refused this coverage and does not incur any premium liability.

For more information on processing SMI refusals, see SM 03040.080C.

4. SMI refusal not filed timely

A refusal is not timely if we receive it after the deadlines indicated in HI 00805.055B.1. in this section. If the beneficiary files after deadline, we consider this a request for voluntary termination of SMI. In this case, SMI coverage ends with the last day of the month after the month the beneficiary files the written request.

Example of untimely SMI refusal:

In May 2012, we award disability benefits to Mr. Roy effective March 2009. He is entitled to Part A effective March 2011 and Part B effective May 2012. SSA notifies Mr. Roy in his Medicare award letter that he has until July 31, 2012 to refuse SMI. He visits the FO in September 2012 to refuse SMI coverage. Since Mr. Roy didn’t refuse SMI by July 31, 2012, we cannot process his written request for refusal. Instead, we treat his request as a voluntary termination of SMI coverage. His SMI coverage ends on October 31, 2012.

5. Refusal rescinded during IEP

If a beneficiary refuses automatic enrollment but later files a request for SMI enrollment during the remainder of the IEP, the request is a valid IEP enrollment, despite the prior refusal. SMI coverage begins based on the new date of filing, as noted in HI 00805.165B.

C. Policy when a current application is pending

RSDI applications include Medicare enrollment information and an explanation that an eligible beneficiary who obtains entitlement to monthly benefits and HI is deemed to have enrolled in SMI unless he or she answers “no” to the enrollment question.

In some cases, a beneficiary not eligible to enroll in SMI may become eligible before we can fully develop and resolve all issues with the claim. When this occurs, the FO should contact the beneficiary to obtain a SMI election or refusal and document the application with his or her response.

D. Policy for refusal made by an incompetent person

We cannot extend the IEP or the general enrollment period (GEP) for a beneficiary because he or she is mentally incompetent during all or part of the period as explained in HI 00805.100.

Do not consider a refusal for SMI as valid if the beneficiary was:

  • eligible for automatic enrollment in SMI; and

  • mentally incompetent at the time of the refusal.

NOTE: This is true even if the beneficiary currently has SMI based on an enrollment filed after the refusal.

For this policy, consider a beneficiary to be incompetent based on one of the following documents:

  • a signed statement from a physician indicating that the beneficiary was incapable of managing his or her own affairs at the time he or she filed the refusal; or

  • a certified copy of a court order showing that the beneficiary was determined, by the court, to be legally incompetent at the time he or she filed the refusal.

Following a determination of incompetence, any future requests for SMI refusal (or SMI enrollment) by the beneficiary must include legal or medical evidence showing that he or she is now competent. For information on developing medical evidence for capability, see GN 00502.040.

E. Policy for cancelling a refusal by an incompetent person

To cancel a refusal, the responsible representative (or the beneficiary) must submit proof that the beneficiary was mentally incompetent at the time he or she filed the refusal. If the beneficiary makes the request to cancel their prior SMI refusal, he or she must now be competent, as shown with legal evidence or other medical evidence as outlined in GN 00502.023.

Cancel the refusal if we receive the proof outlined in HI 00805.055D during the following timeframes:

  • within 12 months of the first month of potential SMI entitlement; or

  • if later, within 12 months of the month of the refusal.

SMI entitlement begins with the month coverage would have started as though the beneficiary never filed the refusal. The beneficiary must pay all premiums owed for any retroactive months of SMI coverage or authorize us, the Railroad Retirement Board or the Office of Personnel Management to withhold them from monthly benefits payable.

E xample of cancelling a refusal by an incompetent beneficiary :

Ms. Tessen was born on January 15, 1959, and we entitle her to retirement benefits at age 63. She receives the IEP package in October 2023 (the first month of her IEP). Ms. Tessen refuses SMI in November 2023. She enrolls again in SMI in March 2024, the sixth month of her IEP, and we award SMI coverage as of April 2024. In September 2024, her sister notifies the FO that Ms. Tessen was mentally incompetent at the time she refused SMI in November 2023.

