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810.5 General Health Insurance Eligibility Requirements

Individuals may participate in the Medicare program if they meet the 

requirements in one of the following categories.

810.5.1 Regular Insured Provision

Individuals who are residents of the United States are eligible for hospital and 

medical insurance if they have attained age 65 and are either entitled to a 

monthly retirement-survivor insurance (RSI) benefit or are not receiving benefits 

but would qualify if they filed an application. In addition, an individual must not be 

convicted of certain crimes against the U.S. to be eligible for medical insurance.

810.5.2 Disability Provision

Individuals who are residents of the United States, under age 65, and have been 

entitled or deemed entitled to a disability benefit under the Social Security Act for 

24 months are eligible for hospital and medical insurance. In addition, an 

individual must not have been convicted of certain crimes against the U.S. to be 

eligible for medical insurance.

NOTE: Effective July 1, 2001, a disability beneficiary diagnosed with Amyotrophic 

Lateral Sclerosis (ALS) is not required to serve the 24-month waiting period for 

Medicare coverage. See section 810.15. 

The ALS Disability Insurance Access Act of 2019, as amended on August 27, 2021, now 

eliminates the 5-month waiting period. The elimination of the 5-month waiting period 

applies to individuals whose applications were approved on or after July 23, 2020.

A disabled individual who is entitled to worker's compensation or public disability 

benefits may have medical insurance coverage based on this entitlement.

Although such coverage does not affect an employee's eligibility for Medicare, 

the Part B Medicare contractor is notified of such additional coverage to prevent 

duplicate reimbursement.

810.5.3 Transitionally Insured Provision

Individuals who have attained age 65 and are not regularly insured are eligible 

for hospital and medical insurance if they are U.S. citizens or lawfully admitted 

aliens and U.S. residents. In addition, if age 65 was attained after 1967, an 

individual must have not less than three quarters of coverage, whenever 

acquired, for each calendar year after 1966 and before the year age 65 was 

attained.

The Social Security Administration (SSA) is responsible for coverage under this

provision.
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810.5.4 Uninsured Provision

Individuals who have attained age 65 and are not regularly or deemed insured 

are eligible for medical insurance if they are U.S. citizens or lawfully admitted 

aliens and U.S. residents. Such individuals may also qualify for hospital 

insurance, called Premium HI, if they enroll or are already enrolled under Part BSMI. In addition, to be eligible for medical insurance, an individual must not have 

been convicted of certain crimes against the U.S.; to be eligible for Premium HI, 

an individual must already be enrolled for medical insurance or be eligible and file 

for medical insurance.

The enrollment periods for medical insurance apply to Premium HI. Eligibility, 

entitlement and collection of premiums for hospital insurance and medical 

insurance under this provision are made by SSA.

810.5.5 End Stage Renal Disease (ESRD) Provision

Individuals of any age with irreversible damage to their kidneys requiring dialysis 

or a kidney transplant may qualify for hospital and medical insurance. Such 

individuals must be entitled to or be the spouse or dependent child of someone 

entitled to a monthly benefit under title II of the Social Security Act or under the 

Railroad Retirement Act or be fully or currently insured.

If the above requirements for entitlement are met, coverage based on end-stage 

renal disease (ESRD) begins the earlier of the first day of:

1. the 3rd month after the month in which dialysis begins (This is the most 

common situation.); or

2. the month dialysis begins, if the individual begins a self-dialysis training 

program in a renal Medicare-approved center before the fourth month of 

dialysis, has completed or is expected to complete the program, and can 

reasonably be expected to self-dialyze after the training, or

3. the month dialysis is resumed following a previously terminated period of 

Medicare coverage based on ESRD, or

4. the month of kidney transplant surgery; or

5. the month a decision of transplant surgery is made, provided:

a. the individual is an inpatient in a renal Medicare-approved hospital 

when the decision is made, and

b. surgery is performed no later than 2 months after the month of that 

decision; or
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6. two months prior to the month of transplant surgery. This 

provision is applicable should surgery be postponed.

Section 402 of the Consolidated Appropriations Act, 2021 (CAA)

extends immunosuppressive drug coverage under Part B for certain 

individuals whose Medicare entitlement based on end-stage renal 

disease (ESRD) would otherwise end 36-months after the month in 

which they received a successful kidney transplant. Patients who meet 

certain criteria will be able to qualify for continuous Medicare-covered 

immunosuppressive drugs. These individuals would not receive 

Medicare coverage for any other items or services (under either Part A 

or Part B) and would only be eligible for the immunosuppressive drug 

coverage if they are not enrolled, and do not expect to enroll, in certain 

disqualifying health care coverage. This change is effective January 1, 

2023. 

Eligibility and entitlement determinations under this provision are 

made by SSA. RR annuitants should be referred to SSA to file for 

Medicare under this provision. SSA will retain jurisdiction of Medicare in 

these cases until the beneficiary qualifies for coverage based on age or 

disability.

Exception: If the RRB is paying a Social Security benefit (LAF E case) 

and SSA determines that the beneficiary is eligible for Medicare on the 

basis of ESRD, the RRB will establish the Medicare record with the 

information provided by SSA. See FOM-810.20. 

810.5.6 Federal Employment Provision

Federal employees pay the hospital insurance portion of the FICA tax 

on all wages paid after December 31, 1982. Federal employees earn 

quarters of coverage for all Federal employment after 1982 for 

Medicare purposes only and require the same number of quarters of 

coverage and regular eligibility requirements as other beneficiaries. Any 

Federal employees who are in an employer-employee relationship with 

a federal agency at any time during January 1983 and were employed 

before January 1983 may receive deemed Federal quarters of 

coverage for their Federal service prior to January 1983, if they are 

required for an insured status for Medicare purposes. Federal quarters 

of coverage can be used alone or in combination with SS wage and/or 

RR compensation quarters to meet the insured status requirements for 

Medicare purposes. Survivors, spouses and children of individuals 

insured on the basis of Federal quarters of coverage are also eligible 

for Medicare coverage.

Eligibility and entitlement determinations under this provision are 

generally made by SSA. However, a disabled RR employee may use 
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creditable Federal quarters of coverage to meet the disability freeze 

20/40 test requirement for Medicare purposes at the RRB. Federal 

service may not be used to establish entitlement to or increase the 

amount of any other type of benefit.

810.10 Medicare Eligibility at RRB Based On Age

A beneficiary who meets the requirements in this section is referred to 

as a QRRB (qualified railroad retirement beneficiary) for Medicare 

purposes.

810.10.1 Employee

To be entitled to Medicare based on age, an employee must:

A. Have attained age 65, and

B. Have at least 120 months of service, or if less than 120 have 

at least 60 months of RR service after 1995, and

C. File an application for HI or for an RR annuity as described 

in FOM-1- 810.25. 

810.10.2 Spouse

To be entitled to Medicare based on age:

A. The spouse must: 

1. Have attained age 65, and

2. Be eligible for a spouse's annuity or be eligible for 

inclusion in the O/M, or

3. File an application for HI alone or for an RR 

annuity, or to be included in the O/M; and

B. The employee must: 

1. Be age 60-61, with 30 years of railroad service, or

2. Be at least age 62 with 120 months of service, or if less 

than 120 months must have 60 months of service after 

1995, or

3. Have a disability freeze and be entitled to an 

annuity from the RRB.

NOTE: When a spouse attains age 65 before the employee meets any 
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of the above requirements, and the spouse is not eligible for Medicare 

on any other earnings record, she or he should file at SSA for uninsured 

beneficiary Medicare (see FOM-1-810.5.4). If the spouse does not do 

this, she or he will be charged a penalty SMI premium rate and the SMI 

effective date will be determined under GEP rules, unless the spouse 

enrolls in a SEP, when she or he becomes eligible for Medicare based 

on the employee's earnings record.

810.10.3 Divorced Spouse

To be entitled to Medicare based on age:

A. The divorced spouse must: 

1. Have attained age 65, and

2. Be eligible for a divorced spouse's annuity, and

3. File an application for HI alone or for an RR annuity; and

B. The employee must: 

1. Have attained age 62, and

2. Have at least 120 months of RR service, or if less than 

120 months have at least 60 months after 1995, but not 

necessarily receiving an annuity.

NOTE: When a divorced spouse attains age 65 before the 

employee meets the above requirements, and the 

divorced spouse is not eligible for Medicare on any other 

earnings record, she or he should file at SSA for 

uninsured beneficiary Medicare (see FOM-1- 810.5.4). If 

the divorced spouse does not do this, when she or he 

becomes eligible for Medicare based on the employee's 

earnings record, she or he will be charged a penalty SMI 

premium rate and the SMI effective date will be 

determined under GEP rules, unless the divorced spouse 

enrolls in a SEP.

810.10.4 Widow(er), Surviving Divorced Spouse and Remarried Widow(er)

To be entitled to Medicare based on age, a widow(er), a surviving 

divorced spouse or a remarried widow(er) must:

A. Have attained age 65, and

B. Be eligible for a widow(er)'s annuity, a surviving divorced 
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spouse's annuity or a remarried widow(er)'s annuity, and

C. File an application for Medicare alone or for an RR annuity.

NOTE: A widow(er), surviving divorced spouse, or remarried 

widow(er) who is paid the RLS without an election (i.e., zero 

annuity rate) is still considered to be a QRRB.

810.10.5 Child

To be entitled to Medicare based on age, a child must:

A. Have attained age 65,

B. Be eligible for a child's annuity or be eligible for inclusion in the 

O/M as the child of the employee, and

C. File an application as described in FOM-1-810.25. 

810.10.6 Parent

To be entitled to Medicare based on age, a parent must:

A. Have attained age 65, and

B. Be eligible for a parent's insurance annuity, and

C. File an application as described in FOM-1-810.25. 

810.15 Medicare Eligibility At RRB Based On Disability

A beneficiary who meets the requirements in this section is referred to 

as a DQRRB (disabled qualified railroad retirement beneficiary) for 

Medicare purposes.

810.15.1 Employee

To be entitled to disability Medicare, an employee must:

A. Be under age 65;

B. File an application and be entitled to an RR disability annuity, or 

file or have filed an application and be entitled to an RR age and 

service annuity and file an application for disability Medicare. 

Refer to FOM-1-810.25 for information about application

requirements;

C. Meet SSA disability freeze requirements which include:
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1. SSA disability medical criteria; and

2. Disability insured status requirements.

a. To have a regular DIB insured status, the employee 

must meet the 20/40 earnings requirement in the 

quarter of disability onset or in a following quarter 

while the employee is continuously disabled.

b. To have a health insurance only DIB insured status, 

the employee's disability onset date must be after the 

ABD and the 20/40 earnings requirement is not met 

on the disability onset date, but is met on the ABD;

and

3. Fulfill the waiting period requirement. The waiting 

period is a specified period of time after the disability 

freeze before SSA will begin paying a disability

annuity.

a. If the annuity began January 1, 1973 or later, the 

waiting period consists of 5 full months after the 

disability freeze date.

b. If the annuity began before January 1, 1973, the 

waiting period consists of 6 full months after the 

disability freeze date; and

D. Complete the qualifying period requirement. The qualifying 

period is a specified period of annuity entitlement following the 

disability freeze onset date and the waiting period when one is

required.

1. Effective December 1, 1980:

a. An individual must be entitled to or deemed 

entitled to a disability annuity for 24 months.

b. The months of annuity entitlement do not have to be 

consecutive as long as any interruption in disability

entitlement is less than 5 years for employees or 

less than 7 years for a widow or child.

Note: Effective July 1, 2001, persons who are diagnosed 

with Amyotrophic Lateral Sclerosis (ALS) do not have to 

serve the 24- month waiting period. ALS is also known as 

Lou Gehrig’s disease. The date of entitlement to Medicare 

is the month following completion of the 5-month waiting 

period or July 1, 2001, whichever is later. The 5-month 
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waiting period is not waived.

Example: An individual diagnosed with ALS has a 

disability freeze onset date is February 4, 2001. His 

Medicare effective date is August 1, 2001.

Note: Effective August 27, 2021, persons diagnosed with 

ALS no longer have to serve the 5-month waiting period 

as well. The elimination of the 5-month waiting period 

applies to individuals with ALS who are found disabled on 

or after July 23, 2020.

Example: An individual diagnosed with ALS has a 

disability freeze onset date of April 23, 2021. His 

Medicare effective date is May 1, 2021.

2. Prior to December 1, 1980:

a. An individual had to be entitled or deemed entitled 

to disability annuity for 24 consecutive months; or

b. An individual had to be included or could have been 

included in the O/M for 24 consecutive months.

810.15.2 Spouse, Divorced Spouse

A spouse or a divorced spouse may only establish entitlement to 

Medicare, based on age, at the RRB. An individual who is entitled to only 

a spouse or divorced spouse annuity at the RRB may qualify for 

disability Medicare at SSA.

If the RRB is paying the spouse’s Social Security disability benefits (LAF 

E case), RRB will establish the Medicare record with the information 

provided by SSA. See FOM-1-810.20. 

810.15.3 Widow(er), Surviving Divorced Spouse and Remarried Widow(er)

To be entitled to disability Medicare, a widow, a surviving divorced 

spouse or a remarried widow must:

A. Be at least age 52, but under age 65;

B. File an application and be entitled to an RR disability annuity or

file an application and be entitled to a widow's insurance annuity, 

a surviving divorced spouse annuity, a remarried widow(er)'s 

annuity or a widow's current annuity and file an application for 

disability Medicare. Refer to FOM- 1-810.25 for information on 

application requirements;
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C. Meet SSA disability medical criteria and become disabled within 7 

years after the month the employee died or within 7 years after the 

last month of previous entitlement to monthly benefits on the 

employee's record; Note that while an annuity under the RRA can 

be granted based solely on alcohol or drug addiction without other 

medical impairments, that type of claim would be denied under the 

SS Act. Therefore, effective with applications filed January 1, 2008 

or later, a disabled widow will be entitled to a disability annuity 

without being entitled to early Medicare if the disability decision is 

based solely on alcohol or drug addiction. Such cases would not 

be eligible for SSEB status. 

D. Meet the waiting period requirements. The waiting period is a 

specified period of time after the applicant meets the disability 

requirements before SSA will begin paying a disability benefit.

1. If the annuity began January 1, 1973 or later, the 

waiting period consists of 5 full months after the SS 

disability onset date.

2. If the annuity began before January 1, 1973, the 

waiting period consists of 6 full months after the SS 

disability onset date.

E. Complete the qualifying period requirement. The qualifying 

period is a specified period of annuity entitlement following 

the date the applicant meets SSA disability benefit 

requirements and the waiting period.

1. Effective December 1, 1980, an individual must be entitled 

to or deemed entitled to a disability annuity for 24 months. 

The months of annuity entitlement do not have to be 

consecutive as long as any interruption in disability 

entitlement is less than 7 years. 

Note: Effective July 1, 2001, persons who are diagnosed 

with Amyotrophic Lateral Sclerosis (ALS) do not have to 

serve the 24- month waiting period. ALS is also known as 

Lou Gehrig’s disease. The date of entitlement to Medicare 

is the first day of the month following the 5-month waiting 

period or July 1, 2001, whichever is later.

2. Prior to December 1, 1980, an individual had to be entitled 

or deemed entitled to disability annuity for 24 consecutive

months.

NOTE: Months of prior entitlement to Supplemental Security Income 
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(SSI) under the Social Security Act can be used to satisfy the 5-month 

waiting period for annuity entitlement and the 24-month qualifying 

period for Medicare for disabled widow(er)s and disabled divorced 

spouses. See RCM 3.2.23. 

810.15.4 Child

To be entitled to disability Medicare, a child must:

A. Be at least age 20, but under age 65,

B. Must file an application (AA-19a) and meet one of the following criteria:

1. Be entitled to a RR survivor disability annuity;

2. Be eligible for inclusion in the O/M if the O/M were

payable. Actual payment of the O/M rate is not necessary 

for the child's Medicare entitlement;

3. Qualify a spouse for an annuity. The spouse does not have 

to be in pay status but just eligible to receive the benefit. A 

disabled child may potentially allow a spouse to be eligible 

for an annuity. For more information, see FOM1 1310.5.3. 

Example: Leslie Bailey is a 62-year-old railroad employee 

who currently receives an occupational disability. However, 

he was denied a disability freeze for early Medicare. His wife, 

Erica, is 61 years old, but has not yet filed for benefits. 

However, she is eligible to receive an annuity because she 

has a minor child in her care. Their disabled daughter, 

Sandra, can file an application because she qualifies the 

spouse to receive an annuity even though she is not in pay 

status. 

NOTE: The youngest age at which a child is eligible to be 

included in the O/M based on disability is age 18. The 

youngest age at which a disabled child can qualify a spouse 

annuity for SSEB consideration is age 16. For these 

reasons, a Form AA-19a should not be developed prior to 

the child’s attainment of age 18 in O/M cases, or age 16 in 

spouse cases. Actual Medicare enrollment will not occur 

prior to age 20.

C. Meet SSA disability medical criteria and become disabled before 

attaining age 22. Note that while an annuity under the RRA can be 

granted based solely on alcohol or drug addiction without other 

medical impairments, the claim would be denied under the SS Act. 
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Therefore, effective with applications filed January 1, 2008 or later, 

a disabled child can be entitled to a disability annuity, or used to 

qualify a spouse for an annuity, without being entitled to early 

Medicare if the disability decision is based solely on alcohol or drug 

addiction. Such cases would not be eligible for SSEB status.

D. Complete the qualifying period requirement. The qualifying period 

is a specified period of annuity entitlement, including cases in which 

there is eligibility under the O/M even if the O/M rate is not paid 

following the date the child meets SSA disability annuity

requirements.

1. Effective December 1, 1980:

a. The child must be entitled to or deemed entitled to a 

survivor disability annuity for 24 months, or

b. The child must be included or could have been included in 

the O/M for 24 months.

Note: A child does not have to complete a 5-month waiting 

period. However, the O/M for a disabled employee does not 

apply until the employee completes a waiting period. 

Therefore, the child 24-month qualifying period cannot begin 

until the employee has completed his or her waiting period. 

The 24-month waiting period begins the later of the 

employee’s annuity beginning date or the date the employee 

attained age 62, or in the case of a disabled annuitant, five 

months after his or her disability freeze date.

Note: Effective July 1, 2001, persons who are diagnosed 

with Amyotrophic Lateral Sclerosis (ALS) do not have to 

serve the 24- month waiting period. ALS is also known as 

Lou Gehrig’s disease. The date of entitlement to Medicare 

is the actual or deemed disability annuity beginning date or 

July 1, 2001, whichever is later.

c. The months of annuity entitlement do not have to be 

consecutive as long as any interruption in disability 

entitlement is less than 7 years. 

