TN 12 (09-22)

GN 01701.140 Entitlement to Hospital Insurance (HI) in Totalization Claims

A. Policy

U.S. and foreign coverage cannot be combined to establish entitlement to premium-free HI. However, the fact that a beneficiary is receiving a Totalization benefit does not preclude the beneficiary from qualifying for premium-free HI under certain circumstances. Entitlement to premium-free HI may be established if the Totalization beneficiary:

  • meets the requirements for entitlement to a non-Totalization benefit but the non-Totalization benefit is denied or terminated because of entitlement to a higher Totalization benefit (e.g., entitlement to a Totalization “A” benefit precludes entitlement to a lesser non-Totalization “B” benefit), or

  • is entitled to non-Totalization benefits on a different Social Security number (SSN), or

  • meets the criteria for one of the alternative methods in HI 00801.001 for establishing entitlement to HI.

Note: Where one of the alternative methods in HI 00801.001 requires a certain number of quarters of coverage (QCs), that requirement must be met based on U.S. QCs alone.

B. Procedure

The following explains how to develop possible entitlement to premium-free HI for Totalization beneficiaries.

1. Applicant is within 3 months of age 65 or older and the number holder is not insured based on U.S. coverage alone

  • Explore the possibility of entitlement to premium-free HI under the conditions in GN 01701.140A.

  • Explain the option of filing for premium HI if the applicant does not qualify for premium-free HI and appears to be eligible for premium HI.

2. Applicant could be entitled to premium-free HI on an SSN other than the SSN on which Totalization benefits are paid

Take an application for benefits on the other SSN even if such benefits are not payable because of the Totalization entitlement.

C. Example

A worker is entitled to a non-Totalization benefit with a primary insurance amount (PIA) of $250. The worker’s spouse is entitled to a Totalization benefit on their own SSN with a pro rata PIA of $140. Consequently, the worker's spouse cannot be entitled to a non-Totalization spouse’s benefit on the worker's SSN. However, an application for spouse’s benefits should be taken to establish entitlement to premium-free HI on the worker's SSN. The spouse’s claim would be processed as a technical entitlement with HI involved.

D. Reference

Eligibility requirements for premium HI, HI 00801.131

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GN 01701.140 - Entitlement to Hospital Insurance (HI) in Totalization Claims - 09/22/2022
Batch run: 09/22/2022