(Medicare General Information, Eligibility, and Entitlement)

40.7.4 - Grace Period for Payment  (Rev. 1, 09- 11-02)  A grace period has been provided for payment of premiums by those who are billed directly.  The period extends for 90 days after the month in which the bill is mailed.  If the premiums are not received in that prescribed time, entitlement terminates at the end of the grace period.  This 90 -day grace period for paying overdue SMI premiums and continuing SMI coverage may be  extended by CMS for good cause for up to an additional 90 days.  Good cause, for example, is found if the enrollee was mentally or physically incapable of paying his or her premiums timely, or had some reasonable basis to believe that payment had been mad e, or the failure to pay was due to administrative error.   40.7.5 - Payment After Grace Period Applies  (Rev. 1, 09- 11-02)  If an extension to the grace period (additional 90 days; a total not to exceed 180 days) has been granted, an enrollee may retain SMI  entitlement by paying all past due premiums if there was a good cause for his/her failure to pay premiums within the initial grace period.   40.7.6 - Premiums Paid by Other Than the Enrollee  (Rev. 1, 09- 11-02)  The following subsections describe premiums paid by other than the enrollee.  40.7.6.1 - Informal Arrangement  (Rev. 1, 09- 11-02)  Enrollees who are being billed directly for Medicare premiums may turn over their premium bills to a friend, relative, employer lodge, union or other organization to pay premiums on their behalf.  The third party payer forwards the proper amount of payment for each enrollee to CMS's Premium Collection Center.  Enrollees participating in this type of informal arrangement continue to receive their premium notice (Form CMS -500), and remain responsible for assuring that premiums paid on their behalf are paid timely in order to avoid termination of Medicare coverage.   40.7.6.2 - Premium Payer  (Rev. 1, 09- 11-02)  Individuals may be designated as the premium payer for an enrollee a nd receive the enrollee's premium bills, if it is judged to be in the enrollee's best interest (e.g., the enrollee is competent, but too physically ill or infirm to be able to handle such matters).  The individual receiving the premium bill must be a relative or friend showing personal interest in the welfare of the enrollee.   40.7.6.3 - Formal Group Arrangement  (Rev. 1, 09- 11-02)  Employers, religious orders, lodges, unions or other organizations may enter into a formal agreement with CMS in order to receive a single bill and pay a lump sum for the premiums due from a group of individuals.  Group payments under a formal group agreement may be made only on behalf of individuals who are already enrolled and are being billed for direct remittance.  This type of arrangement is referred to as a "Formal Group Payer" arrangement.  While included in a formal group payer arrangement, enrollees will no longer receive a premium notice (Form CMS -500).  This arrangement is available only where the number of enrollee s in the group is large enough to make it practicable to send one bill to the group payer and where the following conditions are also met:   Enrollees included under the formal group arrangement are directly billed for their premium, and are not having his/ her premiums deducted from a Social Security, Railroad Retirement, or Civil Service benefit, or, are not having premiums paid by a State Medicaid agency under a State buy- in agreement;    The enrollee authorizes the formal group payer to pay premiums on his/ her behalf;    The formal group payer has a minimum of 20 enrollees; and    The formal group payer agrees to submit premium payments via electronic funds transfer.   If the formal group payer agreement is terminated, or if the group payer alerts CMS to remove an individual from the group payer arrangement, CMS will resume collection of premiums from the individual through the direct billing process.  40.7.6.4 - Premium Surcharge Payment  (Rev. 1, 09-11-02)  States or local Governments may pay a lump sum for the total amount of the SMI late enrollment premium surcharge for a group of individuals.  In order to pay the premium surcharge, States or local Governmental entities are required to enter into a formal agreement with CMS.  An individual is not billed for the premium surcharge portion of his/her SMI premium while under a premium surcharge agreement, however, he/she is billed for the base premium amount.  If the enrollee is receiving a Social Security, Railroad Retirement, or Civil Service annuity, the agencies responsible for these programs will continue to withhold the base premium amount from the annuity.  Enrollees who are billed directly for premiums will continue to receive a premium bill for the base premium amount.  The ultimate responsibility for paying premiums rests with the enrollees.  40.7.6.5 - Premiums Under Buy -In (Rev.  12046, Issued:05- 18-23, Effective:01-01-23, Implementation:06-21-23)  States pay the Part B premiums for any eligible individual specified in the states b uy-in agreement. Under buy- in agreements, states can enroll individuals in Part B at any time without regard to Medicare enrollment periods or late enrollment penalties. Please see the Manual for State Payment of Medicare Premiums, chapter 1, section 1.4 for additional information about state payment of premiums under a buy- in agreement.   40.7.7  Late Enrollment Penalty (LEP) for Premium Part A  (Rev.  12046, Issued:05- 18-23, Effective:01-01-23, Implementation:06-21-23) If an individual did not enroll in premium Part A when first eligible, they may have to pay a higher monthly premium if they decide to enroll later.  The monthly premium for Part A may increase up to 10%. The individual will have to pay the higher premium for twice the number of years the individual could have had Part A, but did not sign up.   