2. Prior to December 1, 1980:

a. The child had to be entitled or deemed entitled to a 

disability annuity for 24 consecutive months or,

b. The child had to be included or could have been included 

in the O/M for 24 consecutive months.
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810.15.5 Parent

A parent may establish entitlement to aged Medicare only.

810.16 Environmental Health Hazard (EHH) Medicare

Libby, Montana is the site of a public health emergency caused by airborne pollutants 

from a vermiculite mine in the 1920s to the 1990s. People who developed certain 

medical conditions as a result of exposure to this health hazard are eligible for Medicare 

under the Affordable Care Act’s “Exposure to Environmental Health Hazards” provision. 

Section 10323 of the Affordable Care Act (ACA) added section 1881A of the Social 

Security Act effective March 23, 2010. This section extends eligibility to Medicare Part A 

and Medicare Part B to individuals exposed to certain environmental health hazards 

(EHH) and diagnosed with a medical condition due to the exposure in certain counties 

of Montana, Washington, and Idaho.

An individual exposed to Environmental Health Hazards (EHH) must meet a presence 

requirement for entitlement to EHH Medicare. He or she must have been present in 

Lincoln County, Montana for a total of at least 6 months during a period ending:

• 10 years or more before the date of the diagnosis, and

• Prior to the implementation of all remedial and removal actions specified 

by the Environmental Protection Agency in the Records of Decision for 

Libby and Troy, Montana.

Residency is not a requirement, and the 6-month period does not have to be 

consecutive (i.e. an individual can meet the presence requirement by having lived, 

worked, or vacationed in Lincoln County, Montana, for short periods over several 

years). 

NOTE: Since all remedial and removal actions have not been completed, there is no 

end date to establishing presence at this time.

810.16.1 Requirements for EHH Medicare Part A Entitlement

The following requirements must be met for entitlement to Medicare Part A based on 

exposure to EHH:

1. The individual must have a specified Asbestos Related Disease (ARD) 

diagnosis.

2. The individual must have been present in Lincoln County, Montana for a 

total of a minimum of six months (not necessarily consecutive) in the 

period ending years or more prior to diagnosis of an ARD and prior to 
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the implementation of all the remedial and removal actions specified by 

the Environmental Protection Agency in Records of Decision for Libby 

and Troy, Montana.

3. The individual must have filed an application for Medicare Part A. There 

are no age or insured status requirements.

NOTE: The Earliest possible protective filing date for EHH Medicare is when the law 

became effective on March 23, 2010. Do not apply protective filing dates established 

prior to March 23, 2010 to EHH Medicare claims. Other than this restriction, normal 

protective filing rules apply.

810.16.2 Effective Date of Medicare Part A

If the individual meets both the presence and the medical requirements as of the date of 

filing (DOF), or by the end of the month filing, Medicare Part A (Hospital Insurance) will 

be effective the first day of the month following the month of filing. If a physician has not 

diagnosed the individual with a qualifying ARD as of the DOF or by the end of the 

month of filing, the effective date of Medicare Part A will be the first day of the month 

after the month the individual is diagnosed with a qualifying ARD if the individual also 

meets the presence requirements listed above.

810.16.3 Effective Date of Medicare Part B

The following rules apply for EHH Medicare Part B during the different enrollment 

periods:

1. Initial Enrollment Period (IEP)

• The first month of EHH Medicare Part A (HI) entitlement is the first month of 

EHH Supplementary Medical Insurance (SMI) eligibility. A beneficiary entitled 

to EHH HI is deemed to have enrolled in SMI during the first 3 months of the 

IEP. The IEP is a 7-month period that begins 3 months prior to the month of 

Medicare Part A entitlement.

• Medicare Part B begins with the first month of Medicare Part A entitlement 

unless the beneficiary refuses SMI.

• The beneficiary has 2 calendar months after receipt of the notice of SMI 

enrollment to refuse coverage timely. A person is not responsible for Part B 

premiums if refusal is timely.

• If the beneficiary declines SMI enrollment, he or she may enroll during the 

remainder of the IEP. The beneficiary may also enroll during the general 

enrollment period (GEP) or a special enrollment period (SEP).
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2. General Enrollment Period (GEP):

• If a beneficiary enrolls or re-enrolls during a GEP, SMI coverage begins the 

first day of the month after you sign up. For example, if the beneficiary signs 

up in January, Medicare Part B coverage begins February 1.

3. Special Enrollment Period (SEP): 

• Beneficiaries entitled to HI based solely on EHH are eligible to enroll in a SEP 

if they have a group health plan (GHP) coverage based on their own, a 

spouse’s or a parent’s current employment status and meet one of the 

following requirements:

o If the beneficiary did not enroll during the IEP, he or she had to be 

covered under a GHP in the first month of SMI eligibility (the month of 

the EHH HI entitlement) and for all months thereafter; or

o If the beneficiary enrolled during an IEP or GEP and Part B coverage 

terminated later, he or she had to be covered under a GHP the month 

SMI coverage terminated and all months thereafter; or 

o If the beneficiary enrolled during an SEP and Part B coverage 

terminated, he or she had to be covered under a GHP at the time SMI 

terminated and all following months.

Beneficiaries entitled to Medicare Part A based on age or disability and EHH may enroll 

in Medicare Part B under these SEP rules if they meet one of the requirements listed in 

RCM 3.2.112.

NOTE: If an individual initially refuses Part B and comes back in the remainder of his or 

her IEP, GEP, or SEP, the Part B effective date is determined according to current 

procedure for the aged and disabled.

If a beneficiary is already enrolled in Medicare at the RRB, SSA could process a 

different enrollment for the person, changing his or her record to indicate EHH 

Medicare. Beneficiaries enrolled with EHH Medicare are offered more services and 

programs in the Libby area. It is to their benefit to apply for EHH Medicare at SSA to 

have their Medicare record reflect entitlement to Medicare based on EHH.

If the individual is a QRRB not otherwise entitled to Medicare, the jurisdiction of 

Medicare will remain with SSA, similar to those entitled to Medicare based on End 

Stage Renal Disease (ESRD). 

810.16.4 Pilot Program for Asbestos Related Disease

The Medicare Pilot Program for Asbestos Related Disease is a program for certain 

people with Medicare in Lincoln and Flathead County in Montana. In March 2014 the 

program was expanded to include coverage of additional beneficiaries and geographic 

areas listed in the chart below. The program provides comprehensive, coordinated, and 

cost-effective care, including services not normally covered under Medicare. 
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Beneficiaries who enroll in this pilot program will be able to work with a nurse case 

manager to help get the care needed.

Montana Washington Idaho

Glacier Ferry Benewah

Lake Lincoln Bonner

Mineral Pend Oreille Boundary

Missoula Spokane Clearwater

Sanders Stevens Kootenai

Lincoln (Current coverage) Whitman Latah

Flathead (Current 

coverage)

Shoshone

A. Eligibility Requirements

To participate in the pilot, EHH Medicare beneficiaries must be entitled to 

Medicare Part A and Medicare Part B, and currently reside within one of the 

following zip codes in the states of Idaho, Montana, or Washington.

Idaho ZIP codes: 

83520 83804 83815 83832 83843 83853 83866 83877

83535 83805 83816 83833 83844 83854 83867

83537 83806 83821 83834 83845 83855 83868

83541 83808 83822 83835 83846 83856 83869

83544 83809 83823 83836 83847 83857 83870
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83546 83810 83824 83837 83848 83858 83871

83553 83811 83825 83839 83849 83860 83872

83801 83812 83826 83840 83850 83861 83873

83802 83813 83827 83841 83851 83864 83874

83803 83814 83830 83842 83852 83865 83876

Montana ZIP codes:

59411 59808 59834 59856 59873 59915 59926 59936

59417 59812 59842 59859 59874 59916 59927 59937

59427 59820 59844 59860 59901 59917 59928 59941

59434 59821 59845 59863 59903 59918 59929

59801 59823 59846 59864 59904 59919 59930

59802 59824 59847 59865 59910 59920 59931

59803 59825 59848 59866 59911 59921 59932

59804 59826 59851 59867 59912 59922 59933

59806 59830 59853 59868 59913 59923 59934

59807 59831 59855 59872 59914 59925 59935
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Washington ZIP codes:

99001 99020 99039 99121 99143 99160 99201 99216

99003 99021 99040 99122 99144 99161 99202 99217

99004 99022 99101 99125 99146 99163 99203 99218

99005 99023 99102 99126 99147 99164 99204 99219

99006 99025 99103 99128 99148 99166 99205 99220

99008 99026 99104 99129 99149 99167 99206 99223

99009 99027 99107 99130 99150 99170 99207 99224

99011 99029 99109 99131 99151 99171 99208 99228

99012 99030 99110 99134 99152 99173 99209 99251

99013 99031 99111 99136 99153 99174 99210 99252

99014 99032 99113 99137 99154 99176 99211 99256

99016 99033 99114 99138 99156 99179 99212 99258

99017 99034 99117 99139 99157 99180 99213 99260

99018 99036 99118 99140 99158 99181 99214 99299

99019 99037 99119 99141 99159 99185 99215 99333

Along with meeting residency requirements, the following requirements must also be 

met: 

• Be enrolled in Medicare under the Affordable Care Act’s “Exposure to 
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Environmental Health Hazards” (EHH) provision.

• Have Medicare Part A (Hospital Insurance)

• Have Medicare Part B (Medical Insurance.

Noridian Healthcare Solutions is running the pilot program for Medicare effective for 

services provided on or after July 1, 2011. Contact Noridian at 1-888-469-9464 to 

receive more information regarding the pilot program. Additional information can also be

found on their website at www.noridianmedicare.com/ard. 

810.16.5 Withdrawal of EHH Medicare Application

A. Policy for Withdrawal from EHH Medicare

A beneficiary may withdraw an EHH Medicare application for any reason at any time 

after filing, even if entitlement has begun. Do not approve any request for withdrawal 

until the beneficiary has repaid any Hospital Insurance (HI) benefits to the Medicare 

program. Upon receipt of a request for withdrawal from EHH Medicare, it should be 

forwarded to the Social Security Administration for processing.

1. When withdrawal of an EHH Medicare application may occur 

Some examples of when withdrawal an EHH Medicare application may occur:

o Medicare is the secondary payer of benefits and the beneficiary discovers 

after HI and SMI are in effect that the employer plan will pay all expenses;

o There is another insurance that is primary to Medicare or will pay all medical 

expenses; or

o The beneficiary requires Part B coverage but does not meet the requirements 

for a special enrollment period (SEP).

2. Termination of HI and SMI upon withdrawal of EHH Medicare application 

Upon withdrawal of the EHH Medicare application, EHH HI terminates retroactive 

to the first month of HI entitlement.

If the beneficiary files a withdrawal request within 60 days of the notification of 

EHH HI and SMI entitlement, EHH SMI terminates retroactive to the first month 

of SMI entitlement. If the beneficiary files a request for withdrawal after the 60-

day period, EHH SMI terminates at the end of the month in which SSA notifies 

the beneficiary of approval of the request for withdrawal. SMI premiums paid for 

the period of entitlement are not refundable.

If the beneficiary is entitled to Medicare based on age, disability, or ESRD, that 

coverage continues.
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3. Refiling for HI (and SMI) after withdrawal

Treat a subsequent application for EHH Medicare as an initial application. The 

claimant has a new IEP for SMI based on the month of HI entitlement. If the 

claimant does not refuse SMI, SMI is effective the month of HI entitlement 

without a premium surcharge for late enrollment.

810.16.6 EHH Medicare Entitlement Appeals

A. Requests for Reconsideration of EHH Medicare Determination

All reconsiderations concerning EHH Medicare entitlement are the responsibility 

of SSA. Claimants should call the EHH toll-free number, 1.888.482.3128 (TTY 

1.406.542.5229), to request a reconsideration form SSA-561-U2 (Request for 

Reconsideration) to appeal an EHH Medicare determination. All EHH Medicare 

reconsideration requests should be forwarded to the SSA field office in Kalispell 

Montana (FO 872).

B. Requests For Hearing and Appeals Council (AC) Review 

The HHS Office of Medicare Hearing and Appeals will handle all hearings. A 

beneficiary must submit a written request for hearing by submitting FORM HA501-U5. This form can be obtained by contacting SSA directly. 

810.16.7 Instructions for RRB Personnel

If an individual contacts you about a change in the law regarding Medicare coverage for 

asbestos-related illnesses in the Libby/Troy, Montana area, advise the beneficiary to 

contact the SSA field office in Kalispell, Montana (1.888.613.5218) if they wish to file a 

claim. SSA is solely responsible for taking applications and determining eligibility. The 

RRB does not take any action regarding EHH Medicare unless advised by SSA on a 

manual basis.

The RRB takes Medicare jurisdiction of EHH beneficiaries when the beneficiary attains 

age 65, is entitled to Medicare based on disability, or the RRB is paying the 

beneficiary’s Social Security benefit. These are the same jurisdiction rules that apply to 

beneficiaries entitled to Medicare based on ESRD. If the EHH beneficiary is an RRB 

beneficiary and is not entitled to Medicare based on age or disability, RRB will not 

withhold the Part B premium from the RRB benefit. The Centers for Medicare and 

Medicaid Services (CMS) will perform the quarterly billing for RRB. 

810.20 Deemed RR Beneficiaries - Social Security Certifications

When the Social Security Administration (SSA) certifies a benefit to the 
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RRB for payment, the certification includes an entitlement determination 

to Part B and/or Part A of Medicare. These beneficiaries are deemed 

QRRBs (qualified railroad retirement beneficiaries) for Medicare 

purposes. If the beneficiary is currently entitled to Medicare, SSA 

furnishes the effective date(s) and the Part B premium rate. The RRB will 

then establish and maintain the beneficiary's Medicare records and will 

collect the Part B premium.

If the beneficiary will be entitled to Medicare in the future, the RRB will 

automatically enroll the beneficiary for Part A and Part B at the 

appropriate time. If the beneficiary does not want medical insurance 

coverage, (s)he may refuse the coverage by notifying the RRB when 

(s)he receives the notice of the entitlement effective dates.

810.25 Enrollment Requirements and Effective Date of Coverage

To establish entitlement to Medicare coverage, an individual who is a 

QRRB (meets the requirements in FOM-1-810.10), a DQRRB (meets 

the requirements in FOM-1-810.15) or a deemed QRRB (meets the 

requirements in FOM-1- 810.20) must file an application or be deemed 

to have filed an application for Medicare. The effective date of 

coverage is dependent on when the application is filed or deemed filed.

Enrollment for Part B is possible only during specified enrollment 

periods. Those periods include:

• An individual’s initial enrollment period (IEP) is the 7-month 

period that begins 3 full calendar months before and ends 3 full 

calendar months after the month in which the individual first 

meets all the requirements for enrollment. Prior to January 1, 

2023, those who enroll in Medicare Part B in any of the last four 

months of their IEP experience up to a three-month delay in their 

coverage. Beginning January 1, 2023, individuals who enroll in 

the month they turn age 65, or in any subsequent month of their 

IEP, the individual’s effective date would be the first day of the 

month following the month of enrollment.

• A general enrollment period (GEP) occurs each year from January 

1 through March 31. SMI entitlement based on a GEP enrollment 

will begin the first of the month after 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. These periods afforded enrollment opportunities to those 

who failed to enroll during their IEPs and to those whose enrollment 

was terminated.

• A special enrollment period (SEP) is available for individuals age 

65 or over who did not enroll for Part B when first eligible or who 
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terminated Part B enrollment because of coverage under a group 

health plan (GHP) based on his or her own or a spouse’s current 

employment status. These individuals may enroll in Part B anytime 

while covered under the GHP or during the 8- month period 

immediately following the last month of GHP coverage based on 

current employment status.

A SEP is also available to disabled beneficiaries under age 65 who 

did not enroll for Part B when first eligible or who terminated Part B 

enrollment because of coverage under a GHP based on his or her 

own or spouse’s current employment status or coverage under a 

large group health plan (LGHP) based on his or her own or a family 

member’s current employment status. These individuals may enroll 

in Part B anytime while covered under the GHP/LGHP or during the 

8-month period immediately following the last month of GHP/LGHP 

coverage based on current employment status.

In addition, Section 5115 of the Deficit Reduction Act of 2005, 

provides a 6- month SEP beginning January 1, 2007, for Part B and 

Premium Part A for an individual who:

• Is serving as a volunteer outside of the United States through 

a program that is sponsored by a tax-exempt organization; and

• Has (or had) health insurance that provided coverage to the

individual while he/she was outside of the United States for 

the duration of the volunteer service.

The individual will be eligible for the SEP once he or she returns to the States.

EXCEPTION: Individuals who are entitled to Premium-HI 

under the Premium-HI for the Working Disabled provision are 

not eligible to enroll during the SEP for International 

Volunteers

In addition, Section 120 of the Consolidated Appropriations 

Act of 2021 (CAA) provides additional SEPs for exceptional 

circumstances for Medicare Parts A and B. These SEPs are 

as follows:

• SEP for Individuals Impacted by an Emergency or 

Disaster

• SEP for Health Plan or Employer Misrepresentation

• SEP for Termination of Medicaid Eligibility

• SEP for Formerly Incarcerated Individuals

• SEP for Other Exceptional Circumstances

These additional SEPs took effect January 1, 2023. For more 
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information on these SEPs, see section FOM-1-810.25.5.

810.25.1 Aged Medicare - Part A

A. Application Requirements - An individual must file an application 

at SSA or RRB for Medicare only, or for a retirement, survivor or 

disability annuity.

1. Annuity Application - If an individual files an annuity 

application, this application is also considered an 

application for Medicare Part A. This application can be 

filed at any time. If the application is filed when the 

individual is age 64 and 5 months or older, enrollment will 

take place and the Part A effective date will be 

established as shown in section B. If the application is 

filed prior to when the individual is age 64 and 5 months, 

enrollment will be automatically done when the individual 

attains age 65 and Part A will be effective at age 65.

2. Medicare Only Application - An individual who has not 

yet filed for an annuity must file a Medicare only 

application for Part A. The application may be filed at 

any time as long as it is no sooner than 3 months prior to 

age 65. The Part A effective date will be based on when 

the application is filed. See Section B.

