(Medicare General Information, Eligibility, and Entitlement)

Medicare General Information, Eligibility, and Entitlement  Chapter 2 - Hospital Insurance and Supplementary Medical Insurance  Table of Contents  (Rev. 12046, 05-18-23)   Transmittals for Chapter 2   10 - Hospital Insurance Entitlement 10.1 - Insured Status  10.2 - Hospital Insurance for the Aged  10.3 - Hospital Insurance for Disability Beneficiaries  10.4 - Hospital Insurance for Persons Needing Kidney Transplant or Dialysis   10.4.1 - Effective Date of Entitlement for Persons on Dialysis  10.4.2 - Entitlement Based on Transplant  10.4.3 - Effect on Self -dialysis Training on Entitlement  10.4.4 - End of Coverage Based on ESRD  10.4.5 - Reentitlement for Beneficiaries with ESRD  20 - Hospital Insurance  Obtained by Premium Payment  20.1 - Eligibility Requirements  20.2 - Premiums for Hospital Insurance                          20.2.1 - Premiums Paid by Other Than Enrollee                                      20.2.1.1 - Part A Buy -in States                           20.2.1.2 - Part A Group Payer States  20.3 - Beginning of Coverage  20.3.1 - Initial Enrollment Period (IEP)  20.3.2 - General Enrollment Period (GEP)  30 - End of Coverage for Hospital Insurance  40 - Supplementary Medical Insurance (SMI)  40.1 - Eligibility for Enrollment 40.2 - Automatic Enrollment in SMI  40.3 - Enrollment Periods  40.3.1 - Enrollment During the Individual's Initial Enrollment Period 40.3.2 -  Enrollment During General Enrollment Period 40.3.3 -  Enrollment During the Individual's Special Enrollment Period                                                                                   (SEP) Related  to Coverage Under Group Health Plans  40.3.4 SEP for International Volunteers  40.3.5 SEP for Certain TRICARE Beneficiaries  40.3.6 SEP for Beneficiaries for Whom Medicare is Now the        Primary Payer (D -SEP)  40.3.7 Special Enrollment Period for Exceptional Conditions   40.3.7.1 SEP for Individuals Impacted by an Emergency or      Disaster 40.3.7.2 SEP for Individuals Affected by Employer Misrepresentation   40.3.7.3 SEP for Formerly Incarcerated Individuals    40.3.7.4 SEP for Termination of Medicaid Coverage    40.3.7.5 SEP for Other Exceptional Conditions  40.4 -  Nature and Purpose of State Buy- in 40.5 -  End of Coverage  40.6 -  Termination and Reenrollment  40.7 -  Premiums  40.7.1 -  Amount of Premiums  40.7.2 -  Increase in Base Premium Amount  40.7.3 -  Collection of Premiums  40.7.4 -  Grace Period for Payment  40.7.5 -  Payment After Grace Period Applies  40.7.6 -  Premiums Paid by Other Than the Enrollee  40.7.6.1 -  Informal Arrangement  40.7.6.2 -  Premium Payer  40.7.6.3 -  Formal Gro up Arrangement  40.7.6.4 -  Premium Surcharge Payment  40.7.6.5  Premiums Under Buy -In  40.7.7 -  Late Enrollment Penalty for Premium Part A  40.7.8  Late Enrollment Penalty for Premium Part B  40.8 -  Waiver of Enrollment Period Requirements Due to Administrative Error              40.9 -  Extended Coverage for Part B Immunosuppressive Drugs (PB -ID)            40.9.1 -  Part B -ID Eligibility Requirements  40.9.2 -  Other Health Coverage Making an Individual Ineligible for Part                                B-ID            40.9.3 -  Effective Date of Entitlement to Part B -ID            40.9.4 -  Initial Enrollment & Reenrollment in Part B -ID            40.9.5 -  Procedure for Enrolling in Part B -ID            40.9.6 -  Termination of Part B -ID            40.9.7 -  Part B -ID Premiums             40.9.8 -  Procedure for Termination of Part B -ID            40.9.9 -  Medicare Savings Programs for Part B -ID Premiums  50 - Identifying the Patient's Health Insurance Record Using the Medicare Card  50.1 -  Medicare Beneficiary Identifier (M BI) 60 - Medicare Part C, Medicare+Choice   10 - Hospital Insurance Entitlement  (Rev. 1, 09- 11-02)  Hospital insurance (HI), as well as supplementary medical insurance (SMI), is available to three basic groups of "insured individuals" - the aged, the disabled, and those with end stage renal disease.  Following is an explanation of how an individual becomes "insured" as well as an explanation of the eligibility requirements for each group.   10.1 - Insured Status  (Rev. 1, 09- 11-02)  To be eligible for premium -free HI, an individual must be "insured" based on his or her own earnings or those of a spouse, parent, or child.  To be insured, the worker must have a specific number  of quarters of coverage (QCs); the exact number required is dependent upon whether the person is filing for HI on the basis of age, disability, or end stage renal disease. QCs are earned through payment of payroll taxes under the Federal Insurance Contributions Act (FICA) during the person's working years.  QCs earned by an individual who pays the full FICA tax are usable to insure the person for both monthly social security benefits and HI.   Federal employees were exempt from payment of FICA taxes prior t o January 1983.  However, beginning in January 1983, Federal employees became subject to the HI portion of the FICA tax (those actually employed in January 1983 were also deemed to have earned HI quarters of coverage for their Federal service prior to Janu ary 1983).  Also, Government employees who pay only the HI portion of the FICA tax are only insured for HI; they are not insured for monthly social security benefits.   State and local Government employees hired after March 31, 1986, are eligible for Medicare coverage and must pay the HI portion of the FICA tax.  A State may elect to cover employees hired prior to April 1986 for the Medicare portion of the FICA tax by requesting an agreement or modification of its existing agreement under section 218 of the Social Security Act.   10.2 - Hospital Insurance for the Aged  (Rev. 1, 09- 11-02)  To be eligible for HI on the basis of age, a person must be age 65 or older and either eligible for monthly social security or railroad retirement cash benefits, or would be eligible for such benefits if the worker's Government QCs were regular social security QCs.  