TN 31 (06-04)

Citations:

ACT AS AMENDED--SECTION 226(b)
Regulations 42 CFR--Sec. 406.12

A. Background

The 1972 Amendments extended HI entitlement to Social Security and Railroad Retirement disability beneficiaries (D-HI) beginning 7/1/73. Anyone entitled to D-HI may also have SMI (D-SMI) for which he/she must pay the same premium as enrollees age 65 or over.

NOTE: Medicare coverage for the disabled is the same, in all respects, as Medicare coverage for aged individuals (i.e., the rules on benefit periods, deductible and coinsurance amounts, etc. are the same for both disabled and aged individuals).

B. Policy

In most cases, D-HI entitlement begins after an individual has been entitled (or deemed entitled) to disability benefits (DIB, DWB, or CDB) for 24 months, i.e., D-HI begins with the first day of the person's 25th month of disability benefit entitlement. (See HI 00801.154 for an explanation of when months of SSI/SSP eligibility can be counted toward the 24 month waiting period for DWBs.)

NOTE: Prior to 12/1/80, the 24 months had to be consecutive (see example in HI 00801.146C.2.).

Even though a cash benefit may not be payable for a particular month, all months of disability benefit entitlement are counted in determining when the 24 month D-HI qualifying period requirement is met. (See example in HI 00801.146C.3.)

EXCEPTION: Section 115 of the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000, waives the 24 month waiting period for beneficiaries whose primary or secondary diagnosis is Amyotrophic Lateral Sclerosis (ALS). The Diagnosis code (either primary (DIG) or secondary (SDIG)) will be 3350.

Since CDB entitlement can begin no earlier than age 18, D-HI entitlement based on CDB entitlement can never begin before the month the beneficiary attains age 20 (or age 18 if the individual’s disability is ALS). This is true even though the individual may have been disabled and entitled to child's insurance benefits for many months prior to age 18. (See example HI 00801.146C.4.)

These individuals are entitled to D-HI beginning 7/01/01, or the first month of disability benefit entitlement, whichever is later. If a beneficiary is diagnosed with ALS after his/her initial disability onset date and is within the 24 month Medicare waiting period, he/she is entitled to Medicare effective with the later of the ALS onset month or 7/01/01. (See example in HI 00801.146C.7.)

Certain widows and widowers who are disabled, but not entitled to disabled widow(er)'s benefits (DWB), may be deemed to be entitled to DWB solely for purposes of establishing or maintaining entitlement to Medicare. (See HI 00801.155 for a complete discussion of the deemed DWB provisions.)

C. Examples

1. DIB in suspense

Bruce was entitled to DIB beginning 8/99. Upon completing a trial work period in 12/00, he is working at the SGA level and continues to do so throughout the 36 month extended period of eligibility. Although the last monthly benefit check he received is for 3/01, he will be awarded D-HI beginning 8/1/01, his 25th month of entitlement to DIB.

2. Prior period of DIB entitlement ended before 12/80

Steven was entitled to DIB beginning 1/75. His entitlement ended 5/77 due to medical improvement. He was reentitled to disability benefits beginning 10/78. The 24 month qualifying period begins 10/78 and Steven is entitled to D-HI effective 10/80.

3. DWB in suspense following entitlement to F benefits

Mary, a DWB beneficiary entitled to D-HI, becomes entitled to an F (parent's) benefit exceeding the amount of her DWB. Only the F benefit is payable, but Mary's right to D-HI is not affected because her DWB entitlement has not been terminated.

4. CDB entitlement

Sally, who was born 5/7/73, became totally disabled at age 5. In 9/84, when her father died, she became entitled to minor child's benefits on his record. The 24 month D-HI qualifying period begins with 5/91, the month she attained age 18, and she is entitled to D-HI beginning 5/93, the month she attains age 20.

5. DIB based on ALS (DIB entitlement begins prior to 7/01)

Robert was entitled to DIB beginning 9/99 with a primary diagnosis of ALS. D-HI entitlement is set up to begin 9/01. In 7/01, the D-HI (and D-SMI) date of entitlement is changed to 7/01 and Robert is sent a new Medicare card and a notice explaining the change in entitlement dates.

6. DIB based on ALS (DIB entitlement begins after 7/01)

Lynn is entitled to DIB beginning 3/02. Since her disability is due to ALS, she is also entitled to D-HI effective 3/02.

7. DIB based on ALS (ALS onset month after initial DOED)

Edward is entitled to DIB beginning 5/02. In 9/03, while still in the 24 month Medicare waiting period, he is diagnosed with ALS. He is entitled to D-HI effective 9/03.