B. Effective Date - Based on when the application is filed, the 

effective date will be the latest of the following:

1. The first of the month in which age 65 is attained, or

Note: An individual whose birthday is on the first day of 

the month is considered to have attained age 65 on the 

day preceding the anniversary of his/her 65th birthday. 

The Medicare effective date will be the first day of the 

month before the 65th birthday.

Example: If the date of birth is January 1, 1927, the 

individual attains age 65 on December 31, 1991, and 

the Medicare effective date is December 1, 1991.

2. The first of the month in which the applicant attains 

status as a QRRB or insured status at SSA, or

3. Six months before the month an application is filed at 

the RRB or SSA. The effective date for the divorced 

spouse of a disabled employee may be 12 months 

before the application is filed.
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Note: Prior to September 1, 1983, applications filed at 

RRB could have 12 months retroactivity. Prior to March 

1, 1981, applications filed at SSA could have 12 months 

retroactivity. 

810.25.2 Disability Medicare - Part A

A. Application Requirements - An individual must file an 

application for a disability annuity or for an aged annuity and 

disability Medicare and be granted a disability freeze or meet 

SSA disability requirements for Medicare. Once the disability 

freeze or the SSA disability requirements are met, the 

beneficiary will be automatically enrolled for Part A after any 

required waiting period and qualifying period is met. The 

exception is for individuals who have been medically 

determined to have Amyotrophic lateral sclerosis (ALS). There 

are no waiting periods for these individuals.

B. Effective Dates - The effective date will be the latest of the

following: 

1. July 1, 1973, or

2. The first day of the 25th month from the employee's RRA 

ABD, or the first day of the 30th month after the 

employee's disability freeze date.

810.25.3 Aged and Disabled Medicare - Part B Initial Enrollment Period (IEP)

A. Enrollment Period - The IEP is a 7-month period that begins 

with the first day of the third month before the month of age 65 

attainment or the disability Medicare effective date, and ends on 

the last day of the third month following the month of age 65 

attainment or the disability Medicare effective date.

Deemed Initial Enrollment Period - If a person has relied on 

documentary evidence which indicated a date of birth later than 

his or her correct date of birth, a deemed IEP may be 

established based on that documentary evidence. A deemed 

IEP may also be established for a person who was born on the 

first day of a month and mistakenly believed that he or she 

attained age 65 on the anniversary of his or her date of birth 

when age 65 was actually attained in the preceding month.

When a deemed IEP is established for a person, all provisions 

of law and instructions relating to enrollment, re-enrollment, 

premiums and coverage will be applied as if the person's 
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alleged date of birth, based on documentary evidence, was the 

actual date of birth.

B. Application Requirements - If a retirement or survivor 

application is filed prior to when the applicant attains age 64 

and 5 months, or a disability application is filed and a disability 

freeze was granted, a separate application is not necessary. 

The individual will be automatically enrolled for Part B when 

enrolled for Part A. A Form G-41 will be issued. If the individual 

does not want Part B, the Form G-41 must be returned before 

the effective date on the card.

If the individual is not a resident of the United States, a Form G44f will be sent with the Part A enrollment package which must 

be signed and returned if the individual wants Part B coverage.

Otherwise, an application must be filed. The application may be 

an annuity application or a Medicare only application. If an 

annuity application is filed when the individual is age 64 and 5 

months and less than age 65 and 3 months, the application is 

considered filed in the IEP. An SMI election must be made on 

the application in order to receive SMI coverage. The SMI 

effective date will be established based on the date of filing.

A Medicare only application may not be filed sooner than 3 

months before the month of age 65 attainment, or 3 months after 

age 65 to be considered filed in the IEP. The SMI effective date 

will be established based on the date of filing.

C. Effective Dates - The effective date of Part B coverage is 

dependent on the date an application is filed or deemed filed.

1. If the individual files an application or is deemed to 

have filed an application during the first 3 months of 

the IEP, Part B will be effective the first day of the 

month age 65 is attained.

2. If the individual files an application during the fourth 

month of the IEP (the month of attainment), Part B will 

be effective the first day of the following month.

3. Effective January 1, 2023, if the individual files an 

application during the fifth, sixth, or seventh month of 

the IEP, Part B will be effective the first day of the 

following month. 

4. Prior to January 1, 2023, if the individual filed an 

application during the fifth month of the IEP, Part B was
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effective the first day of the second month following the 

month the application is filed. If the individual filed during 

the sixth or the seventh month of the IEP, Part B will be 

effective the first day of the third month following the 

month the application is filed.

EXAMPLE OF FILING PRIOR TO JANUARY 1, 2023: 

Month of Filing or 

Deemed Filing → 

Oct Nov Dec Jan Feb Mar Apr

Coverage Begins → Jan Jan Jan Feb Apr June July

 EXAMPLE OF FILING AFTER JANUARY 1, 2023:

Month of Filing or 

Deemed Filing → 

Oct Nov Dec Jan Feb Mar Apr

Coverage Begins → Jan Jan Jan Feb Mar Apr May

D. More Than One IEP – An individual under age 65 may have 

more than one IEP if he or she establishes entitlement to 

Medicare based on disability or end-stage renal disease 

(ESRD) more than once.

Example: The benefits and Medicare eligibility of a disabled 

beneficiary are terminated because the beneficiary recovers 

from his or her disability. If Medicare eligibility is reestablished 

based on a second period of disability, the beneficiary has a 

new IEP beginning 3 months before the new date of entitlement 

to Medicare.

In addition, no matter how often or under what circumstances, 

entitlement occurred prior to age 65, every eligible beneficiary 

has a new IEP at age 65.

NOTE: Disabled beneficiaries who either declined Part B 

coverage or whose Part B coverage was terminated are 

identified in the monthly age 65 attainment processing (FOM-1-

810.30.1) and referred to the Medicare Unit. The Medicare Unit 

enrolls the individuals for Part B, and a new Medicare card 

(Form G-41) is released. If a beneficiary doesn’t want Part B 

coverage, he or she can decline the coverage by completing the 

back of the Form G-41.
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810.25.4 Aged or Disability Medicare - Part B - General Enrollment Period

An aged or disabled individual whose IEP has passed and who is not 

enrolled for Part B, or has refused or terminated Part B coverage, may 

enroll or re-enroll for Part B coverage only in a General Enrollment 

Period (GEP) (unless a Special Enrollment Period (SEP) is applicable). 

Since April 1, 1981, there is no limit to the number of times an individual 

may enroll for Part B coverage. Any individual previously prevented from 

re-enrolling for Part B because he or she voluntarily terminated 

coverage may enroll for coverage during a GEP.

Enrollments in a GEP are subject to penalty premium rates. The monthly 

premium is increased for each 12-month period that an individual could 

have enrolled for Part B, but did not. However, for any month that the 

individual is covered under a group health plan (GHP) or large group 

health plan (LGHP), that month is excluded from the penalty calculation 

if proof of GHP/LGHP coverage is submitted.

In addition, if a beneficiary enrolled in Part B prior to age 65 during a 

GEP, any premium surcharges the beneficiary is paying will be rolled 

back once he or she reaches age 65. The beneficiary will pay the basic 

rate beginning with the month age 65 is attained. This provision assures 

that all individuals attaining age 65 are treated the same with respect to 

Part B premium computation.

A. GEP - Current Requirements

1. Enrollment Period - The GEP is a 3-month period that 

begins on January 1 and ends on March 31 of each

year.

2. Application Requirements - An individual who previously 

filed for Part A and refused Part B, or elected Part B and 

terminated Part B, may complete a Form G-44, Form G44b or submit a signed statement electing Part B.

An individual who is filing an annuity application or a 

Medicare only application in January, February or March 

and his or her IEP has elapsed, must elect Part B 

coverage on the application.

An individual who is filing an annuity application or a 

Medicare only application to establish Part A, in April 

through December and his or her IEP has elapsed, is 

deemed to have filed for Part B in the next GEP. This is 

commonly known as a deemed GEP. The Medicare Unit 

should be notified via e-mail when the field office 

recognizes that the application is for a deemed GEP. The 
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Medicare Unit will establish a call-up for the applicant. At 

the appropriate time, the individual will be enrolled for 

Part B.

Effective Date 

Prior to January 1, 2023, the effective date is July 1 of the 

year in which the application is filed. If a deemed GEP, the 

effective date will be July 1 of the following year.

Beginning January 1, 2023, the effective date based on a 

GEP enrollment will begin the first of the month after the 

month of enrollment. If a deemed GEP, the effective date 

will be February 1 of the following year. 

B. GEP - Requirements Prior to October 1, 1981

1. 4-1-81 through 9-30-81 - During this period, individuals 

whose IEP had ended could apply for Part B coverage at 

any time. The effective date of Part B coverage was the 

first day of the third calendar month following the month 

in which the application was filed.

2. Before 4-1-81 - The first GEP began 10-1-67 and ended 

4-1-68. Subsequent GEPs began on January 1 and 

ended on March 31 of each year. SMI coverage for a 

person who enrolled in a GEP began on July 1 of the 

year in which the person enrolled. All individuals were 

considered eligible to enroll for Part B during the GEP, 

provided their Part B coverage was not terminated twice. 

There were two exceptions:

• The terminations were followed by a period of 

State-Buy In coverage.

• The terminations occurred during entitlement 

to disability Medicare and the beneficiary 

became entitled to aged Medicare.

810.25.5 Special Enrollment Period (SEP)

A Special Enrollment Period (SEP) is provided for individuals age 65 or 

over who did not enroll for Part B when first eligible or who terminated 

Part B enrollment because of coverage under a group health plan (GHP) 

based on his or her own or a spouse’s current employment status. 

These individuals may enroll in Part B anytime while covered under the 

GHP or during the 8-month period immediately following the last month 

of GHP coverage based on current employment status.
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A SEP is also available to disabled beneficiaries under age 65 who did 

not enroll for Part B when first eligible or who terminated Part B 

enrollment because of coverage under a GHP based on his or her own 

or spouse’s current employment status, or coverage under a large group 

health plan (LGHP) based on his or her own or a family member’s 

current employment status. These individuals may enroll in Part B 

anytime while covered under the GHP/LGHP or during the 8-month period 

immediately following the last month of GHP/LGHP coverage based on 

current employment status.

A 6-month SEP is also available for individuals who performed volunteer 

service outside the U.S. through a program sponsored by a tax-exempt 

organization and who have health insurance that provided coverage to 

the individual while he/she was outside the U.S. for the duration of the 

volunteer service. Under the SEP provision, qualifying volunteers can 

delay enrollment in Part B or terminate such coverage for the period of 

service outside the U.S. and re-enroll without incurring a premium 

surcharge. 

EXCEPTION: Individuals who are entitled to Premium-HI under the 

Premium-HI for the Working Disabled provision are not eligible to enroll 

during the SEP for International Volunteers.

NOTE: A disabled beneficiary can qualify for a SEP on the basis of GHP 

coverage based on his or her own or spouse’s current employment 

status, or LGHP coverage based on his or her own or a family 

member’s current employment status. A domestic (or life) partner who is 

under age 65, entitled to Medicare based on a disability and has 

coverage under an LGHP based on the partner’s enrollment in the plan is 

considered to be a family member for the purposes of a SEP.

NOTE: When an individual is notified that his or her GHP or LGHP 

coverage is being terminated retroactively, he or she may enroll in Part 

B during the 8-month period that begins the first month following the 

month of notification.

SEPs were first provided for aged beneficiaries beginning November 

1984, and for disabled beneficiaries beginning January 1987. 

Individuals with end-stage renal disease (ESRD) are not eligible for a 

SEP.

A. Requirements

To be eligible for a SEP, an individual must meet one of the following requirements:
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1. No previous Part B enrollment. An individual who did not 

enroll in the Initial Enrollment Period (IEP) had to be covered 

under a GHP based on his or her own or a spouse's current 

employment status when first eligible for Part B, i.e., the 

month of age 65 attainment or the 25th month of disability 

entitlement. When coverage was under an LGHP, the 

coverage had to be based on the individual’s own or a family 

member's current employment status. 

2. Previous Part B entitlement. If the individual enrolled in Part 

B during an IEP or General Enrollment Period (GEP), but the 

Part B coverage terminated, the GHP coverage had to be 

based on the individual's own or the spouse's current 

employment status at the time of the Part B termination and 

for all the months thereafter. When the individual was 

covered under an LGHP, the coverage had to be based on 

the individual’s own or a family member's current 

employment status. 

Note: If the individual previously enrolled during the GEP, the 

individual must have been enrolled in Part B or covered under 

a GHP/LGHP in the first month of eligibility for Part B, i.e., the 

month of age 65 attainment or the 25th month of disability 

entitlement

3. Subsequent SEP. If the individual enrolled in Part B during an 

SEP, and the Part B coverage was later terminated, the 

individual had to be covered under a GHP based on his or her 

own or a spouse's current employment status at the time of 

the Part B termination. If the individual was covered under a 

LGHP, the coverage had to based on the individual’s own or a 

family member's current employment status at the time of the 

Part B termination.

NOTE: The SEP provisions allow an 8-month period after the 

month GHP or LGHP coverage based on current employment 

status ends to enroll in Part B. When employment or 

GHP/LGHP coverage ends, but before the 8-month period 

expires the beneficiary is once again covered under a GHP or 

LGHP based on current employment status, the SEP is 

deemed not to have occurred. For example, Employee A was 

covered under a GHP for many years based on her own 

employment. She retired in November 2004. However, in 

March 2005, she begins working again and is once again 

covered under a GHP. Employee A retains full SEP 

enrollment rights because less than 8 months elapsed 

between her retirement and subsequent coverage under a
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GHP.

NOTE: There is no limit to the number of subsequent SEPs. 

However, to have a subsequent SEP, the individual must have 

enrolled during the earlier SEPs available to him or her. 

Enrollment during the GEP that falls within an SEP satisfies 

the requirement for an earlier SEP.

4. SEP for International Volunteers. The SEP provision for 

international volunteers allows an individual to enroll during 

an SEP if he or she qualifies as a volunteer working outside 

the U.S. for a tax-exempt sponsoring organization, has or 

had health insurance coverage while outside of the U.S. for 

the duration of the volunteer service and meets one of the 

following requirements:

• If he or she did not enroll in the IEP, the beneficiary had to 

meet the requirements above in the first month of eligibility 

for Part B and all months thereafter.

• If he or she enrolled during the IEP and later terminated

coverage, the beneficiary had to meet the requirements in 

the first paragraph above in the month of the Part B 

termination and all months thereafter. If he or she 

previously enrolled during the GEP, he or she must have 

enrolled in Part B or meet the requirements in the first 

paragraph above in the first month of eligibility. See RCM 

3.2.131 for additional information.

5. SEP for Individuals Impacted by an Emergency or Disaster.

Beginning January 1, 2023, this SEP is for individuals whose ability 

to submit a timely enrollment request has been impacted by an 

emergency or disaster declared by either a Federal, state, or local 

government entity. This SEP would apply for enrolling in Premium 

Part A and/or Part B and would negate potential gaps in coverage 

and otherwise applicable late enrollment penalties resulting from an 

individual’s inability to submit a timely enrollment request. 

This SEP is available to those who, due to a weather-related event 

or other emergency that began January 1, 2023, or later, were not 

able to enroll in premium Part A or Part B or both. 

Eligible individuals are those who:

• During a weather-related emergency or disaster, missed an 

enrollment period, and
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• Either the individual, the individual’s representative payee, 

legal guardian, or person who helps the individual make 

healthcare decisions, resided in areas for which a Federal, 

state, or local government entity (including a Social Security 

regional commissioner) declared a weather-related event or 

other emergency disaster. 

Note: The person must have missed an enrollment period because 

of an emergency or disaster declared by Federal, state or local 

government entities. 

Proof of a disaster declaration may be obtained:

• directly from individual, or

• by verifying other websites or sources, such as:

o the Federal Emergency Management Agency’s 

website, FEMA.gov, to view the declared disasters

o the state’s official website where you can view the 

declaration

o other local government website or paper version of the 

declaration

o the instructions that state that the SSA RC invoked 

disaster procedures

Examples of primary proof of residence can include but are not 

limited to:

• medical records,

• title or deed to real estate,

• rent receipts or rental lease,

• unemployment records,

• utility bills,

• state driver’s license or ID,

• mail addressed to the claimant at an address in the 

affected area,

• telephone directory listing,

• tax assessment notice,

• marriage certificate,

• divorce decree(s),

• summer camp or campground registration,
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• fishing, hunting, or boating license purchased in the 

affected area,

• birth certificate of the claimant’s child,

• school records,

• records that show participation in a social program,

• local bank record or check-cashing card,

• record of volunteer activity, and

• religious, fraternal, or social organization records.

The SEP begins the earlier of:

• the date an emergency or disaster is declared, or 

• the start date identified in the declaration. 

The SEP ends at the end of the month six months after the end 

date which is the later of: 

• the end date identified in the disaster or emergency 

declaration, or 

• the end date of any extensions or the date when the 

declaration has been determined to have ended or has 

been revoked, or

• the date of the declaration, if such date is after the end of 

the disaster.

Coverage begins on the first date of the month following enrollment. 

There will be no late enrollment penalty if enrolled pursuant to this 

SEP.

NOTE: This SEP can be used one-time related to a specific 

exceptional circumstance, but there may be instances where an 

individual may be eligible for more than one SEP in their lifetime if 

they experience multiple exceptional circumstances. 

6. SEP for Group Health Plan or Employer Misrepresentation. 

Beginning January 1, 2023, this SEP was created to provide relief 

to individuals who made enrollment decisions based on 

misinformation from their employer or Group Health Plan (GHP). 

This SEP is based on exceptional circumstances because of 

material misrepresentation by the individual’s employer or GHP, or 

any person authorized to act on its behalf. 
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To be eligible for this SEP, an individual must demonstrate that he 

or she:

a. Did not enroll in premium Part A or Part B during their 

IEP, GEP or another SEP in which they were eligible 

based on information received from an employer or GHP, 

or brokers or agents of health plans that may have been a 

source of misinformation, and

b. an employer, GHP, or a broker or agent of a health plan 

materially misrepresented information or provided 

incorrect information relating to enrollment in premium 

Part A or Part B.

The material misrepresentation or incorrect information must have 

occurred on or after January 1, 2023. 

NOTE: The person must have missed an enrollment period to be 

eligible for this SEP.

To demonstrate material misrepresentation, the individual must 

provide documented proof of the misrepresentation. The evidence 

must prove that:

• Information was provided directly from an employer, GHP, 

or agents and brokers prior to their IEP, GEP or another 

SEP, and

• the inaccuracy that caused the individual not to enroll 

timely.

