evekhm/cms_iom_500 huggingface dataset:
(Medicare General Information, Eligibility, and Entitlement)
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.  Eligible Individuals may enroll as early as:   The month of the emergency or disaster, or   Up to six months after the emergency or disaster has ended.   NOTE: they may also be able to use this SEP if the disaster or emergency  takes place where their authorized representative, legal guardian, or person who makes health care decisions on their behalf resides.  The SEP begins the date an emergency or disaster is declared, or the start date identified in the emergency declaration,  whichever is earlier. The SEP ends six months after the end of the 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or   The end date of any extensions or the date when the declaration has been determined to hav e ended or has been revoked, or   The date of the declaration, if such date is after the end of the disaster.  Coverage begins the first day of the month following enrollment.  40.3.7.2  SEP for Individuals Affected by a Health Plan or Employer Misrepresent ation  (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 misrepresentation or reliance on incorrect information provided by their employer or GHP, agents or brokers of health plans, or any person authorized to act on behalf of such entity may enroll during this SEP.  An eligible person must demonstrate (by documentation or written attestation) both of the following:    They did not enroll in Part  B or Premium Part A during another enrollment period in which they were eligible based on information received from an employer or GHP, agents or brokers of health plans, or any person authorized to act on such organizations behalf.   An employer, GHP, agent or broker of a health plan, or their representative materially misrepresented information or provided incorrect information relating to enrollment in Part B or Premium Part A.   The SEP begins the day an individual notifies the Social Security Administ ration and ends six months later.   Coverage begins the first day of the month following enrollment.
(Medicare General Information, Eligibility, and Entitlement)
The SEP begins the day an individual notifies the Social Security Administ ration and ends six months later.   Coverage begins the first day of the month following enrollment.  40.3.7.3 - SEP for Formerly Incarcerated Individuals  (Rev. 12046, Issued:05- 18-23, Effective:01- 01-23, Implementation:06- 21-23)  Individuals who do not e nroll in Part B or Premium Part A when first eligible because  they were incarcerated may enroll during the SEP.  An eligible person can sign up anytime within the 12 months after their release from incarceration.  The SEP begins the day an individual is r eleased from the custody of penal authorities.  However, individuals have the option to select a retroactive effective date (not to begin  prior to their release date and not to exceed 6 months). If individuals choose this retroactive option, they will be responsible for paying Medicare premiums back to the date of coverage.   Coverage begins the first day of the month following enrollment or up to six months retroactive.   40.3.7.4 - SEP for Termination of Medicaid Coverage  (Rev.  12046, Issued:05- 18-23, Effective:01- 01-23, Implementation:06- 21-23)  Individuals whose Medicaid eligibility terminated may enroll during this SEP.   A person may be eligible based on this condition if they have:    Lost Medicaid entirely,   Missed a Medicare enrollment period, and   Their Medicaid coverage was terminated on or after January 1, 2023.   The SEP begins when an individual is notified of an upcom ing termination of Medicaid  eligibility and ends six months after the Medicaid termination. Medicare benefits start the  month after Medicare enrollment unless the individual elects a start date back to the first  day of the month the individual lost Medicaid and agrees to pay all prior premiums.   Note: Individuals who are still eligible for Medicaid, including a Medicare Savings  Program, and have not received notice of an upcoming Medicaid termination are not  eligible for this SEP.     40.3.7.5 - SEP fo r Other Exceptional Conditions  (Rev. 12046, Issued:05- 18-23, Effective:01-01-23, Implementation:06-21-23)
(Medicare General Information, Eligibility, and Entitlement)
40.3.7.5 - SEP fo r Other Exceptional Conditions  (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 conditions beyond their control caused them to miss an enrollment period may enroll during the SEP. This SEP is available for individuals whose unique conditions do not qualify for other SEPs.  An eligible person must demonstrate (by documentation or written attestation) that conditions outside of their control that occurred on or after January 1, 2023, caused them to miss an enrollment period.  An individuals request 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 forgetfulness, lack of knowledge, or failure to make premium payments.  SSA will determine when this SEP begins on a case-by-case basis, but the SEP will end no less than 6 months after it begins.  Coverage begins the first day of the month following enrollment.   40.4 - Nature and Purpose of State Buy -in (Rev. 11764; Issued 12-22-22; Implementation: 01-01-2023; Effective 01-03-23)  Under the State Buy -in program, states, the District of Columbia, and the U.S. territories may enter into buy- in agreements with CMS to enroll certain individuals who are dually eligible for Medicare and Medicaid into Medicare Part B and pay the premiums on their behalf.   Most states have expanded their buy- in agreements to also include payments of Part A premiums for individuals who must pay a premium to enroll in Medicare Part A and who are eligible for the Qualified Medicare Beneficiary (QMB) eligibility group. State buy -in agreements maximize the number of full- benefit Medicaid recipients enrolled in Medicare, which ensures  that Medicare pays primary to Medicaid. State buy-in agreements also facilitate enrollment in Medicare for low income individuals who are not eligible for full-benefit Medicaid coverage by paying Medicare premiums and cost sharing. Please see the Manual for State Payment of Medicare Premiums, chapter 1, section 1.2 for additional state buy-i n information.    40.5 - End of Coverage  (Rev. 1, 09-11-02)
