TN 71 (05-24)

HI 00801.096 Completion of Items on SSA-18F5

A. Item 1—Name, age and SSN information

Item 1 is needed for SSN purposes. In addition, the place of birth will also be material to the question of citizenship.

The same development will be followed as with the SSA-1F6 (Application for Retirement Insurance Benefits) where there is a question regarding the proper identification of the claimant, see GN 00203.020.

B. Item 2—Earnings information

The earnings items are needed to determine whether or not the individual is fully insured for RIB or meets the QC requirement for HI, see HI 00801.066.

Item 2a and 2b asks the amount of total earnings for last year and this year. These items give sufficient current earnings information to use in determining whether insured status is affected when the earnings record is received

Item 2c asks whether you worked for a railroad after January 1, 1937. If the claimant answers yes, the Railroad Retirement Board may need to be contacted.

C. Item 3—Citizenship and residency requirements

This item pertains to the requirement that the claimant either be a citizen or an alien lawfully admitted for permanent residence who has resided in the U.S. continuously for 5 years before the first month of entitlement.

D. Item4—Marital information

This item aids in determining whether there is eligibility or entitlement on the spouse's E/R and also possible RR entitlement if the claimant's spouse is or was a RR employee, see HI 00801.011 and HI 00801.106. It may also serve as a lead for soliciting a claim from the spouse.

E. Item 5—Premium-HI and SMI Enrollment

Item 5a serves as an enrollment request for Premium-HI. If the applicant completes this item during an enrollment period available and meets all other requirements for entitlement, the applicant will be awarded Premium-HI if ineligible for HI under the regular and deemed insured provisions.

Item 5b serves as an enrollment request for SMI if the individual is not eligible for automatic enrollment. If the individual wishes to enroll, the SSA-18F5 becomes an enrollment request provided it is filed during an enrollment period.

F. Item 6—Current or prior Health Coverage Benefits

This item is needed to screen out persons who are or could be covered under the FEHB Act of 1959, as amended, and thus may be precluded from entitlement under the HI deemed insured provision. If HI entitlement is precluded because of FEHBA involvement, the SSA-18F5 may be used to enroll for SMI. However, a full explanation of any overlapping coverage which might result from SMI enrollment in addition to the FEHBA medical insurance should be given the claimant.

G. Item 7—Signature

This item asks whether you are completing this application for another individual. If so, name, signature, witness signature, and date are required.

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HI 00801.096 - Completion of Items on SSA-18F5 - 05/20/2024
Batch run: 05/20/2024