Ms. Tessen’s sister provides a certified copy of a court order dated July 2023 indicating that the court ruled that Ms. Tessen was legally incompetent. Ms. Tessen’s sister, the legal representative, authorizes the retroactive SMI premiums to be withheld from Ms. Tessen’s monthly benefits. We adjust Ms. Tessen’s SMI entitlement date to January 2024 (the first month her SMI coverage would begin as though she never filed the original refusal).

Even if Ms. Tessen had not enrolled later during her IEP, we could award her SMI as of January 2024.

F. References

  • GN 00502.023 Developing Legal Evidence of Capability

  • GN 00502.040 Developing Medical Evidence of Capability

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

  • HI 00805.110 SMI Enrollment Process

  • 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 00805.165 Individual Enrollment - When A Coverage Period Begins

  • HI 00815.001 General Description

  • HI 00820.035 Termination of SMI Entitlement

  • HI 00820.045 Voluntary Termination of SMI

  • OS 15060.073 CMS-2690, Request for Cancellation of Medicare Part B (Medical Insurance) Under the Social Security Act

  • SM 03040.080 Processing SMI Refusals

  • TC 24001.070 SMI Termination Requests

HI 00805.080 Withdrawal of Enrollment Before It Goes Into Effect

Policy

1. General

An individual, or proper party on his/her behalf, can withdraw the enrollment application by requesting withdrawal any time before SMI coverage is effective.

NOTE: The processing center processes these as a refusal of SMI coverage.

2. How to withdraw

To serve as a withdrawal or termination, there must be an appropriately signed and unequivocal statement that:

  • the individual no longer wishes SMI coverage, or

  • he/she wishes to withdraw or cancel the enrollment request, etc.

This statement should preferably be made on Form CMS-1763 adapted for the purpose, and can be accepted electronically (email or fax) or a signed letter, or by an unequivocal sentence written on one of the prescribed enrollment forms listed in HI 00805.075 signed by (or on behalf of) the individual.

3. When withdrawal must be filed

An individual may withdraw an enrollment request any time before SMI coverage becomes effective.

A withdrawal of the enrollment request is also honored if filed after the effective month of SMI coverage but within 2 months after the month the enrollment request was filed.

An individual who enrolls during a GEP may withdraw the enrollment request at any time up to when SMI becomes effective.

When withdrawal of an enrollment request is not filed in time to prevent enrollment, it serves as a request for voluntary termination of SMI coverage, effective (as of 7/87) with the end of the month after the month in which the request is filed, as explained in HI 00820.050.

EXAMPLE: Millie enrolls in 7/23, the third month of her IEP. She may file an effective withdrawal at any time prior to 08/23 (the next month).

On the other hand, if the withdrawal request is not filed until 10/23, it is treated as a voluntary termination. This means that the SMI coverage (which begins 8/1/23) is terminated 11/30/23 (the end of the month following the month the withdrawal request was filed).

4. Cautions on withdrawing

Whenever an individual indicates that he/she wants to withdraw or terminate SMI enrollment, the FO should ensure that he/she realizes the effect of such action (see HI 00820.060).

If an enrollment form is received which is merely answered “no” and signed by a person who has enrolled for SMI, it should not be treated as a withdrawal or termination of SMI enrollment without further development by the FO or PSC that received it. The individual should be promptly contacted for an unequivocal signed statement clarifying his/her intent.

If withdrawal or termination was intended, it can be considered filed as of the date of receipt of the “no” option form only if the unequivocal statement is submitted within 60 days of such receipt.

NOTE: If Premium-HI for the aged is involved, withdrawal or termination of SMI ends Premium-HI, as well.

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

A. Policy

A person may file for SMI (or be subject to automatic enrollment) after his/ her actual IEP ended and before the beginning of the deemed IEP (based on the documentary evidence on which the person relied).

B. Procedure

1. Deemed IEP begins after GEP

If enrollment occurs during a GEP and the deemed IEP begins after the end of the GEP, coverage begins February of the current year.

EXAMPLE: In 2/10/2023, Mr. Brown files for reduced RIB, with an alleged date of birth of 2/04/60; however, the Numident record shows a date of birth of 2/4/56. Since there is a discrepancy between his claim allegation and the Numident, we request evidence to correct the date of birth on the Numident record (GN 00203.030). Mr. Brown provides the required evidence which confirms the Numident DOB of 2/4/1956 is correct. An unreduced RIB is awarded 8/2022, and HI is awarded effective 8/2022.