Example: The individual receives a letter (or GHP website 

public notice) from their employer or GHP that materially 

misrepresents the Medicare enrollment process which caused 

them to not enroll in Medicare during their IEP.

1. it is directly from an employer or GHP,

2. the information was provided prior to the end of all 

applicable enrollment periods, and

3. the inaccuracy caused the individual not to enroll 

timely.

Alternatively, a written and signed attestation from the beneficiary is 

sufficient evidence for eligibility for this SEP. 

The written attestation must include: 

• a detailed account of the incident including: the 

name/company/title of the person who provided the 
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misinformation; 

• the approximate date in which the misinformation was 

provided; and 

• a description of what misinformation was provided. 

The SEP begins the day the individual contacts RRB about being 

misinformed and ends at the end of the month six months later. 

 

Example: If an individual discovers that they received erroneous 

information from their GHP and they contact RRB with supporting 

documentation on May 16, 2023. 

The individual’s SEP begins on May 16, 2023 and ends on 

November 30, 2023. The individual has until November 30, , 2023 

to enroll under this SEP. 

Coverage begins the first day of the month following the month of 

enrollment. There will be no late enrollment penalty if enrolled 

pursuant to this SEP.

7. SEP for Termination of Medicaid Eligibility.

Many individuals are enrolled in Medicaid when their Initial Enrollment Period 

(IEP) for premium Part A or Part B begins. While some individuals stay 

eligible for Medicaid after they qualify for Medicare, other individuals lose 

Medicaid eligibility entirely. 

Individuals transitioning from Medicaid to Medicare coverage are at risk for 

gaps in coverage and losing access to critical health care. Administrative 

delays may keep individuals in Medicaid for multiple months after they first 

qualify for Medicare and become ineligible for Medicaid benefits. 

Individuals who retain Medicaid after qualifying for Medicare may miss their 

IEP because they continue to be covered by Medicaid and may think they do 

not need or cannot afford Medicare at that time. 

If they lose Medicaid coverage outside of the Medicare General Enrollment 

Period (GEP), they may need to wait months to enroll in Medicare and be 

subject to a late enrollment penalty (LEP) when they can eventually enroll. 

This SEP would help promote continuity of coverage for individuals who lose 

Medicaid eligibility who did not enroll in Medicare on time.

To be eligible for this SEP, an individual must lose Medicaid eligibility entirely 
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on or after January 1, 2023 and have missed a Medicare enrollment period 

for premium Part A or Part B. 

Starting January 1, 2023, individuals are eligible for this SEP once they are 

notified of an upcoming Medicaid eligibility termination. The SEP starts when 

the individual is notified of the termination of Medicaid eligibility and ends 6 

months after the termination of eligibility. States must send individuals notice 

of an upcoming Medicaid termination at least 10 days in advance.

Example: If the state sends the individual a notice dated April 15, 2023

informing them of their Medicaid termination effective May 1, 2023, the 

individual first qualifies for this SEP on April 15, 2023. 

NOTE An individual who received notice of an upcoming Medicaid 

termination and is not yet determined by the State to be a Qualified Medicare 

Beneficiary (QMB) can use this SEP in Group Payer states to enroll in 

Premium-Part A through the conditional enrollment process. 

However, individuals who still are eligible for Medicaid, including a Medicare 

Savings Program, and have not received notice of an upcoming Medicaid 

termination are not eligible for this SEP. States enroll Medicaid beneficiaries 

included in their state buy-in agreements with CMS in premium Part A and 

Part B and pay premiums on their behalf at any time of the year without 

regard to Medicare enrollment periods and LEPs. This process is known as 

state buy-in. 

 

The following proof must be obtained:

1. A letter from the state Medicaid agency or Medicaid-managed care 

plan stating the Medicaid termination date; OR

2. Verification of title XIX termination status, which could alternatively be 

based upon a telephone contact or email with the appropriate public 

assistance office. It must contain the following information:

a. The Medicaid termination effective date.

b. The Medicaid case number.

c. The location of the public assistance office furnishing the 

information and the name of the contact person.

If the individual loses Medicaid coverage on or after January 1, 2023, the 

SEP starts upon notice of upcoming termination of Medicaid eligibility and 

ends six months after the Medicaid termination.

Example: If the state sends an individual a notice on April 15, 2023 

informing the individual of a Medicaid termination effective May 1, 2023, 

the SEP starts on April 15, 2023 and ends on October 31, 2023. 

Individuals have the option to choose an entitlement date:
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Option1: Individuals enrolling in this SEP can choose a prospective 

entitlement to begin the first day of the month following the month of 

enrollment.

Option 2: Individuals enrolling in this SEP can opt for a retroactive 

entitlement date back to the first day of the month of their termination from 

Medicaid coverage, so long as their enrollment is on or after January 1, 

2023.

NOTE: An individual who elects retroactive entitlement will be responsible for 

paying Medicare premiums back to the date of coverage.

There will be no late enrollment penalty if enrolled pursuant to this 

SEP.

8. SEP for Formerly Incarcerated Individuals. 

Beginning January 1, 2023, this SEP is for individuals who age into Medicare 

while incarcerated or who lost Medicare coverage while incarcerated due to 

non-payment of premiums or voluntary termination. This would allow formerly 

incarcerated individuals to avoid potential gaps in coverage and late 

enrollment penalties for months they went without coverage while 

incarcerated. 

To be eligible for this SEP, an individual must:

1. Demonstrate that they are eligible for Medicare, and 

2. due to being incarcerated, failed to enroll or reenroll in Medicare 

premium Part A or Part B during another enrollment period in which 

they were eligible to enroll while they were incarcerated, and 

3. There must be a record that the individual has been officially released 

from custody on or after January 1, 2023, either through the 

appropriate discharge documents or data available to RRB. 

 

This SEP would begin the day of the individual’s release from incarcerations, 

so long as it is on or after January 1, 2023, and end the last day of the 12th

month after the individual is released from incarceration. Coverage would 

start the first day of the month following enrollment. 

Example: Mrs. Q was released from jail on March 1, 2023. Mrs. Q has 

until March 31, 2024, to enroll under the SEP for Formerly Incarcerated 

Individuals.

Individuals have the option of choosing an entitlement date retroactive (up to 

6 months) to the first day of the month of their release from incarceration or 

may choose coverage to begin the first day of the month following the month 

of enrollment, so long as the date is on or after January 1, 2023.

Example: Bob Miller is incarcerated in July 2016 at the age of 59. He 
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turns 65 in March 2022 but fails to enroll in his IEP while incarcerated. Mr. 

Miller is released from incarceration on June 12, 2023. His exceptional 

condition SEP begins the day he is released and will run until June 30, 

2024. Assuming Mr. Miller provides the appropriate documentation of his 

release, he will be able to choose one of two effective dates of coverage:

• Option 1: Effective date retroactive to June 1, 2023. If Mr. Miller 

chooses this option, he will be responsible for paying Medicare 

premiums back to the date of coverage.

• Option 2: Effective date to begin the first of the month after the 

month of enrollment. If Mr. Miller chooses this option, and 

enrolls the day he is released from incarceration, his coverage 

would be effective July 1, 2023.

There will be no late enrollment penalty if enrolled pursuant to this SEP.

9. SEP for Other Exceptional Circumstances.

Effective January 1, 2023, CMS, RRB, and SSA will retain the ability to 

establish SEPs on a case-by-case basis in situations that involve exceptional 

circumstances and warrant an SEP. This SEP will provide an enrollment 

opportunity in circumstances beyond an individual's control that prevented 

him or her from submitting a timely request to enroll in premium Part A 

and/or Part B during the IEP, GEP, or other prescribed SEPs. This SEP 

would only apply to individuals whose unique circumstance do not fall into 

one of the broader SEP categories. 

To be eligible for this SEP, an individual must ensure that the following two 

conditions are met: 

1. They must demonstrate that conditions outside of their control, that 

occurred on or after January 1, 2023, caused them to miss an 

enrollment period; and

2. RRB must determine that the conditions were exceptional in nature. 

This includes, but is not limited to:

• A serious medical emergency of the beneficiary that prevented 

them from access to enrolling in Medicare, 

• Example: Being in a coma or admitted for a long-term inpatient stay, during an enrollment period.

• A natural disaster in a foreign country in which a beneficiary 

resides disrupts mailing and transportation processes during an 

enrollment period.

• An elder or individual that is disabled experiencing involuntary 

restraint due to abuse from a caretaker.

Eligibility for this SEP will only be granted in conditions that are truly 

exceptional in nature and will not be used to grant individuals enrollment due 

to: 
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• forgetfulness,

• lack of knowledge, or 

• lapse in premium payments.

Note: The person must have missed an enrollment period due to the 

exceptional condition to be eligible for this SEP.

The SEP duration would be determined on a case-by-case basis by the 

agency who has jurisdiction over Medicare. Coverage would be effective the 

first day of the month following the month of enrollment.

 

B. Effective Date

An individual can enroll under the SEP provisions while still working. 

If an individual enrolls in Part B while still covered under a 

GHP/LGHP or during the first full month when not enrolled in a 

GHP/LGHP based on current employment status, the individual has 

the option of choosing an effective date of:

• the first day of the month of his or her Part B enrollment, or

• the first day of any of the following 3 months.

If the individual enrolls in Part B during any of the remaining 7 

months of the SEP, coverage begins with the first day of the 

month after the month of enrollment.

Examples of How Part B Effective Date is Determined

If an individual's last day of coverage under a GHP/LGHP based on 

current employment status is March 13, 2005, the following applies:

a. If the individual files for Part B in February 2005, he or 

she can elect coverage beginning February 1, March 

1, April 1, or May 1.

b. If the individual files for Part B in March 2005, he or 

she can elect coverage beginning March 1, April 1, 

May 1 or June 1.

c. If the individual files for Part B in April 2005, he or she can 

elect coverage beginning April 1, May 1, June 1 or July 1.

d. If the beneficiary files for Part B at any time during the 

period of May 1 through November 30, 2005, i.e. the 

remaining 7 months of the SEP, the Part B coverage is 

effective the first day of the month after the month of 
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enrollment.

SEP for International Volunteers. SEP eligibility for international 

volunteers became effective January 1, 2007. An individual who 

qualifies as an international volunteer effective July 1, 2006 or later 

is eligible to enroll in Part B during the SEP. If the last month of 

volunteer service was July 2006, then January 2007 was the last 

month of the SEP. If the last month of volunteer service was August 

2006, then February 2007 was the last month of the SEP, etc.

The SEP for international volunteers is the 6-month period that 

begins the earlier of the first day of the month following the month 

for which the:

• Individual was no longer serving as a volunteer outside the U.S.

• Sponsoring organization no longer has tax-exempt status; or

• Individual no longer has health insurance that provides

coverage outside the U.S.

NOTE: Enrollment in Medicare Part B may not occur prior to 

the end of the IEP. For international volunteers, coverage is 

effective the first day of the month following the month of Part 

B enrollment.

SEP for Individuals Impacted by an Emergency or Disaster

Beginning January 1, 2023, this SEP is for individuals whose ability to 

submit a timely enrollment request has been impacted by an emergency 

or disaster declared by either a Federal, state, or local government entity. 

This SEP would apply for enrolling in Premium Part A and/or Part B and 

would negate potential gaps in coverage and otherwise applicable late 

enrollment penalties resulting from an individual’s inability to submit a 

timely enrollment request. 

This SEP is available to those who, due to a weather-related event or 

other emergency that began January 1, 2023, or later, were not able to 

enroll in premium Part A or Part B or both. 

The SEP begins the earlier of:

• the date an emergency or disaster is declared, or 

• the start date identified in the declaration. 

The SEP ends at the end of the month two months after the end date 

which is the later of: 

• the end date identified in the disaster or emergency declaration, 
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or 

• the end date of any extensions or the date when the declaration 

has been determined to have ended or has been revoked, or

• the date of the declaration, if such date is after the end of the 

disaster.

Coverage begins on the first date of the month following enrollment. There 

will be no late enrollment penalty if enrolled pursuant to this SEP.

SEP for Group Health Plan or Employer Misrepresentation

Beginning January 1, 2023, this SEP was created to provide relief to 

individuals who made enrollment decisions based on misinformation from 

their employer or Group Health Plan (GHP). This SEP is based on 

exceptional circumstances because of material misrepresentation by the 

individual’s employer or GHP, or any person authorized to act on its 

behalf. 

The SEP begins the day the individual contacts RRB about being 

misinformed and ends at the end of the month two months later. 

Example: If an individual discovers that they received erroneous 

information from their GHP and they contact RRB with supporting 

documentation on May 16, 2023. 

The individual’s SEP begins on May 16, 2023 and ends on July 31, 2023. 

The individual has until July 31, 2023 to enroll under this SEP. Coverage 

begins the first day of the month following the month of enrollment. There 

will be no late enrollment penalty if enrolled pursuant to this SEP.

SEP for Termination of Medicaid Eligibility

To be eligible for this SEP, an individual must lose Medicaid eligibility entirely on or 

after January 1, 2023 and have missed a Medicare enrollment period for premium 

Part A or Part B. 

Starting January 1, 2023, individuals are eligible for this SEP once they are notified 

of an upcoming Medicaid eligibility termination. States must send individuals notice 

of an upcoming Medicaid termination at least 10 days in advance.

If the individual loses Medicaid coverage on or after January 1, 2023, the 

SEP starts upon notice of upcoming termination of Medicaid eligibility and 

ends six months after the Medicaid termination.

Example: If the state sends an individual a notice on April 15, 2023 

informing the individual of a Medicaid termination effective May 1, 2023,
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the SEP starts on April 15, 2023 and ends on October 31, 2023. 

Coverage begins the first day of the month following the month of 

enrollment. There will be no late enrollment penalty if enrolled pursuant to 

this SEP.

SEP for Formerly Incarcerated Individuals

Beginning January 1, 2023, this SEP is for individuals who age into Medicare while 

incarcerated or who lost Medicare coverage while incarcerated due to non-payment 

of premiums or voluntary termination. This would allow formerly incarcerated 

individuals to avoid potential gaps in coverage and late enrollment penalties for 

months they went without coverage while incarcerated. 

This SEP would begin the day of the individual’s release from 

incarcerations, so long as it is on or after January 1, 2023, and end the 

last day of the 12th month after the individual is released from 

incarceration. Coverage would start the first day of the month following 

enrollment. 

Example: Mrs. Q was released from jail on March 1, 2023. Mrs. Q has 

until March 31, 2024, to enroll under the SEP for Formerly Incarcerated 

Individuals.

Individuals have the option of choosing an entitlement date retroactive to 

the first day of the month of their release from incarceration or may choose 

coverage to begin the first day of the month following the month of 

enrollment, so long as the date is on or after January 1, 2023.

Example: Bob Miller is incarcerated in July 2016 at the age of 59. He 

turns 65 in March 2022 but fails to enroll in his IEP while incarcerated. Mr. 

Miller is released from incarceration on June 12, 2023. His exceptional 

condition SEP begins the day he is released and will run until June 30, 

2024. Assuming Mr. Miller provides the appropriate documentation of his 

release, he will be able to choose one of two effective dates of coverage:

• Option 1: Effective date retroactive to June 1, 2023. If Mr. Miller 

chooses this option, he will be responsible for paying Medicare 

premiums back to the date of coverage.

• Option 2: Effective date to begin the first of the month after the 

month of enrollment. If Mr. Miller chooses this option, and enrolls 

the day he is released from incarceration, his coverage would be 

effective July 1, 2023.

SEP for Other Exceptional Circumstances 

Effective January 1, 2023, CMS, RRB, and SSA will retain the ability to establish 

SEPs on a case-by-case basis in situations that involve exceptional circumstances 
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and warrant an SEP. This SEP will provide an enrollment opportunity in 

circumstances beyond an individual's control that prevented him or her from 

submitting a timely request to enroll in premium Part A and/or Part B during the 

IEP, GEP, or other prescribed SEPs. This SEP would only apply to individuals 

whose unique circumstance do not fall into one of the broader SEP categories. 

The SEP duration would be determined on a case-by-case basis by the agency 

who has jurisdiction over Medicare. Coverage would be effective the first day of 

the month following the month of enrollment.

C. Definitions

The terms described in this section are those used with the SEP. 

Use the descriptions of these terms to decide:

• If an individual is eligible for a SEP, and

• When the SEP should begin.

NOTE: The terms may also be used in determining whether a 

premium surcharge rollback applies and for what months.

Term Definition

Group Health 

Plan (GHP)

A GHP is any plan of, or contributed to, by one or more employers to 

provide health benefits or medical care (directly or otherwise) to 

current or former employees, the employer, or their families. The 

term GHP also applies to self-insured plans, plans of governmental 

entities (Federal, State and local), and employee organizational plans 

(e.g., union plans or employee health and welfare funds). It also 

includes employee pay-all plans (i.e., plans under the auspices of an 

employer or employee organization, but which receive no financial 

contribution from them.)

NOTE: A self-insured plan is a health insurance plan that an 

employer establishes to pay the health care expenses of its 

employees. Unlike a group health plan that requires the employer to 

pay premiums to a health insurer, a self-insured plan requires the 

employer to pay the health care expenses of employees as the 

expenses are incurred. The employees may or may not be required 

to contribute to the self-insured plan.

NOTE: The term GHP does not include plans that are unavailable to 

employees, i.e., a plan that only covers self-employed individuals. 

For example, a self-employed individual may be covered under a
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health plan offered by a professional association, lodge, fraternal 

organization, etc. If the health plan is available to one or more 

employees of the association, lodge or organization, or one or more 

employees of the self-employed member of the association, lodge, or 

organization, then the health plan can be considered a GHP (or 

LGHP if there are 100 or more such employees). If the health plan is 

only available to self-employed members and not available to any 

employees, then the plan is not a GHP or LGHP.

The employer does not have to be in the United States, and the 

employee is not required to be working in the United States. A 

person working for a foreign employer, who has a plan that meets the 

definition above, is considered covered under a GHP for purposes of 

the SEP and/or premium surcharge rollback.

For SEP purposes, the GHP can be of any size. However, when 

referring to a GHP for the disabled, the term refers to a plan of any 

size below 100 employees.

NOTE: When used in these instructions, the term GHP refers 

specifically to a group health plan based on the current 

employment status of the beneficiary or the beneficiary’s 

spouse.

NOTE: COBRA coverage is not a GHP based on current 

employment status. COBRA coverage does not qualify an individual 

for a SEP.