An individual who is insured for monthly benefits need not actually file for benefits to receive HI benefits.  If such a person continues to work beyond age 65, he  or she may instead elect to file an application for HI only.  Premium- free HI for the aged begins with the month in which the individual attains age 65, provided he or she files an application for HI or for cash benefits and HI within 6 months of the mont h in which he or she attains age 65.  If the application is filed later than that, HI entitlement can be retroactive for only 6 months.  An individual attains age 65 on the day before his or her 65th birthday.  For example, if an individual is born on August 1, the attainment date is July 31, and HI begins with July 1.  Entitlement generally does not end until death.  10.3 - Hospital Insurance for Disability Beneficiaries  (Rev. 1, 09- 11-02)  A disabled person who is entitled to social security or railroad retirement benefits on the basis of disability is automatically entitled to HI after 24 months of entitlement to such benefits.  Since there is a 5 -month disability benefits waiting period, the person actually becomes entitled to HI after being di sabled for 29 months.  In addition, disabled persons who are not insured for monthly Social Security disability benefits but would be insured for such benefits if Government QCs were treated as social security QCs, are deemed to be entitled to disability benefits and automatically entitled to HI after being disabled for 29 months.  The months in the Medicare qualifying period need not be consecutive so that months from a previous period of disability benefit entitlement generally may be counted in determining when the qualifying period requirement is met.  HI entitlement on the basis of disability is available not only to the worker, but to the widow, widower, or child of a deceased, disabled, or retired worker if any of them become disabled within the meani ng of the Social Security or Railroad Retirement Acts.   If an individual recovers from a disability, HI entitlement ends with the month after the month he or she is notified of the disability termination.  For example, if notification is November 15, entit lement ends December 31.  However, if the individual's disability benefit entitlement ends only because he or she was working, HI entitlement may continue for up to 78 additional months.   10.4 - Hospital Insurance for Persons Needing Kidney Transplant or Dialysis (Rev. 1, 09- 11-02)  Individuals of any age with end stage renal disease (ESRD) who receive dialysis on a regular basis or a kidney transplant are eligible for HI (and are deemed enrolled for Supplementary Medical Insurance (SMI) unless such coverag e is refused) if they file an application.  They must also meet certain work requirements for insured status under the social security or railroad retirement programs, or be entitled to monthly social security benefits or an annuity under the Railroad Reti rement Act, or be the spouse or dependent child of an insured or entitled person.  10.4.1 - Effective Date of Entitlement for Persons on Dialysis  (Rev. 1, 09- 11-02)  Entitlement usually begins after a 3 -month waiting period has been served, i.e., with the first day of the third month after the month in which a course of regular dialysis begins.  Entitlement begins before the waiting period has expired if the individual receives a transplant or participates in a self -dialysis training program during the wait ing period.   10.4.2 - Entitlement Based on Transplant  (Rev. 1, 09- 11-02)  Entitlement begins with the month the individual is admitted as an inpatient to a hospital for procedures in preparation for or in anticipation of a kidney transplant, provided the transplant surgery takes place within the following 2 months.  If the transplant is delayed more than 2 months after the preparatory hospitalization, entitlement begins with the second month prior to the month of transplant.  Under the Medicar e, Medicaid, and State Children's Health Insurance Program (SCHIP) Benefits Improvement and Protection Act of 2000, Congress extended immunosuppressive drug benefits to lifetime, as long as the beneficiary is entitled to Medicare and was entitled to Medicare when his/her transplant took place.   10.4.3 - Effect on Self-dialysis Training on Entitlement  (Rev. 1, 09- 11-02)  Entitlement begins with the first month of the course of dialysis if the individual is expected to complete the self -dialysis training program and self -dialyze thereafter.   10.4.4 - End of Coverage Based on ESRD  (Rev. 1, 09- 11-02)  HI coverage based on ESRD ends with the earliest of the following dates:    The day an individual dies,   The last day of the 12th month after the month the course of  dialysis is discontinued, unless the individual receives a kidney transplant during that period or begins another course of dialysis, or    The last day of the 36th month after the month the person receives a kidney transplant.  10.4.5 - Reentitlement for Beneficiaries with ESRD (Rev. 1, 09- 11-02)  If a person whose entitlement based on ESRD has ended begins a new course of regular dialysis or has a kidney transplant, reentitlement begins without a waiting period.  20 - Hospital Insurance Obtained by Premiu m Payment  (Rev. 1, 09- 11-02)  20.1 - Eligibility Requirements (Rev. 1, 09-11-02)  Individuals who want hospital insurance coverage but who are not otherwise eligible (i.e., do not qualify under either the regular or deemed insured provisions, in 10.1, 10.2, 10.3, 10.4 in this chapter) may obtain such coverage by enrolling timely, paying a monthly premium, and upon meeting the following three requirements:   Attaining age 65,   Enrolling or already having enrolled in the SMI program,   Being a resid ent of the U.S., and either:  o A citizen, or   o An alien lawfully admitted for permanent residence who has resided continuously in the U.S. for the 5 years prior to the month of enrollment.