Since Mr. Brown filed an application establishing HI entitlement during a GEP and while eligible to enroll (being age 65 and entitled to HI), he is deemed to have requested SMI enrollment. Unless he refuses such deemed enrollment timely, he has coverage beginning February 2023, as he is deemed to have filed the first day of the then current GEP. If Mr. Brown had filed his application in 7/23 (i.e., not during a GEP), he would be deemed enrolled during the 2024 GEP, because this would permit coverage to begin earlier than enrollment in his deemed IEP (11/24-5/25).

2. Deemed IEP begins during GEP

If the deemed IEP begins during a GEP, but after the enrollment request was filed, deem the person to have enrolled during the deemed IEP. The effective date of coverage follows the IEP rules.

EXAMPLE: Mrs. Adams files a SMI enrollment request on 2/15/92. She submits her original birth certificate showing that she was born 6/24/25. She explains that she did not enroll for SMI when first eligible because she only recently discovered the birth certificate. She previously believed she was born on 6/24/27 in reliance upon an insurance policy issued in 1945 showing the 6/24/27 DB.

Because Mrs. Adams relied on documentary evidence showing she was younger than her true age, a deemed IEP of 3/92-9/92 is established for her. This deemed IEP begins after her filing date, but during a GEP. She is effectively enrolled during her deemed IEP and is awarded coverage beginning 6/92.

3. Enrollment after GEP

If the enrollment request is filed outside a GEP, deem the person enrolled during the next GEP or in the deemed IEP. If the person enrolls in the deemed IEP, coverage starts based on the IEP rules. If the person enrolls outside the GEP and deemed IEP, he or she is deemed to have filed the first day of the next GEP.

NOTE: This is not considered a late enrollment and there are no months which count toward a premium increase.

4. Report of contact is required

If an individual files for SMI in a GEP or deemed IEP after a prior enrollment request was denied because the individual was older than alleged and outside an enrollment period, prepare an RC as described in HI 00805.150 E.

HI 00805.165 Individual Enrollment - When A Coverage Period Begins

A. Policy - General

The beginning of an individual's SMI coverage period depends on the enrollment period and the month in which he/she enrolls, or is deemed enrolled.

B. Policy - IEP enrollment

1. Rules on January 1, 2023 and after

For an individual who first meets the eligibility requirements of HI 00805.005 and enrolls in the IEP January 1, 2023 or after (see HI 00805.015), the beginning of the SMI coverage period is related to the month of enrollment, as follows:

a. Before first month of eligibility

If an individual enrolls in the 3 months prior to the first month of eligibility for SMI, the coverage period will begin on the first day of the month of eligibility.

b. In first month of eligibility or in the last 3 months following the month of first eligibility

If an individual enrolls in the first month of eligibility or in the last 3 months following the month of first eligibility, the coverage period begins with the first day of the next month.

EXAMPLE: If a person first meets the requirements in June and enrolls in July, the coverage period begins the first day of August.

2. Rules before January 1, 2023 - Historical Information

For an individual who first meets the eligibility requirements of HI 00805.005 on or after 3/1/66 and enrolled during the IEP before or on 12/31/22 (see HI 00805.015), the beginning of the SMI coverage period is related to the month of enrollment, as follows:

a. Before first month of eligibility

If an individual enrolls in the 3 months prior to the first month of eligibility for SMI, the coverage period will begin on the first day of the month of eligibility.

b. In first month of eligibility

If an individual enrolls in the first month of eligibility, the coverage period begins with the first day of the next month.

c. In the month following the month of first eligibility

If an individual enrolls in the month following the first month of eligibility, the coverage period begins with the first day of the second month following the month in which he/she enrolls.

EXAMPLE: If a person first meets the requirements in June and enrolls in July, the coverage period begins the first day of September.

d. In last 2 months of the IEP

If an individual enrolls in the last two months of the IEP, the coverage period begins the first day of the third month following the month of enrollment.

