TN 31 (06-04)

A. Procedure

When an individual wishes to file for Premium-HI for the Working Disabled:

1. Application

Take a CMS-18-F5 (Application for Hospital Insurance, OS 15060.085).

• Modify the title to read “Application for Premium Hospital Insurance for the Working Disabled.”

• Complete only items 1(A), 2, and 16.

• Do not complete items 15 or 17.

NOTE: The “conditional” enrollment procedures applicable to Premium-HI for the Aged described in HI 00801.140D.2. do not apply to enrollment in Premium-HI for the Working Disabled. However, see HI 00801.174 for circumstances under which an individual may withdraw an enrollment request without incurring premium liability,

2. Medical evidence

Obtain an SSA-454-BK (Report of Continuing Disability Interview) and SSA 827s (Authorization for Source to Release Information to the Social Security Administration) from the enrollee.

• Complete all sections of the SSA-454-BK.

• Explain that updated medical information may be needed in order to verify continuing disability.

• Advise the enrollee that he/she will be notified if additional medical evidence is needed.

3. Premium reduction

If a disabled worker, disabled widow(er), or disabled adult child is eligible for a reduced HI premium on his/her own account or on the account of another NH as a spouse, widow(er), or divorced spouse, include in file evidence that the 30 QC requirement is met. Also, include, as appropriate, proof of marriage, death, and divorce (see HI 00801.134D.) following regular title II rules.

4. QDWI referrals

Explain the QDWI provision under which States are required to pay HI (but not SMI) premiums for certain needy Premium-HI enrollees (see SI 01715.005 for a listing of QDWI eligibility requirements).

Refer individuals interested in the QDWI benefit to the appropriate State welfare agency. Emphasize the importance of promptly contacting the State.

Advise individuals that, if they are determined ineligible for QDWI status, they may withdraw their Premium-HI enrollment without incurring any premium liability if they submit a written request for withdrawal by the end of the third month following notice of HI coverage (see HI 00801.174).

5. Routing

1. a. Prepare an SSA-3601 in red to forward the claim to ODO. Complete the SSA-3601 as follows.

   • Circle ODO (PSC-7);

   • Check Non-DOFA;

   • Complete claim number using existing claim number and BIC from the MBR;

   • Complete FO telephone number;

   • In “Remarks”, enter “Claim for Premium Hospital Insurance for the Working Disabled.” If the individual is eligible for a reduced HI premium as described in HI 00801.170E.2., also include the remark “HI Premium Reduction Case.”

2. Attach a current MBR to the claim and mail to:

   SSA, ODO
   Attn: Module ____
   1500 Woodlawn Drive
   Baltimore, MD 21241-1500

3. At the time the claim is mailed, notify ODO via MDW that the claim was received to allow ODO lead time in obtaining the prior disability folder for association with the claim when received. Prepare the MDW to read: “SUBJECT: Premium-HI for the Working Disabled. Retrieve folder for claim number, BIC, beneficiary name.”

B. Reference

Premium Medicare for the Working Disabled, DI 40510.140