(Medicare General Information, Eligibility, and Entitlement)
40.5 - End of Coverage  (Rev. 1, 09-11-02)  An individual may notify CMS in writing, at any time, that he or she no longer wishes to participate in the supplementary medical insurance plan.  Termination of coverage takes effect at the close of the calendar month following the calendar month in which the request for termination was filed.  Enrollment under medical insurance is terminated because of nonpayment of premiums.  Termination is effective with the end of the grace period provided for payment of premiums.  ( See chapter 2, 40.7.4 of this manual.)  For individuals under age 65, enrollment is terminated because HI entitlement ended.  SMI terminates at the same time as HI.   If not terminated sooner, coverage ends with the beneficiary's death.  40.6 - Termination and Reenrollment  (Rev. 1, 09-11-02)  An individual whose enrollment has terminated may reenroll only in a general enrollment period or a special enrollment period if the requirements are met.
(Medicare General Information, Eligibility, and Entitlement)
40.7  Premiums  (Rev. 1, 09-11-02)  A premium is due for each month of entitlement under SMI.  The SMI premium covers about one-fourth of the cost of the Part B program.  40.7.1 - Amount of Premiums  (Rev. 1, 09-11-02)  In the third quarter of each calendar year, the Secretary of the Department of Health and Human Services announces the base premium for SMI coverage that is payable as of the following January 1.  The SMI premium is the same for all enrollees even though the cost to the program is greater for ESRD enrollees and the disabled than it is for the aged.  The SMI premium is refigured each year and is based on the lower of one- half of SMI program costs per aged enrollee or the general percentage by which social security benefits were increased during the calendar year in which the announcement occurs.  (During the 5-year period, January 1984 through December 1988, the formula for computing the SMI premium has been modified to provide that the Part B premium reflects exactly one -fourth of the cost of the Part B program.  Beginning with the premium announced for the period beginning January 1989, however, the method of computing the SMI premium reverts back to the pre-January 1984 rules.)  40.7.2 - Increase in Base Premium Amount  (Rev. 1, 09- 11-02)  The base premium that is announced by the Secretary is paid by most enrollees.  However, it is increased for those who enroll late or reenroll after a prior termination of entitlement.  The amount of the increase is 10 percent of the ba se rate for each full 12 -month period during which the individual could have been but was not enrolled in the program.  However, months in which an individual has GHP coverage based on current employment status are not counted as months in which the indivi dual "could have been, but was not enrolled."  This exception does not apply to individuals who are entitled to Medicare on the basis of ESRD.   40.7.3 - Collection of Premiums  (Rev. 1, 09- 11-02)
(Medicare General Information, Eligibility, and Entitlement)
40.7.3 - Collection of Premiums  (Rev. 1, 09- 11-02)  SMI premiums are collected from benefits payable (in order of priority) by the Railroad Retirement Board, SSA, or Office of Personnel Management (Civil Service) unless the individual is covered under a State buy- in agreement.  If the individual is entitled to such benefits but the payments are in suspense, e.g., du e to work deductions, he or she is billed for the amounts due.  Uninsured beneficiaries are also billed directly for the premiums due.  Premium bills are sent every 3 months unless the individual specifically requests a monthly bill or is also entitled to Premium -  HI (in which case a monthly combined SMI -Premium- HI bill is sent).   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)
(Medicare General Information, Eligibility, and Entitlement)
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)
(Medicare General Information, Eligibility, and Entitlement)
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.
(Medicare General Information, Eligibility, and Entitlement)
 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.
(Medicare General Information, Eligibility, and Entitlement)
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.
(Medicare General Information, Eligibility, and Entitlement)
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
(Medicare General Information, Eligibility, and Entitlement)
 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.
(Medicare General Information, Eligibility, and Entitlement)
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.   When an individuals Medicare Part A entitlement based on ESRD  ends prior to January 1, 2023:   If they submit the attestation to enroll from October 1, 2022 through December 31, 2022, Part B -ID begins effective January 1, 2023.   If they submit the attestation to enroll after December 31, 2022, Part B -ID begins the following month.