EXAMPLE: If a person first meets the requirements in June and enrolls in August, the coverage period begins the first day of November. If enrollment is in September, the coverage period begins on the first day of December.

e. Overriding rules

No coverage could begin before 7/1/66. All persons eligible before 6/66 and enrolling before 6/66, had SMI coverage beginning 7/1/66.

C. Description of IEP enrollment

1. Rules on January 1, 2023 and after

The following chart (valid for persons who enroll after January 1, 2023) illustrates the situations in B.1, above.

EXAMPLE: An individual’s 65th birthday is April 10 and they first meet the eligibility requirements for enrollment on April 1:

Enrolls in IEP:

Entitlement begins on—

January

April 1 (month eligibility requirements first met)

February

April 1

March

April 1

April

May 1 (month following month of enrollment)

May

June 1 (month following month of enrollment)

June

July 1 (month following month of enrollment)

July

August 1 (month following month of enrollment)

2. Rules before January 1, 2023 - Historical Information

The following chart (valid for persons first eligible after June 1966) illustrates the situations in B.2, above.

This Chart Illustrates the Initial Enrollment Period

D. Policy - GEP enrollment

If an individual enrolls or re-enrolls during a GEP (January through March), but after the IEP, the SMI coverage period begins the first of the month following the month of enrollment.

Prior to January 1, 2023, SMI entitlement based on a GEP enrollment always began July 1 of the year during which the GEP enrollment took place.

E. Policy - Equitable relief

Because of the problems caused by retroactive SMI entitlement, in many equitable relief cases (see HI 00805.170), an individual's SMI entitlement may begin with the month in which the SMI award is processed rather than a much earlier date based on the time of enrollment.

F. References

HI 00805.240 Other Situations Where Equitable Relief May Apply

A. Introduction

HI 00805.170 through HI 00805.235, HI 00805.260, and HI 00805.720 through HI 00805.730 set forth specific situations that call for relief and the appropriate remedies. It is unreasonable to expect to cover in POMS all types of Government error that may occur.

Because certain similarities exist among the types of Government error, additional situations can be resolved with reference to existing instructions.

B. Procedures

Follow the procedures below to see how cases can be handled using instructions from the preceding sections.

1. Delayed notice of SMI

Grant relief as described in HI 00805.195 when there has been a delay in sending notice of SMI entitlement to the individual.

NOTE: The delay is usually apparent from the claims file.

2. Earlier SMI entitlement date

In cases of amended awards or allowances of previously denied claims resulting in a SMI award or SMI entitlement date earlier than on a prior award, process in accordance with HI 00805.195.

3. Later SMI entitlement date (Non-DIB)

If an amended award results in a SMI entitlement date later than the date on the prior award, process in accordance with HI 00805.210 except for DIB cases.

4. Later SMI entitlement date (DIB)

When the SMI entitlement date is changed to a later month in a DIB case, it is usually because a competent individual did not promptly report some event affecting entitlement to DIB.

Grant equitable relief in such a case only if there is evidence (HI 00805.175) that it was because of Government error that the individual withheld pertinent information.

NOTE: There does not have to be a finding of fraud or similar fault to preclude equitable relief in such cases.

5. SMI refusal Is not recorded

If an eligible individual who refused SMI has SMI entitlement shown on the HI record and received a Medicare card or other notice of SMI entitlement without having had premiums billed or deducted from benefits:

  • offer the individual the opportunity to have SMI and pay the premiums due from the first month of coverage;

  • develop waiver under HI 00805.220;

  • accept premium payments on an installment basis (see HI 00805.180), if waiver is not applicable.

IMPORTANT: The individual also has the choice of electing no coverage at all, or coverage beginning only with the current month. However, if he/she does this, any Part B benefits paid during the retroactive period for which the premiums are owed are overpayments and are subject to recovery. Waiver of such Part B overpayments is never applicable.

6. Erroneous entitlement information

If an individual is erroneously informed that he/she has SMI as of a certain date when in fact the entitlement is either to be denied or to begin later:

  • award SMI as of the first day of the month in which the individual received the misinformation or, if later, the erroneous month of entitlement, and

  • terminate SMI with the last day of the month in which he/she receives the correct information that he/she is not entitled (unless by such date the beneficiary is in or has passed the IEP).

