Take a CMS-18-F5 (Application for Hospital Insurance, OS 15060.085).

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  Modify the title to read “Application for Premium Hospital Insurance for the Working Disabled.”

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  Complete only items 1(A), 2, and 16.

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  Do not complete items 15 or 17.

Obtain an SSA-454-BK (Report of Continuing Disability Interview) and SSA 827s (Authorization for Source to Release Information to the Social Security Administration) from the enrollee.

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  Complete all sections of the SSA-454-BK.

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  Explain that updated medical information may be needed in order to verify continuing disability.

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  Advise the enrollee they will be notified if additional medical evidence is needed.

If a disabled worker, disabled widow(er), or disabled adult child is eligible for a reduced HI premium on own account or on the account of another NH as a spouse, widow(er), or divorced spouse, include in file evidence that the 30 QC requirement is met. Also, include, as appropriate, proof of marriage, death, and divorce (see HI 00801.134D.) following regular title II rules.

Explain the QDWI provision under which States are required to pay HI (but not SMI) premiums for certain needy Premium-HI enrollees (see SI 01715.005 for a listing of QDWI eligibility requirements).

Refer individuals interested in the QDWI benefit to the appropriate State welfare agency. Emphasize the importance of promptly contacting the State.

Advise individuals that, if they are determined ineligible for QDWI status, they may withdraw their Premium-HI enrollment without incurring any premium liability if they submit a written request for withdrawal by the end of the third month following notice of HI coverage (see HI 00801.174).

Upload documents to the Evidence Portal (EP) as follows:

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  Select Action: Store Evidence

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  Lookup Type/SSN: SSN/enter claim number as SSN

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  Select Document Type: Claim/DWI

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  Comments: Add “Prem-HI for the Working Disabled”.

  NOTE: If the individual is eligible for a reduced HI premium as described in HI 00801.170E.2., also include the remark “HI Premium Reduction Case.”

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  Claim File Matching: Select the claimant from the options listed for existing claim filings

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  Store Method: Select Import and attached all documentation (SSA-454, SSA-827, and CMS-18-F5)

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  Select the “Next” button to upload the documents.