Identification Number:
HI 00805 TN 51
Intended Audience:See Transmittal Sheet
Originating Office:Centers for Medicare & Medicaid Services (CMS)
Title:Supplementary Medical Insurance Entitlement
Type:POMS Transmittals
Program:Medicaid,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. 51, 07/20/2022

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

Updated section with SMI enrolment dates.

Summary of Changes

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

Updated Examples 1 and 2 with SMI enrolment dates.

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 first 3 months of the IEP if he /she:

  • 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 he or she is entitled to HI.

EXAMPLE: Mr. Bennett established entitlement to DIB beginning 7/89 and is entitled to D-HI (HI based on disability) beginning 7/91, his 25th month of DIB entitlement. He is deemed enrolled in D-SMI during the first 3 months of his 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, he or she 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, the individual is deemed to have filed the enrollment request on the first day of next GEP.

EXAMPLE 1(Before1/1/2023): Mary Hanover did not file for monthly benefits and Medicare when she attained age 65 in 9/90. In 11/91, she filed and was awarded monthly benefits and HI. She did not refuse SMI. Because filing occurred after her IEP, but not during a GEP, she 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 1/1/23):Maggie Winston did not file for monthly benefits and Medicare when she attained age 65 in 5/23. In 7/24, she filed and was awarded monthly benefits and HI. She did not refuse SMI. Because filing occurred after her IEP, but not during a GEP, she is deemed to have enrolled in SMI on the first day of the next GEP (1/01/25) with coverage beginning 2/1/25.

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 51 - Supplementary Medical Insurance Entitlement - 7/20/2022