7. Delays by Department of Homeland Security (DHS)

Where there are cases of delays by the DHS in changing status of Cubans, Indo-Chinese, and other refugees who have been in the U.S. for 5 or more years, use the following procedures:

  1. a. 

    If a claim for Medicare entitlement was denied solely for lack of the required evidence of change in status (i.e., form I-151 or I-551) which the individual stated he/she had requested from DHS, reopen the claim if the I-151 or I-551 is submitted within 4 years of the date of the denial notice.

    Ensure that the I-151 or I-551 shows a date of lawful admission for permanent residence that predates or is within the life of the original application.

    NOTE: Make the award effective with the month the evidence was submitted to SSA by the individual.

    The award may be retroactive to the first possible month of entitlement based on the original application if the individual pays the retroactive premiums (installment payments are acceptable, see HI 00805.180);

  2. b. 

    If the same circumstances as in a., above exist, but the original claim was also subject to denial because it was not filed in an IEP or a GEP, deemed it filed in the first subsequent GEP after the date of the application with entitlement dates being the February of the subsequent GEP;

  3. c. 

    If the individual had not filed an application while awaiting the I-151 or I-551 from DHS, consider the month of receipt of the I-151 or I-551 to be the 4th month of the IEP (even if a retroactively established date of entry is shown on the forms).

    •  

      Obtain verification of the date this evidence was issued from DHS.

      Assume that the date of receipt of the I-151 or I-551 by the claimant is within 7 days of the date of issuance, unless the claimant is convincing in his /her statement that the date of receipt was later than 7 days after issuance.

      If the claimant alleges that 30 days or more elapsed between the date of issue and date of receipt, obtain confirmation of the likelihood of such a delay from DHS or the Post Office. In the absence of such verification, use the 7-day assumption to establish the month of receipt.

    IMPORTANT: Obtain an application at the initial contact to protect the individual's rights to choose an alternative (earlier) date of SMI entitlement. (See HI 00805.185D where State buy-in is involved.)

8. Change in date of birth

Follow the procedures in HI 00805.210 in the following circumstances (assuming there is no formal finding of fraud or similar fault on the part of the enrollee):

SSA made the proper determination of an individual's DB based on the information in file, but it later comes to SSA's attention that the initial determination was wrong (e.g., a birth certificate is discovered) and the individual was not age 65 until later than originally determined.

9. Changes in SMI due to appeal

Consider equitable relief in any SSA decision affecting SMI entitlement or termination which is subsequently reversed on appeal, even if the original decision was the only one possible based on the evidence in file (i.e., the appeal decision was affected by receipt of new evidence).

If, after the appeal, the date of entitlement to SMI is earlier, offer to the beneficiary the choices described in HI 00805.195.

If SMI begins later, follow HI 00805.210 to permit the former period of entitlement to stand unless the individual promptly requests that his/her entitlement to SMI be changed.

If a SMI termination is reversed or changed to a later date, follow HI 00805.215.

If SMI is terminated earlier, allow the erroneous period to stand unless the individual promptly requests that the period of SMI entitlement be altered in accordance with the revised determination.

10. Untimely notice of termination

If a SMI terminating event occurs but the individual does not receive timely notice of the termination, continue SMI entitlement through the end of the month in which the individual learns that SMI entitlement has ended.

HI 00805.270 General Eligibility Requirements for the Special Enrollment Period

A. Policy for general eligibility requirements

An individual is eligible to enroll under the Special Enrollment Period (SEP) provisions if he or she meets one of the following requirements.

1. No previous Supplementary Medical Insurance (SMI) enrollment

If the individual did not enroll in the initial enrollment period (IEP), he or she must be covered under a group health plan (GHP) based on his or her own or a spouse’s current employment status in the first month of eligibility for SMI and for all months thereafter. If the individual was covered under a large group health plan (LGHP), the coverage must be based on his or her own, or a family member’s current employment status.

The first month of eligibility for SMI is the fourth month of the IEP, as explained in HI 00805.015.