Current 

Employment 

Status

In general, an individual has “current employment status” if he/she is 

actively working as an employee, is the employer (including a selfemployed individual) or is associated with the employer in a business 

relationship.

An individual also has “current employment status” if he or she is not 

actively working, but meets all of the following conditions:

retains employment rights in the industry;

employment has not been terminated by the employer (if the 

employer provides the coverage); or membership in the employee 

organization has not been terminated (if the employee organization 

provides the coverage);

is not receiving disability benefits from an employer for more than 6 

months;
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is not receiving railroad retirement or Social Security disability 

benefits; and

has employment based GHP coverage that is not COBRA 

continuation coverage.

Persons who retain employment rights include but are not limited to:

those who are on strike, furloughed, temporarily laid off or who are on 

sick leave;

teachers and seasonal workers who normally do not work throughout 

the year; and

individuals who have health coverage that extends beyond or 

between periods of active employment.

The following information further defines “current employment status” 

for specific situations.

1. Individual Covered Under A Retirement GHP is Rehired

A group health plan based on former employment becomes a GHP 

based on “current employment status” if the employer who is 

furnishing the retirement GHP rehires the individual and the amount 

of work the individual performs is sufficient to earn coverage from the 

employer had the individual not retired.

The employment under the GHP is attributed to current employment 

status. This is true even if the payment for the GHP coverage is 

deducted from a pension or annuity payment.

If employed by an employer other than the one providing the group 

health plan coverage however, the GHP is a retirement plan and is 

not based on current employment status.

2. Employment Status of Senior Judges

Senior Federal judges are retired judges of the U.S. court system and 

the Tax Court. They may continue to adjudicate cases, but they are 

entitled to full salary as a retirement benefit whether or not they 

perform judicial services for the Government. The remuneration they 

receive as senior judges is not regarded as wages for Social Security 

retirement test purposes. Since they are considered retired for Social 

Security purposes, they are not considered to have current

employment status for purposes of the SEP and premium surcharge 

rollback.
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3. Clergy and Members of Religious Order

Members of religious orders who have not taken a vow of poverty are 

considered to have current employment status with the order if:

the religious order pays FICA taxes on behalf of that member; or 

the individual receives remuneration from the order for services

furnished, regardless of whether the order pays FICA taxes on behalf 

of that member.

Members of religious orders who have taken a vow of poverty are not 

considered to have current employment status if the services 

performed as a member of the order are considered employment for 

social security purposes only because the Order elected social 

security coverage under 3121(r) of the Internal Revenue Code.

4. Individuals Serving as Volunteers

Volunteers are considered to have current employment status if they 

perform services or are available to perform services for an employer 

and receive payment for their services. For example, AmeriCorps 

(which includes VISTA, the National Civilian Community Corps and 

State and National volunteers) and Peace Corp volunteers are 

considered to have current employment status since they receive 

remuneration from the Federal Government. Payment may be 

monetary or non-monetary. Benefits (including health benefits) that a 

volunteer receives are considered as payment if the benefits are 

subject to FICA taxes under the Internal Revenue Code.

Large Group 

Health Plan 

(LGHP)

The term “LGHP” refers exclusively to the disabled.

An LGHP is a group health plan that is available to employees of one 

or more employers who normally employed at least 100 employees 

on at least 50 percent of its business days during the previous 

calendar year.

If a plan is a multi-employer plan, such as a union plan, which covers 

employees of some small employers and employees of at least one 

employer that meets the 100 or more employees’ requirement, 

Medicare is secondary payer for all employees enrolled in the plan. In 

this situation, all the employers (large and small) in the multiemployer plan are considered "large," and their plan coverage is 

considered LGHP coverage.
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NOTE: When used in these instructions, LGHP means specifically a

large group health plan covering a disabled beneficiary.

LGHP Is No

Longer a 

Large Plan

An LGHP is no longer considered a large plan effective January 1 of 

the year following the year in which the employer no longer 

employed 100 employees on at least 50 percent of its business days 

in that year. For purposes of these instructions, it is to be treated as a 

GHP at that point. The CMS Regional Office should resolve any 

questions about the size of a plan.

Medicare 

Secondary 

Payer (MSP) 

Provisions

In general, Medicare is secondary payer for services covered under 

any of the following:

Group health plans (GHPs) of employers that employ at least 20 

employees and that cover Medicare beneficiaries age 65 or older who 

are covered under the plan by virtue of the individual's current 

employment status with an employer or the current employment 

status of a spouse of any age.

Large group health plans of employers that employ 100 or more 

employees and that cover Medicare beneficiaries who are under age 

65, entitled to Medicare on the basis of disability, and covered under 

the plan by virtue of the individual's or a family member's current 

employment status with an employer.

Medicare is secondary for these individuals even if the employer 

policy or plan contains a provision stating that its benefits are 

secondary to Medicare benefits or otherwise excludes or limits its 

payments to Medicare beneficiaries.

Spouse An individual is considered a spouse for SEP purposes if he/she is a: 

Spouse for RRA benefits or Social Security Title II purposes

Divorced Spouse – if a divorced spouse is covered under the GHP or 

LGHP of a former spouse, the divorced spouse is considered to be a 

“spouse” for purposes of these provisions even though he/she may 

not otherwise meet this definition.

Due to the repeal of the Defense of Marriage Act (DOMA) on June 26, 

2013, we are now able to process SEP requests for individuals with
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GHP or LGHP coverage based on the current employment of a samesex spouse. Same-sex marriages are treated the same as oppositesex marriages for purposes of the SEP.

When considering a spouse for SEP purposes, the following 

individuals cannot be recognized as a spouse under any 

circumstances:

Domestic (or life) partner age 65 or older and covered under a GHP, 

and

Domestic (or life) partner under age 65, entitled to Medicare based on 

disability, and covered under a GHP.

This provision does not apply to domestic (or life) partners under age 

65 who are entitled to Medicare based on disability and have LGHP 

coverage as a “family member.” Under the SEP provisions, a 

domestic partner who has coverage under an LGHP based on the

other partner’s enrollment in the plan, is considered a family member.

Prior to December 2004, CMS’ policy was that the SEP provision 

applied to a domestic partner if the GHP included the domestic 

partner within the definition of “spouse,” i.e., where domestic partners 

were given “spousal” coverage by the plan. An individual who 

refused SMI in the belief that he or she was eligible to enroll during a 

SEP as a domestic partner, and whose IEP began December 2004 or 

earlier, may be able to enroll under equitable relief provisions.

Family 

Member

Family member is defined as “a person who is enrolled in an LGHP 

based on another person's enrollment.”

The term encompasses not only individuals who are related (by 

blood, marriage or adoption), but also individuals who are related 

provided they are enrolled in the LGHP based on the worker’s 

enrollment.

Family members include, but are not limited to a spouse, a natural, 

adopted, foster or step-child, a parent, or a sibling.

Domestic (or life) partner - a domestic partner who is under age 65 

and who has coverage under an LGHP based on the other partner's 

enrollment in the plan, is considered a family member for the 

purposes of these provisions.
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Sponsoring 

Organization

A sponsoring organization may be a social, religious, educational, 

scientific, and/or charitable organization as described in section 

501(a) and (c)(3) of the Internal Revenue Code of 1986. The 

sponsoring organization can be a corporation, or any community 

chest, fund or foundation organized and operated exclusively for 

religious, charitable, scientific, testing for public safety, literary, 

educational purposes, or to foster national or international amateur 

sports competition. Also included are organizations for the prevention 

of cruelty to children or animals.

D. Application Requirements

Field office personnel must determine if the requirements for a SEP exist 

before they secure the necessary application for enrollment and evidence 

of coverage under a Group Health Plan (GHP) or Large Group Health Plan 

(LGHP). Field office personnel must determine the following:

• If the health plan is a GHP or LGHP, and

• Whether the individual’s GHP coverage was based on his or her own or 

the spouse's current employment; or if disabled, whether theindividual’s 

LGHP was based on his or her own or a family member’s current 

employment status. 

Use the following chart to determine whether the individual needs GHP 

or LGHP coverage to qualify for a SEP:

Type of 

Beneficiary

Beneficiary Can 

Qualify for SEP 

On Basis Of:

If Coverage is Based on 

Current Employment Status 

of:

Aged GHP Self or spouse

Disabled GHP Self or spouse

LGHP Self or family member

NOTE: Careful questioning is needed to determine whether the GHP or LGHP is 

based on a current employment status. It is not sufficient to ask “Are you covered by 

an employer group health plan? You must also determine if the coverage is based on 

a current work status. Remember that GHP or LGHP coverage based on a retirement 

plan does not qualify an individual for a SEP. (See FOM-1-810.35.2.1) if an individual 

does not qualify for a
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SEP on the basis of GHP or LGHP based on a current employment 

status.)

1. Application

• If the individual is filing an application for benefits at the same 

time he or she is enrolling for Part B during a SEP, a separate 

application is not required. Instead, answer the appropriate 

Medicare-related questions on APPLE.

• If the individual is not filing for benefits at the same time he or 

she is enrolling for Part B, obtain a completed Form G-44b. See

FOM-I-1720 for completion instructions.

• Here are the Medicare-related questions on APPLE that may 

need to be completed when enrolling an individual during a 

SEP:

Note: For purposes of items on APPLE, consider that “EGHP” 

refers either to a GHP or LGHP.

Beginning Dates, Filing Dates, Medicare

• Applicant is 64 years and 5 months of age or older? Y/N

Medicare Part B Enrollment

• Currently entitled to Part B? Y/N

• Recently filed for Part B? Y/N

• I wish to enroll for Part B Medicare? Y/N

Medicare Part B Special Enrollment

• Current EGHP Coverage? Y/N

• Date Last Worked

• EGHP Beginning Date

• EGHP Ending Date

• Previous EGHP Coverage? Y/N

• Special Enrollment Period? Y/N
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• Part B Effective Date

NOTE: If the applicant has GHP coverage, but it is not based on his 

or her own or the spouse’s current employment status (or if 

disabled, the applicant does not have LGHP coverage based on his 

or her own or a family member’s current employment status), 

answer the first question “No.”

Proof of Employer Group Health Plan Coverage

• Name of Employer

• Name of EGHP

• Date Employment Ended or Will End

• EGHP Beginning Date

• EGHP Ending Date

• Document Type 

Notes:

The items on the Proof of Employer Group Health Plan Coverage 

screen are to be answered with respect to the individual with the 

“current employment status” on whose GHP or LGHP coverage the 

beneficiary qualifies for a SEP.

If the name of the GHP or LGHP is not known, enter “Unknown” for 

name of EGHP.

2. Proof of GHP or LGHP

The preferred proof of GHP or LGHP coverage based on a current 

employment status is a completed Form RL-311-F. Other 

acceptable proofs are a letter on stationary from the employer or 

insurance company (GHP or LGHP) showing the information 

requested on Form RL-311-F, or Form CMS-L564.

When the employer, GHP or LGHP cannot provide all evidence of 

the GHP or LGHP coverage, the following are acceptable 

documents: 

a. Income tax returns that show health insurance premiums paid;

b. W-2s reflecting pre-tax medical contributions;

c. Pay stubs that reflect health insurance premium deductions;

d. Health insurance cards with a policy effective date;

e. Explanations of benefits paid by the GHP or LGHP; and
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f. Statements of receipts that reflect payment of health insurance 

premiums.

Field office representatives should try to obtain proofs for the entire 

period from when the applicant first became eligible for Medicare 

through the application date. This may require additional RL-311Fs. 

Enter the proof(s) on APPLE by completing the items on the Proof 

of Employer Group Health Coverage screen. See item 1 above.

After entering the proof on APPLE, scan the documents to the 

Medicare Unit according to the following:

• If the proofs were provided as part of an APPLE application, 

scan the RL-311F and any supporting documents to the 

Medicare Unit as an actionable item under the G-180B 

“Headquarters-Medicare” using form type “RL-311F”. 

• If the proofs were not provided as part of an APPLE 

application, scan the G-44B, RL-311F, and any supporting 

documents to the Medicare Unit as one actionable item 

under the G-180B “Headquarters-Medicare”, using form type 

“SEP ENROLLMENT”.

SEP for International Volunteers. Under the SEP provision, 

qualifying volunteers can delay enrollment in Part B or terminate 

such coverage for the period of service outside the U.S. and reenroll later after they return to the U.S. without incurring a premium 

surcharge for late or re-enrollment. If an individual requests 

termination of Part B because he or she will be serving as a 

volunteer outside of the U.S., field office personnel will advise the 

beneficiary of the eligibility requirements that must be met in order 

to re-enroll during the SEP for International Volunteers. The 

Medicare Unit (MU) will handle the Part B termination.

When the beneficiary is ready to enroll or re-enroll, field office 

personnel is responsible for collecting the required proof and 

documentation of the volunteer service, tax-exempt status of the 

sponsoring organization, and health insurance coverage. Fieldoffice 

personnel will image the application and documentation and forward 

them to the MU enrollment inbox. The evidence may be in any 

form, as long as there is no question that the evidence is from 

the sponsoring organization, health insurance plan, and all 

required information is present. If the evidence of volunteer 

service, tax-exempt status of the sponsoring organization, and 

health insurance coverage outside of the U.S. is obtained by 

telephone, field office personnel must record the information on the 
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Contact Log.

• Evidence of Volunteer Service and Tax-Exempt Status of the 

Sponsoring Organization – The evidence must show that the 

individual served as a volunteer outside of the U.S. through a 

program sponsored by a tax-exempt organization.

• Evidence of Health Insurance Coverage Outside of the U.S. – The 

evidence must show that the individual had health insurance that 

provided coverage for the individual outside of the U.S. for the 

duration of the volunteer service.

All Medicare Part B enrollment requests will be processed by the field 

office. The field office will then image the SEP enrollment package 

containing the Part B enrollment request, evidence of volunteer service, 

tax-exempt status of the sponsoring organization, and health insurance 

coverage outside of the U.S. to the Medicare Unit. Field office personnel 

may give the individual Form G-93 (found on RRAILS) that requests the 

information below. It is up to the individual to obtain the information from 

the necessary parties:

1. For evidence of volunteer service and the tax-exempt status of the 

sponsoring organization, request the following information:

a. Name, address, and telephone number of the sponsoring 

organization

b. Is your organization tax exempt as defined in section 501(a) of the 

Internal Revenue Code of 1986? [ ] YES [ ] NO

c. Does your organization meet the definition in section 501(c)(3) of 

the Internal Revenue Code of 1986? [ ] YES [ ] NO

d. If yes to either of the above questions, provide your tax 

identification number.

e. Did the individual serve as a volunteer outside of the United States 

as a member of your organization? [ ] YES [ ] NO

f. Date volunteer service outside of the United States began:

g. Date volunteer service outside of the United States ended:

2. For evidence of health insurance coverage outside of the United States, 

request the following information:
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a. Name, address, and telephone number of health insurer

b. Does (or did) the individual have any health insurance that provides 

(or provided) coverage for services outside of the United States?

[ ] YES [ ] NO

c. When did the health insurance begin?

d. When did the health insurance end?

If the individual is enrolling in Part B during the GEP, the field office will 

forward the enrollment request to MU for handling. Field office personnel 

should notate “Premium Surcharge Relief – INT’L VOLUNTEERS” on the 

request. All necessary information should be included.

If the individual is already enrolled in Part B and is requesting premium 

surcharge relief, field office personnel should notate “Premium Surcharge 

Relief – INT’L VOLUNTEERS” on the request. All necessary evidence 

should be included and forwarded to MU to re-calculate the penalty rate.

810.25.6 Unique Enrollment Situations - Parts A and B

A. Overlapping Initial and General Enrollment Periods - If an application is 

filed and an individual's IEP and GEP overlaps the individual will be 

enrolled for Parts A and B based on the IEP. If an application is filed after

the end of the IEP but before the end of the GEP, the Part B effective date 

will begin the first day of the month after the beneficiary enrolls. 

B. Overlapping IEP/SEP - An individual cannot claim a SEP which is within 

his/her IEP. An application that is filed after the individual's GHP or LGHP 

coverage has terminated, but before the end of the IEP must be enrolled 

for Part B based on the IEP. Regulations do not permit an individual to 

claim an SEP during an IEP.

C. Overlapping IEP/SEP/GEP - If an application is filed and an individual's 

IEP, GEP and SEP overlap, the individual will be enrolled for Part Bbased 

on the IEP. If an application is filed after the end of the IEP and a GEP 

and SEP overlap, the individual may choose either a GEP or SEP.

D. Overlapping Disability and Age 65 Enrollment Periods - In some 

instances, a beneficiary's Part B IEP period for disability Medicare will 

overlap the Part B IEP period for aged Medicare. In such instances the 

beneficiary will be enrolled for Parts A and B based on the earliest IEP.
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E. Waiver of Part B Enrollment Period Requirements - Relief is available to 

certain individuals whose SMI enrollment rights were prejudiced due to 

action, inaction or error of government officers, employees or agents. The 

RRB is authorized to establish an enrollment and coverage periods and to 

adjust premium liability if there is evidence or record showing that the 

individual took reasonable, appropriate and timely measure to assert his 

rights, and due to administrative fault or other action these rights are likely 

to be seriously impaired unless relief is given. See section 810.35. 

810.25.7 Aged Medicare - Parts A and B - Uninsured Individuals

Those individuals not insured at either the RRB or SSA may enroll for Aged 

Medicare Part B only or Aged Medicare Parts A and B at SSA. The IEP and GEP 

enrollment provisions for Part B insured beneficiaries apply to both Parts A and B 

for uninsured beneficiaries.

810.30 Application Requirements

810.30.1 Beneficiary on the Rolls During IEP

Annuitants and beneficiaries of SS benefits certified by the RRB currently on the 

rolls (whether payment is in force or in suspense) is not required to submit an 

application or additional evidence for HI or SMI. The annuity application or 

supplement previously filed automatically establishes timely Medicare 

entitlement. The automatic enrollment process begins 6 months prior to 

attainment of age 65. Individuals who are automatically enrolled through this 

process are referred to as attainments. A Medicare record is established and a 

Form G-41 is released before the beginning of the IEP. However, if an individual

is receiving an annuity based on age and wishes to establish earlier Medicare 

eligibility based on disability, additional information will be required as described 

later in this section.

IPIs are enrolled through manual call-up and processing in the Medicare Unit. 

No field office action is generally required to enroll an IPI for Medicare.

If an individual is automatically enrolled for Medicare (Part A and B), he or she 

may refuse the coverage any time before entitlement begins without penalty.

