evekhm/cms_iom_500 huggingface dataset:
(Medicare General Information, Eligibility, and Entitlement)
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)
(Medicare General Information, Eligibility, and Entitlement)
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)
(Medicare General Information, Eligibility, and Entitlement)
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.
(Medicare General Information, Eligibility, and Entitlement)
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.
(Medicare General Information, Eligibility, and Entitlement)
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.
(Medicare General Information, Eligibility, and Entitlement)
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.  20.2 - Premiums for Hospital Insurance  (Rev. 1, 09-11-02)  Each year, the Secretary of the Department of Health and Human Services announces the amount of the hospital insurance premium payable for each month in the following calendar year.  The applicable premium amount is 33/76 (about 43.4 percent) of the hospital insurance deductible for that calendar year.  The premium is rounded to the nearest $1.  An individual who is not entitled to free Part A and wishes this type of coverage must enroll him/herself during the appropriate enrollment period.  A premium is due for ea ch month of entitlement under Premium HI.   20.2.1 - Premiums Paid by Other Than the Enrollee  (Rev. 11764; Issued 12-22-22; Implementation: 01-01-2023; Effective 01-03-23)  The following subsections describe Medicare Part A premiums paid by other than the enrollee.   20.2.1.1 - Part A Buy -in States  (Rev .11764; Issued 12-22-22; Implementation: 01-01-2023; Effective 01-03-23)  States that include the payment of Medicare Part A premiums for Qualifying Medicare Beneficiaries (QMBs) in their state buy -in agr eements are known as Part A buy -in states. Individuals in Part A buy- in states can file for Premium Part A at any time, without regard to enrollment periods. Late enrollment penalties do not apply. Please see the Manual for State Payment of Medicare Premiums, chapter 1, sections 1.7 and 1.11 for additional information about Part A buy- in states.        20.2.1.2 - Part A Group Payer States  (Rev. 11764; Issued 12-22-22; Implementation: 01-01-2023; Effective 01-03-23)
(Medicare General Information, Eligibility, and Entitlement)
States that do not include the payment of Medicare Part A premiums for QMBs in their state buy -in agreements are known as  group payer states. To become entitled to Part A, individuals in group payer states can file for premium Part A during their Initial Enrollment Period (IEP) or the General Enrollment Period (GEP). Part A premiums and any applicable late enrollment penalties are paid under a group payer arrangement. Please see the Manual for State Payment of Medicare Premiums, chapter 1, section 1.7 and 1.11  for additional information about Part A group payer states.    20.3 - Beginning of Coverage  (Rev. 1, 09-11-02)  20.3.1 - Initial Enrollment Period (IEP)  (Rev. 1, 09-11-02)  Persons may enroll for premium hospital insurance by filing a request during the IEP which begins the third month before the month of first eligibility and lasts for 7 months.  The individual's IEP for premium hospital insurance is in most cases the same 7-month period as the IEP for SMI.  The individual may enroll for hospital insurance when he or she enrolls for SMI , or later during his or her IEP.  The beginning date of an individual's premium hospital insurance coverage period is determined by the rules applicable to SMI coverage based on an SMI enrollment during an IEP.  (See chapter 2 40 in this chapter.)  20.3.2 - General Enrollment Period (GEP)  (Rev. 1, 09-11-02)  Eligible persons who have not enrolled for premium hospital insurance during their IEP, or whose premium hospital insurance has been terminated, may enroll during a GEP (January 1 - March 31 of each year) if they are enrolling or have enrolled for SMI.  As with SMI, an eligible person who enrolls for hospital insurance during a GEP will have hospital insurance coverage beginning the following July.  The same restrictions on enrollment and reenrollment apply as in the SMI program. Individuals who enroll late may pay a 10 percent premium penalty.  30 - End of Coverage for Hospital Insurance  (Rev. 1, 09-11-02)  A beneficiary's entitlement under the provision terminates:   With the month of the individual's death,   With the last day of the third month following the premium billing month (for nonpayment of premiums),
(Medicare General Information, Eligibility, and Entitlement)
 With the last day of the third month following the premium billing month (for nonpayment of premiums),   With the end of the month following the month in which he or she files a voluntary request for termination,   With the month SMI coverage is terminated, or    With the month before the month in which he or she becomes entitled to hospital insurance under the regular or ESRD provisions.  (See 2, 10.4 of this chapter.)  40 - Supplementary Medical Insurance (SMI)  (Rev. 1, 09-11-02)  Unlike the HI benefits program, which is largely financed by compulsory taxes on employers, employees, and the self-employed, the SMI benefits program is a voluntary program financed from premium payments by enrollees, together with contributions from funds appropriated by the Federal Government, and certain deductible and cost-sharing provisions.  40.1 - Eligibility for Enrollment  (Rev. 1, 09-11-02)  To obtain SMI coverage, eligible individuals must enroll in the plan during an enrollment period open to them and pay the required premiums.  They are eligible to enroll if they are entitled to premium- free HI, or are age 65 and resident citizens or resident aliens.  To  qualify as a resident alien, an individual must have been lawfully admitted for permanent residence and have resided continuously in the United States during the 5 years immediately preceding the month of enrollment.   40.2 - Automatic Enrollment in SMI  (Rev. 1, 09-11-02)  Beneficiaries (except those residing in foreign countries or Puerto Rico) are deemed to have enrolled in SMI in the month before the month for which they are entitled to HI so that HI and SMI coverage star t in the same month.  Thus, monthly beneficiaries other than disability beneficiaries are deemed to enroll in the month before attainment of age 65.  Disability beneficiaries are deemed to enroll in the 24th consecutive month of entitlement to disability b enefits.   Every potential "deemed" enrollee is given a reasonable opportunity (at least 2 months) to decline SMI enrollment by filing notice to this effect.  He or she is deemed not to have enrolled and does not incur any premium liability.  A refusal of S MI not timely filed is treated as a request for voluntary termination under existing disenrollment rules once it has been established that the individual does not wish to have SMI.