2. Previous SMI entitlement

If the individual enrolled during an IEP and later terminated SMI coverage, he or she must be covered under a GHP based on his or her own, or a spouse’s, current employment status the month of SMI termination and for all months thereafter. If the individual was covered under a large group health plan (LGHP), the coverage must be based on his or her own, or a family member’s current employment status.

NOTE: If the individual previously enrolled during the GEP, he or she must have enrolled in SMI or have coverage under a GHP or LGHP in the first month of eligibility for SMI.

3. Subsequent SEP

If the individual enrolled in SMI during an SEP, and later terminated SMI coverage, he or she must be covered under a GHP based on his or her own, or a spouse’s, current employment status the month of SMI termination and for all months thereafter. If the individual was covered under a large group health plan (LGHP), the coverage must be based on his or her own, or a family member’s current employment status.

N OTE: There is no limit on the number of subsequent SEPs. However, to have a subsequent SEP, the individual must enroll during the earlier SEPs available to him or her. Enrollment during a GEP that falls within an SEP satisfies the requirement for an "earlier SEP enrollment.”

B. Reference

HI 00805.275 SEP Enrollments--Break in Employment or GHP/LGHP Coverage

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

A. Policy for when enrollment can occur

Beginning 03/95, individuals who are age 65 or over, or disabled, can enroll (or re-enroll) in (SMI) and Premium HI:

  • during any month (including a partial month) in which they are enrolled in a group health plan (GHP) or a large group health plan (LGHP) based on current employment status; (For the definition of LGHP see HI 00805.266A); or

  • in any of the 8 consecutive months following the last month, during any part of which, the individual was enrolled in the GHP based on current employment status.

For SEP purposes, we consider a partial month of GHP and LGHP coverage based on current employment status to be a full month of coverage.

NOTE: The requirements for GHP coverage do not apply to “disabled family members” other than a spouse. Other family members can have an SEP only based only on LGHP coverage.

B. Policy for SEP enrollment requests filed during the initial enrollment period

1. When the IEP takes precedence over an SEP

The SEP is for those who do not enroll in SMI during the initial enrollment period (IEP). With the exception of the situation described in HI 00805.275B.2, when a beneficiary enrolls in SMI or Premium-HI, or both, during the IEP, you must always process the enrollment as an IEP enrollment. This is true even though the beneficiary has the option of choosing an entitlement date up to 3 months in the future when enrolling during an SEP. Follow IEP coverage rules found in HI 00805.165 B.1.

2. When an SEP enrollment is allowed during the IEP

A DIB beneficiary whose SMI entitlement ends for any reason prior to age 65 has a new IEP at age 65. DIB individuals who file an SEP enrollment request during the IEP based on attainment of age 65 are allowed to enroll under the SEP provisions if the request is filed prior to the age-65 attainment month. You must process a request filed during the last 4 months of the IEP (age 65 or later) as an IEP enrollment.

E xample of SEP occurring during IEP

Ms. Smith (born February 12, 1958) was first eligible for Medicare effective October 2016 based on disability. She refused SMI because she had coverage under her husband’s GHP, based on his current employment status.

Ms. Smith’s IEP based on age 65 attainment is November 2022 through May 2023. She files an SEP enrollment request in November 2022, requesting a SMI start date of December 2022, the month her husband is retiring.

Since she filed the enrollment request prior to February 2023 (the month she attains age 65), we can process the SEP enrollment.

C. Policy when the SEP and GEP overlap

An individual who enrolls in an SEP month that occurs in January, February, or March can elect to have the enrollment processed either as a general enrollment period (GEP) enrollment or as an SEP enrollment.

If the individual chooses a GEP enrollment, coverage begins the first of the month following the month of enrollment (unless the enrollment is based on an initial establishment of HI). Calculate the premium surcharge using the months through the end of the month of enrollment. However, subtract the months of GHP or LGHP coverage from the premium surcharge calculation.

D. Policy for individuals covered under more than one GHP

An individual, who has coverage under two GHPs, LGHPs, or a combination of the two, can enroll in SMI anytime, as long as the coverage is based on current employment status. The individual can also enroll during the 8-month period that begins the month following the last month he or she has coverage under any group health plans based on current employment status.