If an individual wants to refuse Medicare Part A, he/she must submit a written 

request cancelling their application and Medicare coverage. In addition, any 

annuity payments must be repaid to RRB. The individual is also responsible for 

the repayment of any Medicare Part A and Medicare Part B benefits paid out for 

the beneficiary. The individual cannot elect to withdraw only the Medicare Part A 

application.

A beneficiary can refuse only Medicare Part B without affecting their claim for 

Medicare Part A and monthly benefit.
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810.30.2 Beneficiary Files for An Annuity During or After IEP

Providing this is the first application filed and the beneficiary has not previously 

refused Medicare Part B coverage, a separate application is not required to 

establish HI or SMI entitlement. However, the applicant in these instances must 

answer the question on the annuity application referring to whether he or she 

wants SMI coverage. The HI coverage effective date may be established 

retroactive for up to 6 months from the filing date (12 months for the divorced 

spouse of a disabled employee). However, the SMI coverage effective date will 

be determined as though the beneficiary enrolled in a GEP unless the application

is filed during the IEP. Therefore, if the annuity application is filed between 

January 1 and March 31, and SMI is elected, SMI coverage begins the next 

month following the month the application was filed. 

Otherwise, the application is used to deem the individual’s enrollment in the next 

GEP unless a "no" election was made on the annuity application. If a "no" 

election is made, the beneficiary must file Form G-44b or send a signed 

statement to elect SMI during a GEP or SEP.

If the beneficiary does not answer the question on the annuity application about 

SMI coverage and is not enrolled in Medicare under another record, SMI 

coverage would have to be elected during a SEP or GEP. Enrollment in this 

situation could not be automatic.

810.30.3 Employee Filing For or Entitled to an Annuity Based on Age Wants 

to Establish Early Medicare Based on Disability

In addition to the annuity application and evidence that is being or has been 

developed previously, a supplemental Form AA-ld must be developed to

establish entitlement to disability Medicare (HI and SMI). The Form AA-ld should 

be marked "Application for Disability Freeze." In addition, proof of disability, Form 

G-251 should be developed.

810.30.4 Widow(er), Surviving Divorced Spouse or Remarried Widow(er) 

Filing for or Entitled to an Annuity Based on Age Wants to Establish Early 

Medicare Based on Disability

In addition to the annuity application and evidence required for payment of the 

annuity, a Form AA-17b must be developed to establish entitlement to disability 

Medicare (HI and SMI). In addition, proof of disability should be developed. Also 

develop Form G-251 for a widow(er), but not for a surviving divorced spouse or a 

remarried widow(er).

810.30.5 Employee Filing for Medicare Only

An employee who does not wish to retire but wants to establish entitlement to 

Medicare only, must file a Form AA-6 and proof of age. The application will 

establish entitlement to HI and entitlement to SMI if the employee elects 
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coverage and the application is filed during his or her IEP, GEP, or a SEP.

An employee who previously filed an informational application while age 62 to 64 

to qualify his or her spouse for Medicare must complete a new Form AA-6 during 

an open enrollment period to qualify for Part A coverage and to enroll for Part B 

coverage.

In addition, the following evidence may be required as indicated:

Evidence When required

Proof of Military Service If needed to establish 120 months of RR service; 

or 60 months of RR service after 1995.

Lag Service statement from 

employer

If needed to establish 120 months of RR service; 

or 60 months of RR service after 1995.

In a letter to the RR contact official, request a report of the number of months of 

lag service through the application filing date. Submit a copy of the letter with the 

application. The reply should be sent to MU.

810.30.6 Spouse or Divorced Spouse Filing for Medicare Only

A spouse who meets the requirements in section 810.10.2 or a divorced spouse 

who meets the requirements in section 810.10.3 and wants to establish 

entitlement to Medicare must file a Form AA-7.

The application will establish entitlement to HI, and entitlement to SMI if the 

spouse or divorced spouse elects coverage and the application is filed during the 

IEP, a GEP, or a SEP. In addition, the following evidence is required:

Evidence When required

Proof of age of spouse or 

divorced spouse

Always.

Proof of age of employee Always. (Will already be in file if employee is 

receiving annuity.)

Proof of marriage to employee Always.

Proof of divorce from employee Always from divorced spouse.

Proof of termination of prior 

marriage

Only if there is reason to doubt that the marriage 

terminated.
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Proof of termination of latest 

marriage

Always from a divorced spouse who remarried.

Form G-346 completed by 

employee

Required only when legal spouse is filing and the 

spouse’s application filing date is more than 90 

days from the voucher date of the employee’s 

initial award. When the employee and spouse are 

separated, request the Form G-346 directly from 

the employee. If the employee refuses to 

complete Form G-346, the spouse must submit 

statements concerning the employee's prior 

marriages from two other persons who know the 

facts, preferably relatives of the employee. If she 

cannot do that, she should submit a statement 

explaining why. The file will be reviewed to 

determine if additional evidence (e.g., a search of 

court records) is required.

NOTE: When completing Form G-346 that 

accompanies a spouse Medicare-only application, 

item 8 of Form G-346 does not need to be 

completed.

Proof of employee's military 

service

If needed to establish 120 months of RR service; 

or 60 months of RR service after 1995.

Employee's lag service 

(statement from Employer)

If needed to establish 120 months of service; or 

60 months of RR service after 1995. In a letter to 

the RR contact official, request a report of the 

number of months of lag service through the 

application filing date. Submit a copy of the letter 

with the application. The reply should be sent to 

MU.

810.30.7 Widow(er), Surviving Divorced Spouse or Remarried Widow(er) 

Filing for Medicare Only

A widow(er), surviving divorced spouse or remarried widow(er) who meets the 

requirements in section 810.10.4 and wishes to establish entitlement to Medicare 

must file a Form AA-8.

The application will establish entitlement to HI and entitlement to SMI if the 

applicant elects coverage and the application is filed during the IEP, a GEP, or a 

SEP. In addition the following evidence is required:
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Evidence When required

Proof of death of employee Always.

Proof of age Always.

Proof of marriage to employee Always.

Proof of termination of prior 

marriage

If there is doubt a prior marriage ended.

Proof of divorce Always from a surviving divorced from employee 

spouse.

Proof of remarriage(s) Always from remarried widow or a surviving 

divorced spouse who remarried.

Proof of military service If needed to establish 120 months of RR service; 

or 60 months of RR service after 1995.

Employee's lag 

(statement from employer)

If needed to establish 120 months of RR service; 

or 60 months of RR service after 1995. In a letter 

to the RR contact official, request a report of the 

number of months of lag service through the

month of death. Submit a copy of the letter with

the application. The reply should be sent to MU.

810.30.8 Child Filing for Medicare Only

A child who is eligible as described in section 810.15.4 and who meets the 

relationship, dependency and O/M requirements, but who is not receiving an 

annuity or considered in the payment of the employee or spouse annuity, must 

file a Form AA-19a to establish entitlement to Medicare. Since the youngest age 

at which a child is eligible to be included in the O/M based on disability is age 18, 

and age 16 is the youngest age at which a disabled child can qualify a spouse 

annuity for SSEB consideration, a Form AA-19a should not be developed prior to 

the child’s attainment of age 18 in O/M cases, or age 16 in spouse cases. (To be 

entitled to Medicare, the child must have been eligible for O/M inclusion for at 

least 24 months and be at least 20 years of age.)

The application will automatically enroll the child for HI and SMI when all 

entitlement requirements are met. If the child does not want SMI coverage, 

refusal of coverage can be made by notifying the RRB upon receipt of the notice 

informing of the entitlement effective date. In addition, the following evidence is 

required: proof of relationship, proof of the child's age and medical evidence.
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810.30.9 All Beneficiaries, Electing Part B After Part A Established

A. Separate application not required - A separate application to establish Part 

B coverage is not required, if a beneficiary:

1. Filed an annuity application or a Medicare only application during 

the previous year, and

2. Part A had not been established prior to that application at either 

SSA or RRB, and

3. The beneficiary elected Part B coverage on the application.

Beneficiaries meeting the above requirements are deemed to have filed 

during a GEP.

B. Separate application required - Beneficiaries who do not meet the 

requirements in A. above may apply for Part B coverage by submitting one 

of the following during a General Enrollment Period (January 1 through 

March 31 of each year):

1. Form G-44 - This form is released by headquarters to beneficiaries

in the United States when Part B coverage was refused, withdrawn 

or terminated in the previous year, or

2. Form G-44b (see FOM-I-1720), or

3. A statement which clearly states the individual wants to enroll for 

Part B coverage.

The beneficiary will be enrolled for medical insurance effective the first 

day of the month following the month in which they enroll of the year in 

which the Forms G-44, G-44b or a statement is submitted . For example, 

if the Form G-44b is submitted in February, Medicare becomes effective 

March 1.

810.30.10 All Beneficiaries Filing In A SEP

See FOM-I-810.25.5 for information about the application requirements for 

individuals filing for Part B during a SEP.

810.35 Equitable Relief

810.35.1 General

The 1972 amendments to the Social Security Act authorized relief when an 

individual's SMI enrollment, termination or coverage rights are prejudiced 

because of an error, misrepresentation or inaction of an employee or agent of the 

Government. In such situations, RRB may take whatever action is necessary to 
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prevent or correct inequity to the individual, including (but not limited to) the 

designation of an enrollment and coverage periods, and appropriate adjustment 

of premium liability. The effective date of this amendment was 7-1-66. The 

equitable relief provisions may be applied to any eligible Part B enrollee.

To be eligible for equitable relief, evidence of the following elements must exist:

• The individual took such appropriate and timely measures to assert his or 

her rights as could reasonably be expected under the circumstances, and

• Because of administrative fault, delay or erroneous action or inaction by 

an employee or agent of the RRB or another Federal government agency, 

the individual’s enrollment or premium rights would be impaired unless 

relief is given. (An "agent" of the Federal government is one who is 

authorized to act on behalf of the Federal government in matters 

pertaining to Medicare, such as an employee of the Part B carrier.)

Relief cannot be provided merely because of hardship or because of "good 

cause" for failure to enroll. There must be some erroneous action or inaction by 

the Federal government which is prejudicial to the rights of the individual.

Whether or not the individual used Medicare coverage is not a factor in 

determining if equitable relief may be granted.

The elements which must be present in every case where equitable relief is 

granted are:

A. Government error, misrepresentation, or inaction; and

B. Prejudice to the individual's SMI rights. This may consist of carrying 

private insurance that the individual did not need, electing surgery in 

advance of entitlement because he or she was misinformed about their 

entitlement date, missing an enrollment period, being unable to pay a 

large premium arrearage which accrued due to government delay, or any 

other hardship with health care needs that can be traced to government 

error, misrepresentation or inaction on enrollment, premium collection or 

termination of entitlement; and

C. Evidence of the error - Usually the headquarters file will show evidence 

that an error has occurred, e.g., delay in awarding coverage, an erroneous 

termination, failure to deduct or bill for premiums. It is also possible that an 

individual may allege that his or her rights were prejudiced due to 

misinformation that was received. Such allegations must be substantiated. 

Equitable relief may not be granted in this situation unless there is 

documentary evidence in the form of statements from employees, agents 

or persons in authority that the alleged misinformation, misadvise, 

misrepresentation, inaction or erroneous action actually occurred, or that 

there is a strong likelihood based on personal knowledge or prior 

experience that it occurred.
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NOTE: If equitable relief is being considered because a beneficiary 

alleges that he or she received incorrect information or advice from an 

RRB field office or that an RRB field office erred in handling a request, the 

RRB claims representative identified as having given the misinformation 

must submit a statement explaining his or recollection of the event. If the 

employee cannot recall the interview or discussion, he or she should 

nevertheless report on the probability that she or she gave misinformation 

or incorrect advice to the individual. If the claims representative cannot be 

identified for any reason, the district manager should report on the 

likelihood of such an error. The statement should be submitted to the 

Medicare Unit.

EXCEPTION: If the individual caused or contributed materially to the 

government error by fraud or similar fault, equitable relief will not be 

granted even if the above three factors are present in the case.

810.35.2 Common Situations Involving Equitable Relief

A. Enrollment not processed timely - For a variety of reasons involving 

government fault or error, an individual's SMI enrollment request may not 

be processed until several months or years after coverage should have 

started. Similarly, there may be a delay of several months or years in 

notifying the enrollee that coverage has been awarded.

Serious inequity is likely to result where such an individual is required to 

pay for a long period of retroactive coverage which he or she may not

have known existed; the individual may have continued to carry 

nongovernmental health insurance, or the individual may have deferred 

necessary treatment because he or she did not know they were insured 

for the cost of such treatment, and/or the individual may be unable to pay 

the premiums which accumulated over a long period of months or years.

1. Enrollment processed or enrollee notified 6 months or more after 

coverage should have started - If an enrollment request is filed 

timely but not processed, or the enrollee is not notified of the start 

of his coverage within the first 6 months after coverage should have 

started, the individual is enrolled effective with the month final 

action is taken to process the award. Months elapsing after the end 

of the enrollment period in which the request was filed (or deemed 

to have been filed) will not be counted in determining the premium 

rate. The enrollee will be sent a special notice of SMI award, 

informing him or her of the option of having SMI coverage begin 

earlier (the date coverage would have started if the enrollment 

request were handled timely), provided that within 30 days he or 

she (l) requests the earlier date of coverage, and (2) either pays all 

back premiums due for months of coverage prior to the month 
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shown on the award notice, authorizes deduction of the back 

premiums from monthly benefit payments or arranges for an 

alternate method of payment.

If the individual selects the earlier effective date and arranges to 

pay all back premiums, the Medicare Unit will adjust the HI record 

to show the earlier date of coverage. The Medicare Unit should 

then determine whether it is necessary to alert the enrollee to the 

need for prompt filing of Part B claims for any covered services he 

or she may have received during the first months of SMI 

entitlement. If the time limit for filing claims for services received in 

the first months of coverage has ended, or will end within 6 months 

after the beneficiary is informed of the earlier coverage date, the 

enrollee is advised that claims for such services will be honored if 

filed within 6 months after the month he or she is notified.

If the enrollee has already made it clear that he or she wants only 

current coverage or wants (and is willing to pay for) earlier 

entitlement, SMI coverage is awarded accordingly without providing 

notice of coverage date options.

These procedures also apply when an application for enrollment 

was denied initially for any reason, and as a result of 

reconsideration or a hearing, the original decision is reversed.

2. Enrollment not processed but premium deductions in force - 

enrollee not notified until 6 or more months after coverage should

have started - It is possible, especially in the case where only an 

SS benefit is being paid, that premium deductions were initiated 

timely but the necessary enrollment activities were omitted. In such 

cases, the enrollee may or may not know about the deductions.

Since no valid enrollment has been processed, claims for benefits 

could not be filed. It is possible that the individual is aware that 

deductions are being made, but that he simply has not yet had a 

claim to file.

In such cases, the individual is enrolled effective with the date 

deductions began. The individual is notified by Headquarters of the 

effective date of coverage. If the enrollee spontaneously objects 

within 2 months after the month in which he is notified of his 

coverage, the SMI award may be reversed. Any premiums 

collected should be refunded and the individual will be deemed not 

to have enrolled or, in automatic enrollment cases, will be deemed 

to have refused enrollment. If he desires SMI, but does not wish to 

accept coverage effective with the earlier date when deductions 

began, Headquarters advises him of the next general enrollment 

period. The beneficiary cannot accept an intermediate effective 
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date of coverage. If the beneficiary declines coverage effective with

when the deductions began, he may suffer a premium penalty if he 

enrolls in a later GEP.

3. Individual dies before award is made - If a SMI award is delayed so 

that notice of the choice in A. or B. above could not be made by the 

individual prior to his death, any of his survivors can be given the 

option of electing SMI as of the date entitlement should have begun 

and paying the premiums, or refusing SMI entirely. If an amended 

award, which would cause earlier SMI entitlement is made to a 

person who already has SMI but the enrollee dies before he is able 

to make the choice of having earlier SMI entitlement, the survivors 

can be given the choice of accepting the new (earlier) SMI 

entitlement date and paying the additional premiums or refusing 

earlier entitlement.

B. SMI awarded on later of 2 timely enrollment requests - After a person has 

been awarded SMI on the basis of an enrollment request, an examiner 

may discover an earlier, timely enrollment request, still unprocessed. If we 

revised the existing SMI award to change the effective date to one that 

would be consistent with the earlier enrollment request, the enrollee could 

be required to pay for many months of undesired SMI coverage. Such 

action would likely result in complaints of hardship and inequity.

A case involving an unprocessed earlier request for a person currently 

enrolled will be handled as follows:

1. The enrollee's premium rate is reduced, if necessary, to be 

consistent with the enrollment period in which the earlier request 

was filed. Any excess premium amounts already collected will be 

refunded or used as a credit against any future premium liability. 

The enrollee is notified that his prior premium rate had been 

incorrectly computed, and that the error has been corrected. No 

field office action is necessary. 

2. However, if the file reflects a current or timely protest (filed within 6 

months of notice) against the existing SMI award, the Medicare Unit 

will notify the enrollee that he may have his SMI coverage begin at 

the earlier date provided that within 30 days he so elects and pays 

the retroactive premiums which have accrued, authorizes the 

deduction of such premiums from his monthly payments or 

arranges an alternative method of payment.

C. Delayed or incorrect advice frustrates enrollment or termination rights - In 

some cases, an individual may be prevented from taking timely and 

appropriate action to enroll for or terminate SMI coverage due to 

administrative delay or misadvise. For example, an individual may write to 
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the RRB shortly before or during an enrollment period open to him, but be 

prevented from enrolling because we did not answer his inquiry until most 

or all of the enrollment period had elapsed. Relief in such cases will be 

provided to insure that the enrollee's desires are met. Similar relief is 

provided in cases where an enrollee inquires about SMI termination and a 

reply is not given in time to permit him to file a voluntary termination 

request within the same calendar quarter in which he inquired about 

termination.

Cases of this type are to be handled as follows:

1. Inquiry shows unequivocal desire to enroll - When an individual 

inquires about SMI during or within 9 months prior to the start of an 

enrollment period open to him, and from the nature of the inquiry it 

is clear that he wants SMI, he should be awarded coverage based 

on filing on the first day of that period. However, if taking action to 

provide such relief would result in the award of 6 or more months of 

retroactive coverage, SMI is awarded beginning with the month in 

which the individual is notified. The individual is informed of his right 

to obtain earlier coverage by requesting such coverage and paying 

the accrued premiums.