For individuals enrolling using the SEP Related to Coverage Under Group Health Plans, the premium Part A LEP is calculated by adding the months that have elapsed between the close of the individuals IEP and the end of the month in which the individual enrolls. For enrollments after your IEP has ended, months where you had group health plan coverage are excluded from the LEP calculation.   For individuals enrolling us ing an Exceptional Conditions SEP, the International Volunteers SEP, or the SEP for Certain TRICARE Beneficiaries, no LEP will be applied.   40.7.8  Late Enrollment Penalty (LEP) for Premium Part B  (Rev.  12046, Issued:05- 18-23, Effective:01- 01-23, Impleme ntation:06- 21-23) If an individual did not sign up for Part B when first eligible, the individual may have to pay a late enrollment penalty for as long as the individual has Medicare. The individuals monthly premium for Part B may go up 10% for each full 12- month period that the individual could have had Part B, but did not sign up for it.  For individuals enrolling using the SEP  Related to Coverage Under Group Health Plans, the Part B LEP is calculated by adding the months that have elapsed between the cl ose of the individuals IEP and the end of the month in which the individual enrolls. For enrollments after your IEP has ended, months where you had group health plan coverage are excluded from the LEP calculation.   For individuals enrolling using an Exce ptional Conditions SEP, the International Volunteers SEP, or the SEP for Certain TRICARE Beneficiaries, no LEP will be applied.   For individuals enrolling using the D -SEP, the Part B LEP is calculated by adding all months during which the large group heal th plan (LGHP) was secondary payer beginning with the end of the IEP, or the date LGHP coverage began.   40.8 - Waiver of Enrollment Period Requirements Due to Administrative Error  (Rev. 1, 09- 11-02)  CMS and SSA are authorized to take necessary action to correct an erroneous SMI or premium hospital insurance enrollment or nonenrollment which was based upon the action, inaction, or error of a Government officer, employee, or agent.  The action may include designating special individual enrollment periods and premium adjustments.   For the purpose of this provision, an individual's enrollment or nonenrollment in SMI is considered to have been prejudiced and due to the "action, inaction, or error" of an officer, employee, or agent of the Government, if there is  an official record or other evidence showing that:    The individual took reasonable appropriate and timely measures to assert his or her rights, and    Due to administrative fault or other action, which may or may not have been erroneous at the time taken, his or her rights have been or are likely to be impaired unless relief is given.   This authority applies to all Part B cases which have arisen since the Medicare program began on July 1, 1966.  It is applied to cases that come to CMS's or SSA's attention; however, MACs should not search their files.   40.9 - Extended Coverage for Part B Immunosuppressive Drugs (PB -ID) (Rev. 11646; Issued:10- 19-22; Effective:01 -01-23; Implementation:01 -03-23)  The Consolidated Appropriations Act of 2021 amended sec tion 1836(b) of the Social Security Act to add a new form of coverage that provides solely for coverage of immunosuppressive drugs beginning January 1, 2023, for eligible individuals whose entitlement to Medicare based on End -Stage Renal Disease (ESRD) end s the 36th month after the month in which the individuals receive a successful kidney transplant.   This new benefit is referred to as the Part B immunosuppressive drug benefit or Part B -ID.  Beneficiaries enrolled in Part B -ID will not be covered for an y other Medicare benefit or for any items or services other than Part B Immunosuppressive Drugs.   40.9.1 - Part B -ID Eligibility Requirements  (Rev. 11764; Issued 12- 22-22; Implementation: 01- 01-2023; Effective 01- 03-23)  An individual is eligible for Part B -ID if he or she:   1. Is or was entitled to Medicare Part A based on ESRD that ends 36 months after a successful kidney transplant; and  2. Attests that he or she is not enrolled in other health coverage that would make them ineligible for Part B -ID, as outline d in section 40.9.2. Every individual enrolling in Part B -ID must:  i. Attest that they are not enrolled in other health coverage and do not expect to enroll in other coverage which would make them ineligible for Part B -ID; and  ii. Agree to notify SSA within 60 da ys of enrolling in other health coverage.    NOTE: An individual can inform SSA of other health coverage up to 6 months in advance   40.9.2 - Other Health Coverage Making an Individual Ineligible for Part B-ID (Rev . 11764; Issued 12- 22-22; Implementation: 01- 01-2023; Effective 01- 03-23)  An individual who has other certain health coverage is not eligible for Part B -ID. Other health coverage includes:   Group Health Plans or Individual Health Plans;   Enrolled in the patient enrollment system of  the Department of Veterans Affairs (VA) or otherwise eligible to receive immunosuppressive drugs from the VA;   TRICARE for Life;   Health Insurance Marketplace qualified health plans; and   Medicaid or State Childrens Health Insurance Program (CHIP) coverage that includes immunosuppressive drugs.   40.9.3 - Effective Date of Entitlement to Part B- ID (Rev. 11646; Issued:10- 19-22; Effective:01 -01-23; Implementation:01 -03-23)  The effective date of an individuals eligibility for the Part B -ID benefit depends on when their entitlement to Medicare Part A based on ESRD ends and when they submit the attestation described in section 40.9.1 of this chapter.   When an individuals Medicare Part A entitlement based on ESRD ends on or after January 1, 2023:   If they submit  the attestation before the end of the 36th month after the month of the kidney transplant (i.e. before their Medicare Part A entitlement based on ESRD ends), Part B -ID begins effective at the start of the month after their Medicare Part A on the basis of ESRD ends.     If they submit the attestation after their Medicare Part A entitlement ends, Part B -ID begins at the start of the month following the month in which the attestation is submitted.