(Medicare General Information, Eligibility, and Entitlement)
40.3 - Enrollment Periods (Rev. 12046, Issued:05- 18-23, Effective:01- 01-23, Implementation:06 -21-23)  Enrollment is possible only during specified enrollment periods:    An individual's initial enrollment period (IEP) is of 7 months duration.  It 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.    A general enrollment period (GEP) occurs each year from January 1 through March 31. Coverage is effective the month following the month of enrollment.     Special enrollment periods (SEP) are available to enable certain individuals to enroll in Medicare outside of the IEP and the GEP.   40.3.1 - Enrollment During the Individual's Initial Enrollment Period  (Rev. 12046, Issued:05- 18-23, Effective:01- 01-23, Implementation:06- 21-23)  Coverage begins on the first day of:    The month in which the individual first becomes eligible for SMI if enrollment takes place during the first 3 months of the initial enrollment period,    The month following the month of enrollment if enrollment occurs during the fourth through seventh month of the initial enrollment period.  40.3.2 - Enrollment During General Enrollment Period  (Rev. 12046, Issued:05- 18-23, Effective:01- 01-23, Implementation:06- 21-23)  Coverage begins the first day of the month following the month of enrollment.   40.3.3 - Enrollment During the  Special Enrollment Period (SEP)  Related to Coverage Under Group Health Plans  (Rev. 12046, Issued:05- 18-23, Effective:01- 01-23, Implementation:06- 21-23)  If an individual enrolls in SMI or premium HI while still covered under a GHP or LGHP or during the first full month when not enrolled in a GHP/LGHP based on current employment status, coverage begins either with:    The first day of the month of SM I or premium HI enrollment, or    At the individual's option, with the first day of any of the following 3 months.  If the individual enrolls during any of the 7 remaining months of the special enrollment period, coverage begins with the first day of the month following the month of enrollment.
(Medicare General Information, Eligibility, and Entitlement)
If the individual enrolls during any of the 7 remaining months of the special enrollment period, coverage begins with the first day of the month following the month of enrollment.   40.3.4 - SEP for International Volunteers  (Rev. 12046, Issued:05- 18-23, Effective:01- 01-23, Implementation:06- 21-23)  Individuals who do not enroll in Part B or Premium Part A when first eligible because they were performing volunteer service outside of the United States may enroll during this SEP.   Eligible Individuals may enroll if:   They volunteered outside of the United States through a program that covers at least a 12- month period; and  Is sponsored by a tax exempt organization; and  The individual has (or had) health insurance that provided coverage to the individual while he or she was outside of the U.S. for the duration of the volunteer service.   The SEP for 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 of the United States;   Organization no longer has tax -exempt status; or   Individual no longer has health insurance that provides coverage outside of the United States.   Coverage begins the first day of the month following enrollment.  40.3.5 - SEP for Certain TRICARE Beneficiaries  (Rev. 12046, Issued:05- 18-23, Effective:01- 01-23, Implementation:06- 21-23)  Individuals who enroll in Part A based on disability or ESRD, but do not enroll in Part B because they were eligible for TRICARE standard or TRICARE prime, may enroll during this SEP. Eligible individuals are those who are:   Under age 65, and   Eligible for TRICARE Standard at the time of HI entitlement and:   A military retiree or military retiree family member, or   On active duty or a family member of an active duty service member with Medicare based on ESRD.   Eligible individuals may enroll:   If notified of Medicare entitlement during the IEP - The month after the end of the IEP, or   If notified of Medicare entitlement after the IEP - The month of notification of Medicare entitlement.   Coverage begins:  If notified of Medicare entitlement during the IEP:   The month of enrollment, or   The first month after the end of the IEP
(Medicare General Information, Eligibility, and Entitlement)
Coverage begins:  If notified of Medicare entitlement during the IEP:   The month of enrollment, or   The first month after the end of the IEP   If notified of Medicare entitlement after the IEP:   The month of enrollment, or   The month SMI terminated based on the refusal.   If entitlement is based on ESRD, coverage begins:   The month of HI entitlement, or   The month of enrollment, or   The month after the end of the IEP.  40.3.6 - SEP for Beneficiaries for Whom Medicare is Now the Primary Payer (D -SEP)  (Rev. 12046, Issued:05- 18-23, Effective:01- 01-23, Implementation:06- 21-23)  Individuals entit led to Medicare Part A based on disability, but who did not enroll in Part B because Medicare was the secondary payer for covered services, may enroll using this 7-month SEP.   Eligible individuals may enroll with the later of:   The month in which the employer notifies the beneficiary that Medicare is the primary payer, or   The month Medicare becomes the primary payer.    Coverage begins either:   The first day of the month of filing for Part B, or   During any month of the 7- month D -SEP, or   Retroactive to the mo nth Medicare becomes the primary payer provided the beneficiary makes arrangements to pay the past due premiums; either by a lump sum payment or by monthly installments.   40.3.7  SEP for Exceptional Conditions  (Rev. 12046, Issued:05 -18-23, Effective:01- 01-23, Implementation:06- 21-23)  Effective January 1, 2023, the following SEPs for exceptional conditions are available for Premium Part A and Part B, respectively.   40.3.7.1 - SEP for Individuals Impacted by an Emergency or Disaster  (Rev. 12046, Issued:05- 18-23, Effective:01- 01-23, Implementation:06- 21-23)  Individuals who do not enroll in Part B or Premium Part A when first eligible due to having an emergency or disaster as declared by a federal, state, or local government entity may enroll during this SEP.