2. Inquiry does not show unequivocal desire to enroll - If the inquiry 

does not express a clear and unequivocal desire to enroll, the 

individual will be mailed an enrollment card (Form G-44) and a 

letter informing him that he may obtain coverage as of the date his 

coverage would have started if we had promptly replied to his

inquiry. The letter explains that he may only have the earlier date of 

coverage if within 30 days he completes Form G-44 and returns it 

with a premium payment, if no benefits are currently payable. If the 

Form G-44 is returned promptly, he will be deemed to have filed his 

enrollment request timely. Otherwise, he must file during the next

GEP.

D. SMI awarded erroneously - In some cases, after an individual has been 

enrolled, new evidence may be discovered indicating that SMI should 

have been disallowed; e.g., the individual had not yet attained age 65, or 

had not filed his enrollment request during an enrollment period open to 

him. Ordinarily, the individual will wish to retain his SMI because he may 

have given up his non- governmental health insurance or incurred 

substantial medical expenses in reliance on the SMI award. These 

erroneous SMI awards are handled in accordance with 1 and 2 below.

EXCEPTION: If an individual erroneously awarded SMI makes a timely 

protest against enrollment (i.e., before his SMI entitlement begins, or if 

later, within 6 months after the month in which he is notified of his SMI 

entitlement), the erroneous period of SMI coverage is deleted from the 
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health insurance records, and any premiums paid refunded provided he 

repays any SMI benefits paid pursuant to the erroneous enrollment.

1. Error discovered in or after actual IEP - If the error is discovered 

after the start of the individual's actual IEP, the SMI award will not 

be disturbed unless it was procured through fraud or similar fault of 

the individual. If it is determined that there was fraud or similar fault, 

equitable relief will not be granted, the SMI award will be annulled, 

and any Part B payments made during the period of erroneous 

entitlement will be treated as overpayments.

2. Error discovered before the actual IEP - If fraud is not involved and 

an individual was enrolled erroneously, and the error is discovered 

before the start of his actual IEP, HI and SMI coverage will be 

canceled with the last day of the month in which the action is taken. 

The Medicare Unit will notify the individual of the reason for the 

cancellation, and of the time when he may again enroll. No refund 

of premiums or recovery of payments due to utilization is made in 

this circumstance. 

E. SMI terminated erroneously - When an individual's SMI coverage is 

terminated erroneously, he is in approximately the same situation as the 

person whose enrollment was not processed timely. That is, he does not 

know whether he has SMI or not; he may enroll in a nongovernmental 

health plan to assure some protection for his medical expenses; he may 

defer necessary treatment because of his uncertainty about being insured 

against the cost of such treatment, etc. When the error is finally corrected,

it would be unfair to reinstate his entitlement retroactively and require him 

to pay premiums for past SMI coverage that he had been unable to use at 

the time. Accordingly, the options offered to the individual whose 

enrollment was not processed timely are also offered to the individual 

whose SMI was terminated erroneously, if 6 months or more premiums 

are owed.

1. Error discovered 6 or more months after termination - When 6 

months or more premiums are owed, individuals are given the 

same kind of option for termination as given in late enrollment 

cases. 

If the individual pays in full, authorizes withholding of the full 

amount from his monthly payments or agrees to monthly 

installments coverage is reinstated as of the month of the 

erroneous termination. If necessary, MU alerts the enrollee to the 

need for filing his claims promptly based on any SMI services on 

which the ordinary deadline for filing may have passed or be within 

6 months of the month of reinstatement.
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If the enrollee has already made it clear that he wants only 

prospective coverage or that he wants (and is willing to pay for) 

coverage during the retroactive period, SMI is reinstated 

accordingly without mentioning the option, providing he is willing to 

pay the premium arrearage.

If the enrollee protests that he does not want SMI coverage and 

such protest is filed within 2 months after the month in which he is 

notified that his coverage was reinstated, the SMI reinstatement is 

reversed (i.e., the original termination is permitted to stand) and any 

premiums collected are refunded.

2. Error discovered less than 6 months after month of termination - If 

an erroneous termination is discovered less than 6 months after the 

effective month of termination, no relief from premium liability may 

be granted. Action is taken to reinstate SMI coverage and collect 

past premiums due as soon as possible. If the enrollee 

spontaneously protests, the Medicare Unit will offer alternative 

methods of recovery.

F. Inadvertent failure to bill for or deduct premiums - non-buy-in cases - In 

some cases, long after a person has been awarded SMI and notified of his 

or her SMI coverage, it is learned that premiums have inadvertently not 

been billed or deducted from benefit payments for a period of months or 

years. By the time premium collection is initiated or resumed, the 

individual may have difficulty in paying the arrearage, especially in a lumpsum. To avoid hardship or the necessity of terminating SMI in cases

where premium arrearages accumulated because of administrative error, 

relief may be provided as follows:

1. Premium arrearage of 6 months or more - When premiums are due 

for 6 months or more, and monthly RR or SS payments are in 

current pay status, the Medicare Unit releases a notice to the 

enrollee explaining the arrearage and the proposed method of 

recovery (cash refund or full withholding). If the enrollee does not 

request any relief options offered by the notice within 30 days, the 

Medicare Unit will take recovery action. However, if a request for 

relief is received after 30 days, it will still be honored.

2. Premium arrearage of less than 6 months - Where the premium 

arrearage is not substantial, payment of the amount owed within 

the usual grace period will not normally create undue hardship for 

the enrollee. Therefore, no advance offer of waiver is given where 

SMI premiums are due for 5 or fewer months of coverage.

Although no mention of waiver is made in the arrearage letter in 
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these situations, if the enrollee spontaneously complains of 

hardship the Medicare Unit will not recover the arrearage. If 

payments have already been suspended, they are to be reinstated 

and waiver development initiated.

3. Premium arrearage due to IRMAA, penalty surcharge, or Medicare 

Advantage Part B premium reduction – In cases involving a 

premium arrearage that is the result of retroactive changes in the 

amount of a Part B premium because of (1) the addition of or a 

change in an Income Related Monthly Adjustment Amount 

(IRMAA), (2) the imposition of a premium surcharge, or (3) a 

change in a Medicare Advantage premium reduction, equitable 

relief will automatically be considered if the amount of the arrearage 

exceeds 5 times the current standard Part B premium. Exception: 

When the premium arrearage is due to IRMAA, the amount must 

exceed 5 times the current standard Part B premium plus the 

amount of the individual’s IRMAA.

Note that the determining factor in these situations is the amount of 

premiums due, not the number of months for which an adjustment 

to the premium is due. See RCM 3.2.108 and RCM 3.2.109 for 

additional details and examples of equitable relief for beneficiaries 

subject to IRMAA and equitable relief in cases involving Medicare 

Advantage Part B premium reductions.

Note: Automatic consideration of equitable relief in these types of 

cases generally means that the initial notice that premiums are due 

explains the options to pay by installment and to request waiver of

payment of the premiums if payment would cause financial 

hardship. Cancellation of Part B coverage for the months for which 

additional premiums are due cannot be considered.

4. Collection of current premiums - To prevent a premium arrearage 

from increasing while development is under way to establish an 

installment payment schedule, or to determine whether payment of 

the arrearage can be waived, the enrollee should pay for current 

coverage.

5. When relief from premium liability will be considered and granted - 

Many individuals, while willing and able to pay current premiums by 

deduction from monthly benefits or by direct remittance, may not 

have the resources to pay the premium arrearage even in minimum 

monthly installments of $20.00.

As explained above, if the arrearage is for 6 months or more, upon 

resumption of billing or premium deductions the individual will be 

notified about the possibility of waiver. Likewise, waiver will be 
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considered even for individuals with smaller arrearages if they 

request it or complain that it would be a hardship to pay the 

arrearage. The same criteria will be applied in determining whether 

waiver can be granted, regardless of whether the arrearage is 6 

months or less.

Where 6 months or more of retroactive premiums are owed, only 

the premiums for current coverage are deducted or billed 

immediately. The arrearage is not recovered until 30 days after the 

enrollee has been notified of the arrearage to give him the 

opportunity to claim hardship.

If the beneficiary requests waiver, the field office will be requested 

to obtain a completed Form DR-423.

The individual should be relieved of the obligation to pay an 

arrearage of premiums caused by governmental fault if payment of 

the amount would deprive him or her of funds which are reasonably 

necessary for ordinary living expenses. This is the same test used 

in determining whether recovery of an annuity overpayment would 

defeat the purpose of title II of the Social Security Act. The Division 

of Debt Recovery (DRD) will determine whether the arrearage 

situation meets the criteria for waiver and will so notify the enrollee. 

Authority to provide waiver is contained in section 7(d) of the 

Railroad Retirement Act and section 1837(h) of the Social Security 

Act. If the waiver request must be denied, DRD advises the 

individual that installment payments or partial withholding are still 

permissible.

G. Delayed deletion from state buy-in rolls results in premium arrearage - An 

individual whose state buy-in coverage terminates is deemed to be 

individually enrolled with continuing coverage and premium liability from 

the month after the month in which his buy-in coverage terminates. In 

some cases, because of program delays, 4 or more months may elapse 

between the end of the buy-in coverage and initiation of premium 

collection.

Such individuals are not required to pay more than 3 months of premium 

arrearage. Most state buy-in deletions are handled mechanically and relief 

is automatically given to anyone owing 4 or more months of retroactive 

premium (i.e., deductions or billing will be made for only 3 retroactive 

months and the current month).

When a premium arrearage of 2 or 3 months will be recovered, no special 

advance notice is sent to the beneficiary. However, if the individual 

spontaneously complains that he or she cannot afford to pay 1, 2 or 3 

months retroactive premiums, it is possible to grant relief from even the 3 

months arrearage. The district office will be requested to secure Form DR- 
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423 from the beneficiary. "Hardship" cannot be assumed without this 

development, because the individual's loss of state buy-in presupposes an 

improvement in the beneficiary's financial status.

The Division of Debt Recovery (DRD) will determine whether the 

arrearage situation meets the criteria for waiver and will so notify the 

enrollee. If the waiver request must be denied, DRD will advise that 

installment payments and partial withholding are still permissible.

H. Delayed deletion from state buy-in rolls prejudices termination rights - 

Persons who wish to terminate their individual SMI coverage after state 

buy-in coverage ends, face the same disadvantages if delayed deletion 

occurs, as those beneficiaries who choose to continue coverage. See

FOM-1-810.40.2. 

By law, the states may terminate buy-in coverage as early as 2 months 

prior to the month they actually report to CMS that a specific individual has 

been deleted from the buy-in rolls. Each month, CMS furnishes RRB a 

tape of that month's accretion and deletion activity.

Because of administrative delays, several months may have elapsed 

between the date of the state's deletion and the date the individual is 

notified of the deletion. Such an individual would technically owe 

premiums for the elapsed months. The law was not intended to penalize 

such individuals who had no opportunity to request termination during the 

last month they were covered by the state. Therefore, if an individual was 

not advised by the state of the deletion in or before the month of deletion, 

equitable relief can be granted. This allows an individual's SMI coverage

to end effective with the termination of buy-in coverage (thus allowing him 

or her to avoid entirely any premium liability), if all the following conditions 

are met:

1. The individual submits a written request to have his or her 

individual SMI coverage end effective with the end of state buy-in 

coverage.

2. Such request is filed within 30 days of the date of the notice 

informing the beneficiary that the state is no longer paying 

premiums.

3. The individual certifies that he or she has incurred no medical 

services covered under SMI during the months after buy-in 

termination.

If an individual did receive medical services covered under SMI 

after the end of buy-in coverage, his or her individual entitlement 

must continue until the end of the month in which the termination 
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request is filed (if the request is filed within 6 months of buy-in 

termination). No intermediate date may be selected for the 

termination effective date.

I. SEP enrollment under equitable relief provisions – In certain cases, a 

disabled beneficiary may decline Part B coverage because his or her Group 

Health Plan (GHP) or Large Group Health Plan (LGHP) may erroneously 

assume the role of primary payer, even though the GHP/LGHP coverage is 

not based on a current employment status. This mistake may not be 

identified until the GHP/LGHP coverage terminates, or the employer 

otherwise identifies the mistake. Under the equitable relief provisions, a 

disabled individual who was misinformed (or not informed) about whetherthe 

GHP/LGHP was the primary payer may enroll in Medicare during a disability 

special enrollment period (D-SEP). The D-SEP, for beneficiaries who qualify 

under this situation, are entitled to a 7-month period beginning the later of:

• The date of the notice from the employer advising that the GHP/LGHP is 

no longer the primary payer, or

• The last month for which the GHP/LGHP is the primary payer of benefits.

If there is proof, or the likelihood, that misinformation (including no 

information) was provided by an employee of the Federal government, the 

employer, or the GHP/LGHP, equitable relief may be granted to correct the 

results of the unjust situation. In general, you can consider that the 

beneficiary was misinformed if the GHP/LGHP continued to provide coverage 

as the primary payer even though the beneficiary, spouse, or family member

no longer had a current employment status. Premium surcharges can be 

waived or reduced, and a special enrollment period granted.

As a result of the repeal of the Defense of Marriage Act (DOMA) on June 26, 

2013, we are now able to process premium surcharge rollback request 

actions for individuals who enrolled in the GEP, but had GHP or LGHP 

coverage based on current employment of a same-sex spouse. Same-sex 

marriages are treated the same as opposite-sex marriages for purposes of 

the premium surcharge rollback.

Certain SEP requests filed after the 8-month SEP ended may be approved if 

all of the following criteria are met:

• The individual filed a SEP request for SMI after October 2012 and 

was denied.

• The SEP for the individual must end within the months of June

2013 through April 2014.

• The second SEP request is received prior to June 2014.

• The first denial was based on the existence of a same-sex marriage 
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due to the application of Defense of Marriage Act (DOMA) rules and all 

other eligibility criteria were met.

Give the individual the option to have the date of entitlement be based on the 

month of the first or the second filing.

Beneficiaries age 65 or older or under age 65 and covered under a GHP 

based on the current employment status of a domestic (or life) partner are not 

spouses for SEP and premium surcharge rollback purposes. However, under 

the equitable relief provisions, these beneficiaries are permitted to enroll in 

Part B as if the SEP provisions still apply. Grant equitable relief to the 

following individuals who:

• Refused Part B and whose initial enrollment period (IEP) begins 

12/2004 or earlier; or

• Enrolled in Part B during the IEP and voluntarily terminated coverage

prior to 12/2004.

1. Background - An individual may have one or more types of health 

insurance or coverage in addition to Medicare. The terms “primary payer” 

and “secondary payer” refer to who pays health insurance costs 

first. Depending on the circumstances, Medicare may be the primary or 

secondary payer on a health insurance claim.

The Omnibus Budget Reconciliation Act of 1993 (OBRA-1993) made 

Medicare the secondary payer for a disabled beneficiary covered by a

LGHP based on the current employment status of the individual or a family 

member. For individuals who do not have LGHP coverage based on their 

own current employment status or the current employment status of a 

family member, OBRA-1993 made Medicare the primary payer of benefits.

Note: Because individuals may not have previously enrolled in Medicare 

Part B, OBRA-1993 allowed them to enroll during what was supposed to 

be a one-time disability special enrollment period (D-SEP).

A disabled beneficiary might decline enrollment in Medicare Part B when 

first eligible because his or her GHP/LGHP is the primary payer of 

benefits. When coverage under the GHP/LGHP ends, the beneficiary 

then wants to enroll for Part B during a SEP. In many cases, however, 

there is a problem. The individual is not eligible for a SEP under the 

regular provisions because his or her GHP/LGHP coverage is not based 

on a current employment status.

CMS has a process by which employers are to notify disabled individuals 

when the GHP/LGHP is no longer the primary payer of benefits. However, 

many employers continue to provide GHP/LGHP coverage as the primary 
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payer after there is no longer a current employment status

2. Evidence Requirements The individual may enroll or re-enroll in SMI 

under the equitable relief provisions if he or she submits a letter from the 

employer or other documentation that shows:

• The GHP/LGHP has been primary payer of benefits for some 

period of time in or after January 1987;

• The GHP/LGHP should not have been primary payer; and

• The GHP/LGHP stopped (or will stop) making primary payments 

as of a specified date.

The employer should complete Form RL-311-F, clearly showing the 

beginning and ending dates of the GHP/LGHP coverage. Form RL-311-F 

is not required if Form G-44B is submitted with correspondence from the 

employer of the GHP/LGHP that clearly shows all of the information 

requested on Form RL-311-F, including the dates that the individual was 

covered by the GHP/LGHP. If documentation cannot be obtained from the 

employer concerning the dates of GHP/LGHP coverage and the change in 

status as primary payer of benefits, the beneficiary must submit a 

statement providing as much of the information as possible.

3. Enrollment Requirements The individual must enroll within 7 months of:

• The date of the notice from the employer advising that the GHP/LGHP 

is no longer the primary payer, or

• The last month for which the GHP/LGHP is the primary payer of 

benefits.

Obtain Form G-44B from the individual. In item 7 (Remarks), the applicant 

should indicate that he or she wants to enroll under the equitable relief 

provisions, and provide an explanation as to what misinformation he or 

she received and who provided the misinformation.

The Form G-44B, Form RL-311-F, and any correspondence that support 

the applicant’s request to file under the equitable relief provisions, should 

be imaged as an actionable item to the Medicare Unit under a G-180B 

“Headquarters-Medicare” using form type “SEP ENROLLMENT”. It is no 

longer necessary to mail the documentation to the Medicare Unit.

NOTE: If Form G-44B is received without Form RL-311-F or supporting 

correspondence, pend for receipt of the latter two before imaging. When 

all documents are received, scan them together as a multi-page 

document. Headquarters staff will index the package as form type, 

Employer SEP Ltr.
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4. SMI Effective Date The SMI effective date for a beneficiary who files for 

SMI during a D-SEP is:

• The first day of the month of enrollment in SMI, or

• The first month the GHP/LGHP is no longer primary payer. The 

beneficiary must agree to pay all premiums due, if applicable.

5. Examples:

• Employee A last worked for the Patapsco and Back Rivers Railroad in 

March 1991, and began receiving a disability annuity in September 

1991. He was enrolled in Medicare Part A effective September 1993, 

but declined Part B coverage because he had LGHP coverage through 

Bethlehem Steel, the railroad’s parent company. The LGHP continued 

to provide coverage as the primary payer even after the change in law 

(OBRA-1993).