NOTE: A disabled adult child or family member, other than a spouse covered under both a GHP and an LGHP, may enroll only based on the LGHP coverage.

E xample of coverage under more than one GHP

Mr. Robinson has never enrolled in SMI because he had LGHP coverage based on his own employment and GHP coverage based on his wife’s current employment. The coverage under his LGHP ended when he retired in January 2010, but he remains covered under his wife’s GHP.

Mr. Robinson can enroll in SMI anytime while covered under the GHP based on his wife’s current employment status or during the 8-month period that begins the month following the month he no longer has coverage under the GHP based on current employment status.

E. Policy for SEP enrollment when the worker dies

As previously stated, a spouse or family member can enroll in SMI anytime while covered under the worker’s GHP or LGHP based on current employment status. When a surviving spouse or family member has coverage under the worker’s GHP or LGHP at the time the worker died, he or she can enroll during the 8-month period that begins the month following the month of the worker’s death.

F. Policy for SEP when GHP or LGHP coverage terminates retroactively

When an individual receives notification that the GHP or LGHP coverage has terminated retroactively (for any reason), he or she may enroll in SMI during the 8-month period that begins the first month following the month of notification.

Example of when GHP or LGHP coverage terminates retroactively

Barry, who attained age 65 in March 2008, was employed at the Higgins Corporation and covered under the company’s GHP since January 1998. He is entitled to HI-only, effective March 2008.

In March 2011, the employer notifies Barry that the number of hours he is currently working does not qualify him for the GHP coverage offered by the company and that the GHP coverage is terminating retroactive to January 1998.

Barry may enroll in SMI during the period of April 2011 through November 2011. Exclude all months of coverage under the GHP from March 2008 through March 2011 from the premium surcharge calculation.

G. Policy when there is a break in employment or GHP or LGHP coverage

The SEP provisions permit an 8-month period after the month GHP or LGHP coverage based on current employment status ends to enroll in SMI (or Premium-HI). Therefore, when employment or GHP or LGHP coverage ends, but before the 8-month period expires, a beneficiary is once again covered under a GHP or LGHP based on current employment status, the SEP is deemed not to have occurred. This protects the individual’s rights to an SEP or to a subsequent SEP.

E xample of break in employment

Michele, age 67 and covered under a GHP for many years based on her own employment, retired on November 15, 2010. However, in March 2011, Michele begins working and has GHP coverage.

Michele retains full SEP enrollment rights because less than 8 months elapsed between her retirement and subsequent coverage under a GHP. This means that she can enroll at anytime while covered under the GHP or during the 8-month period that follows the last month she has coverage under the GHP based on current employment status.

H. Policy when an LGHP becomes a GHP

An LGHP becomes a GHP when it is no longer a “large plan,” as described in HI 00805.266A.3. When this situation occurs, family members (other than a disabled worker and his or her spouse) who did not enroll while the plan was an LGHP can only enroll during the 8-month period that begins the month following the last month the GHP was an LGHP. The worker and his or her spouse can enroll any time while covered under the GHP based on current employment status or during the 8-month period that begins the month following the month the GHP coverage or employment ends, whichever occurs first.

E xample of when an LGHP becomes a GHP

Leslie and her son, Michael, both disabled beneficiaries, have been covered under her working husband’s LGHP since they first became eligible for Medicare in 1995. They did not enroll in SMI.

In February 2010, her husband’s employer reduced the staff to less than 100 employees for the balance of that year. Based on the reduction, the LGHP became a GHP effective January 01, 2011.

While Leslie can enroll under the SEP provisions at any time while covered under the GHP based on current employment status, Michael can only enroll January 2011 through August 31, 2011 (the 8-month period following the last month the GHP was an LGHP).

I. References

HI 00805.015B Initial Enrollment Period

HI 00805.266 Definitions of Terms Used in the Special Enrollment Period and Premium Surcharge Rollback Provisions

HI 00805.740 SEP and Premium Surcharge Provisions for the Aged 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 00805 TN 49 - Supplementary Medical Insurance Entitlement - 6/13/2022