On March 25, 2003, Employee A was notified that his LGHP coverage 

would end March 31, 2003, because of the bankruptcy of Bethlehem 

Steel. Employee A contacted the RRB in July 2003 to apply for Part B 

coverage effective August 1, 2003. Because he applied within 7 

months of the date that his LGHP coverage was terminated and was 

“misinformed,” i.e. not properly informed that his LGHP coverage

should have been the secondary payer under the OBRA-1993 

provisions, he was granted a special enrollment period.

• Employee B last worked for the Union Pacific Railroad in September 

1999, and began receiving a disability annuity effective March 1, 

2000. He was enrolled in Medicare Part A effective March 2002, but 

declined Part B because he was covered under the Union Pacific’s 

Long Term Disability (LTD) Plan, administered by United HealthCare.

Although Employee B did not have a current employment status, the 

LTD Plan continued to provide coverage as the primary payer until 

2003. On September 9, 2003, Employee B was notified that, because 

he was eligible for Medicare on the basis of his disability, the LTD Plan 

would only provide secondary medical coverage effective January 

2003. Employee B must contact the RRB within 7 months of the 

September 9, 2003 notice in order to be granted a special enrollment 

period to enroll for Medicare Part B coverage.

• Employee C attained age 65 in November 2004. He refused Part B 

coverage because he was covered under his domestic (or life) 

partner’s group health plan (GHP). His partner, Mr. Smith, is working 

and the GHP includes domestic partner within the definition of spouse. 
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In October 2011, Employee C contacts a field office about enrolling in 

Part B because his partner is retiring January 1, 2012. Since a 

domestic partner, age 65 or older, cannot be recognized as a spouse, 

the SEP provisions no longer apply. However, under the equitable 

relief provisions, Employee C may enroll in SMI during any month in 

which he has coverage under the GHP based on current employment 

or during the 8-month period that begins with the first full month after 

the GHP coverage based on current employment ends.

J. Equitable relief and the Affordable Healthcare Act – Individuals who are 

entitled to Medicare Part B should NOT be enrolled in an individual market 

health insurance Exchange (also referred to as the Marketplace) plan. 

However, individuals who were dually enrolled in Medicare Part A and the 

Exchange and subsequently enrolled in Part B with a penalty may be eligible 

for an opportunity to request a reduction in their Part B late enrollment 

penalty.

In March and June of 2017, CMS mailed a notice to all beneficiaries who are 

entitled to Medicare Part A and enrolled in an individual Exchange plan. This 

notice advised beneficiaries that they may be able to enroll in Part B without 

penalty or having to wait for the GEP. This opportunity is available until 

September 30, 2017.

Individuals eligible under this provision should be directed to enroll in 

Medicare Part B immediately, and should not wait to enroll during the GEP.

Also, proof of enrollment in the Marketplace can be furnished by providing a 

copy of the letter from CMS notifying the beneficiary of dual enrollment or the 

beneficiary’s insurance card from the marketplace.

Additional information contained in following memo from CMS: Assistance for

Individuals with Medicare Part A and Marketplace Coverage Information for

SHIPs and Marketplace Assisters. 

K. Equitable Relief and the Weather-Related Emergencies of 2017 – Extreme 

weather events in 2017 caused disruption to mail delivery and affected 

operations at local field offices. This affected our ability to notify some 

beneficiaries of their Medicare enrollment or process their enrollment request 

timely.

As a result, some beneficiaries were not able to make their Medicare Part A 

or Part B enrollment or refusal request during their Initial Enrollment Period 

(IEP) or Special Enrollment Period (SEP). As such, CMS is providing 

equitable relief to beneficiaries who could not submit their Part A or Part B 

enrollment, or Part B refusal requests timely.

Equitable relief is to be considered on a case-by-case basis for beneficiaries 

who had difficulties submitting timely:
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• IEP enrollment requests,

• IEP refusals, or

• SEP enrollment requests

These considerations are for beneficiaries who, at the start of the incident 

period, were:

• In their IEP or SEP, and

• who resided in areas for which the Federal Emergency Management 

Agency (FEMA) declared a weather-related emergency or a major 

disaster

This consideration of equitable relief is only for the period of September 1, 

2017 through May 31, 2018.

Processing Instructions – Process these cases following the normal rules 

for equitable relief as outlined in RCM 3.2.95. Medicare examiners and Field 

Office representatives are encouraged to be as responsive and flexible as 

possible when a current or new beneficiary affected by a weather-related 

emergency or major disaster contacts us for any of the following reasons:

• Non-receipt of his or her Medicare award notice or Initial Enrollment 

Period package; or

• Inability to file an enrollment request or refusal timely.

When a favorable equitable relief determination is made, consider the late 

IEP or SEP enrollment request as filed timely. Limit the Part A or Part B

effective date to a month granted under normal processing procedures for 

timely IEP and SEP filing.

Field Office Actions – Follow these steps:

1. Consider whether the case meets the requirements above.

2. Document the beneficiary’s statement identifying him or her as a resident 

of an area affected by a weather-related emergency or major disaster.

3. For beneficiaries requesting Part B enrollment, complete Form G-44B and 

annotate “Resident of the Federal Emergency Management Agency 

(FEMA) declared disaster areas” in the remarks area of the form.

4. For beneficiaries requesting a Part B refusal, obtain a written statement 

from the beneficiary requesting SMI refusal as a resident of the FEMA 

declared disaster areas.

5. Make an entry on the Contact Log with your analysis of the information, 

and your decision as to whether we should provide relief. Include the 

reasons for approval or disapproval based on your review. Annotate that 

the beneficiary requesting a Medicare enrollment or SMI refusal is a 
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resident of the Federal Emergency Management Agency (FEMA) declared 

disaster areas.

6. Forward the case to the Medicare Unit following normal procedures.

MU Actions – Follow these steps:

1. Review the written statement and available evidence in support of 

enrollment or refusal.

2. For enrollments, process approved equitable relief cases following normal 

Equitable Relief procedures.

3. For refusals, process approved SMI refusals by following normal business 

procedure.

810.40 Termination

810.40.1 Termination of HI Coverage

A. Beneficiary under age 65 - Disability HI coverage, other than for end-stage 

renal disease ends the earlier of:

1. The day of death; or

2. The month before the month age 65 is attained; or

3. For a beneficiary who is not eligible for a trial work period (TWP), the 

month in which the disability benefit ends or if later the month after 

the month in which the notice of termination is mailed.

Example: A determination is made that disability benefits are no 

longer payable to a beneficiary effective April 30, 2005 because his 

impairment is no longer disabling. If notice of the termination is 

mailed in February or March 2005, HI coverage ends at the same 

time the disability benefits end. If notice of the termination is not 

mailed until May 2005, HI coverage ends June 30, 2005.

If disability benefits stop because the beneficiary has substantial 

gainful activity (SGA) following a TWP, coverage may continue after

the beneficiary’s disability entitlement ends. In cases where disability 

benefits end because of SGA following a TWP, HI coverage ends as 

follows:

• If the beneficiary’s disability ceases (the first month of SGA 

following the end of the TWP) prior to the 14th month of his or her 

re-entitlement period, also referred to as an extended period of 

eligibility (EPE), and he or she engaged in SGA in the 16th month 

of the EPE, HI coverage ends the last day of the 57th month 
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following the end of the 36 month disability re-entitlement period 

or, if later, the end of the month following the disability termination 

notice.

Example: A beneficiary has been entitled to HI based on 

disability since May 2000. Although he continues to be severely 

impaired, he completed a TWP in a sheltered workshop on 

September 30, 2001. He continues working at SGA levels, and 

his disability benefits are terminated effective December 31, 2001 

(the end of the second month following the month his disability 

ceased) and his disability entitlement ends October 1, 2004 (the 

first month of SGA after the 36-month re-entitlement period ends). 

His HI coverage, however, continues through June 30, 2009, the 

last day of the 57th month following the end of his 36 month reentitlement period.

• If the beneficiary’s disability ceases prior to the 14th month of the 

EPE, but he or she does not engage in SGA in the 16th month of 

the EPE, HI coverage ends the last day of the 77th month 

following the first month of SGA occurring after the 16th month or, 

if later, the end of the month following the disability benefit 

termination notice.

Example: A beneficiary has been entitled to HI based on 

disability since May 2000. He completes a TWP in a sheltered

workshop on September 30, 2001. He continues working at SGA 

levels for 12 months, stops working until May 2003, and then 

resumes working at SGA levels. His disability benefits are 

terminated effective December 31, 2001 (the end of the second 

month following the month his disability ceased). His disability 

entitlement ends October 1, 2004 (the first month of SGA after his 

36-month re-entitlement period ends). His HI coverage, however, 

continues through October 31, 2009, the last day of the 77th 

month following the first month of SGA after the 16th month of his 

re-entitlement period.

• If the beneficiary’s disability ceases after the 13th month of the 

EPE, HI coverage ends with the last day of the 80th month 

following the month the disability ceases or, if later, with the end 

of the month following the disability benefit termination notice.

Example: A beneficiary has been entitled to HI based on 

disability since May 2000. He completes a TWP on September 

30, 2001, and begins a 36-month period of re-entitlement on 

October 1, 2001. His disability ceases in February 2003, when he 

is determined to have performed SGA in that month. Because his 

disability ceased after the 13th month of his re-entitlement period, 
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his HI coverage continues through October 31, 2009, the last day 

of the 80th month following the month his disability ceased.

NOTE: If medical improvement or some other non-SGA terminating 

event occurs prior to the dates provided above, HI coverage ends the 

later of (1) the month in which disability benefits are terminated, or(2) 

the month after the month in which the benefit termination is mailed 

to the beneficiary.

NOTE: A beneficiary cannot voluntarily terminate HI (Part A) 

coverage. In order to withdraw from Part A, the beneficiary must 

withdraw his or her application for an annuity and repay all benefits 

received, including RRA and SSA payments and any benefits paid 

under Medicare.

B. Beneficiary age 65 or over - HI coverage ends with the day of death or 

when the person's eligibility for benefits under the Railroad RetirementAct 

and/or the Social Security Act ends. In case of death, protection continues 

through the month of death. However, a person over age 65 who no 

longer qualifies for benefits under either of the Acts may reinstate the HI 

protection if either of the following requirements are met.

1. Qualifies under the special transitional provision (FOM-1-810.5.3); 

or

2. Qualifies under the uninsured HI provision (FOM-1-810.5.4).

C. Premium HI beneficiary - Coverage under premium HI ends:

1. With the day of death;

2. The last day of the month following the month the beneficiary files a 

notice of voluntary termination with SSA;

3. The last day of the second month following the due date for 

premium payment if the premium is not paid;

4. On the date of termination of SMI coverage;

5. With the first month of eligibility for HI as an insured or deemed 

insured person at RRB or SSA.

810.40.2 Termination of SMI Coverage

SMI coverage may terminate for any of the following reasons: death of the 

enrollee, recovery from disability for persons under age 65, nonpayment of SMI 

premiums, voluntary termination. The effective date of termination in each 

instance is discussed below.
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A. Death of enrollee - SMI coverage extends through the date of death.

B. Recovery from disability - SMI coverage ends with the later of:

• The last month of entitlement to a monthly disability benefit, or if later 

the month after the month in which the notice of termination is mailed. 

If disability benefits stop because the beneficiary is working, but the 

person has not recovered from his or her disability, coverage may 

continue after monthly disability benefits stop. See FOM-1-

810.40.1.A.3).

• The month after the month the beneficiary is notified of the termination 

of benefits.

C. Non-payment of premiums - SMI coverage terminates at the end of the 

grace period provided for the payment of overdue premiums. Normally, 

the grace period for payment of premiums is the 90-day period following 

the month in which the bill is issued. The grace period may be extended 

for another 90 days if there was good cause for failure to pay the overdue 

premiums within the initial 90-day period.

D. Voluntary termination - Any beneficiary not covered under a state buy-in 

agreement may request termination of his or her SMI coverage at any 

time. A request for termination must be made in writing, unequivocally

stating a desire to end SMI coverage, and signed by the enrollee. In lieu of 

a handwritten statement, the beneficiary may sign form G-795, Request 

for Termination of Medicare Part B, Medicare Insurance.

Termination in these cases is effective with the last day of the month after 

the month in which the written notice is officially filed. (Prior to July 1, 

1987, the effective date for dis-enrollment was the end of the quarter after 

the quarter the request was filed.) Premiums must be paid through the 

effective month of termination.

A signed statement or form G-795 from the beneficiary must be submitted 

to confirm the request to terminate Part B coverage. Be sure to stamp the 

date of receipt on the statement. Image the signed statement or form to 

the Medicare Unit (do not use the RRA FILE ONLY cover sheet). The 

Medicare Unit will terminate SMI coverage and release a confirmation 

letter to the beneficiary.

Note: Do not submit e-mails to the Medicare Unit requesting Part B 

election changes for beneficiaries. The Medicare Unit can take no action 

without the beneficiary’s signed statement or form G-795. The Medicare 

Unit will, however, initiate action to terminate coverage based on a 

facsimile of the signed statement or form.
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E. Voluntary termination following state buy-in deletion - If an individual's 

state buy-in coverage ends, the enrollee's SMI coverage continues as if he 

or she had filed in an IEP. If an individual desires to end SMI coverage 

after state buy-in deletion, he or she may do so by filing a written request 

or form G-795 as described above. See FOM-1-810.35.2).

Prior to 4-1-81, termination for those in current pay status was effective 

with the third month after the last month of buy-in coverage if the 

termination request was filed within that 3-month period. Those not in 

current pay status were terminated according to the rules for regular 

"voluntary termination;" i.e., termination was effective the last day of the 

calendar quarter after the quarter in which the written notice was officially 

filed.

Effective April 1, 1981, any individual whose state buy-in coverage has 

been terminated and who files a notice requesting termination of his 

individual SMI during the last month of buy-in coverage or during the 6 

succeeding months will have his or her individual SMI terminated at the 

end of the month in which the notice was filed. Refer to FOM-1-810.35.2H

for a further discussion of relief that may be offered.

810.45 Jurisdiction Of Coverage

The term "jurisdiction" is used in the Medicare program to indicate whether RRB 

or SSA is responsible for enrolling a person, issuing an ID card, and collecting 

premiums.

810.45.1 How Jurisdiction Is Determined

RRB has jurisdiction of the health insurance of all QRRBs and all persons whose 

SS benefits are paid by RRB ("deemed" QRRBs). However, an HI record will not 

be established until a QRRB or "deemed" QRRB files a railroad retirement or 

social security application. If SSA has jurisdiction when an HI record is initially 

established, that agency will continue to have jurisdiction until the QRRB files a 

railroad retirement application or an inquiry is received and HI clearance is 

requested by RRB. At that time, HI jurisdiction is automatically transferred to 

RRB.

If an individual does not meet the definition of a QRRB and SS benefits are not 

payable at RRB, the RRB does not have jurisdiction. For example, SSA has 

jurisdiction over the health insurance of an employee with less than 120 service 

months or less than 60 service months after 1995, the disabled child of an 

employee who is under age 62 and not under a DF, or a survivor who elected an 

RLS. Once established at RRB, HI jurisdiction will generally not change as long 

as the person is a QRRB or SS benefits are payable at RRB.
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810.45.2 Situations Which Cause Jurisdiction to Change from SSA to RRB

Medicare jurisdiction will be transferred from SSA to RRB when:

• A beneficiary who filed for and was entitled to Medicare coverage atSSA, 

files for and becomes entitled to an RR annuity.

Exception: If Medicare coverage is based on the End Stage Renal Disease 

(ESRD) provision, coverage will not be transferred to RRB until the annuitant 

qualifies for coverage based on disability or a regular insured status

• A spouse, widow(er), surviving divorced spouse or remarried widow(er) 

receiving a DIB benefit and Medicare coverage at SSA attains age 65.

• An annuitant who had Medicare coverage at SSA based on one DOB, attains 

age 65 based on a later DOB established at RRB.

Although RRB has jurisdiction of Medicare coverage for all QRRBs, no special 

attempt will be made to obtain jurisdiction of QRRBs with Medicare coverage at 

SSA until an annuity is payable at RRB or until the attainment of age 65.

NOTE: In cases in which the RRB is paying the beneficiary’s social security 

benefits (LAF E cases), Medicare jurisdiction will be established on RRB records

based on information provided by SSA. This includes disabled spouses and 

cases involving ESRD.

810.45.3 Situations Which Cause Jurisdiction to Change from RRB to SSA

Medicare jurisdiction will be transferred from RRB to SSA when:

• A non-disabled applicant is at least 64 years and 9 months old but is not a 

QRRB or "deemed" QRRB;

• An annuitant, IPI or Medicare only enrollee who is not a "deemed" QRRB 

loses QRRB status (included are cases in which the employee dies and SSA 

has jurisdiction of survivor benefits, or a disabled child marries);

• A "deemed" QRRB is no longer entitled to SSA benefits; or

• A "deemed" QRRB is no longer entitled or potentially entitled to a railroad 

retirement annuity.

810.45.4 Where and What Type of Application to File

An individual who meets the eligibility requirements must file an application for 

Medicare alone or for retirement, survivor or disability benefits at the RRB or SSA 

or for inclusion as an IPI at the RRB. The following chart summarizes the type of 

application that may be filed and where it should be filed.
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BENEFICIARY'S STATUS ACTION REQUIRED TO ESTABLISH 

ENTITLEMENT TO MEDICARE

Not QRRB.

Not insured at SSA.

Must file an application for Medicare only at 

SSA. Premiums will be paid directly to SSA.

Not QRRB.

Insured at SSA.

Must file an application for Medicare only or 

for a benefit at SSA.

QRRB - Non-annuitant. Insured at 

SSA, but has not filed.

Must file an application for Medicare only or 

an application for benefits at SSA or at RRB.

QRRB - Non- annuitant. Insured at 

SSA and benefit certified to RRB (may 

be in suspense).

An application for Medicare only is not 

required. The beneficiary should be enrolled 

automatically by RRB. SSA certifies Medicare 

coverage to RRB when they transmit payment

to us.

QRRB - Annuitant (may be in 

suspense) SSA status immaterial.

An application for Medicare only is not 

required. The beneficiary should be enrolled 

automatically.

QRRB - Filing for annuity in IEP, GEP 

or SEP, and not previously enrolled for 

Medicare; SSA status immaterial.

An application for Medicare only is not 

required. If the beneficiary is at least 64 years 

and 5 months of age and has not received an 

ID card, the question on the annuity 

application concerning SSA SMIB must be 

answered.

Victim of Chronic Renal Disease –

QRRB status immaterial.

Must file an application for Medicare at SSA.
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