TN 31 (06-04)

A. Policy - General

1. Need for SMI

The first month of R-HI entitlement is the first month of R-SMI eligibility. As explained in HI 00801.246, most of the dialysis expenses incurred by ESRD patients are covered by SMI rather than by HI. Practically all R-HI beneficiaries use very costly health care services from the time they first become entitled to R-HI and rarely gain anything by refusing R-SMI entitlement.

(If something is to be gained by refusing R-SMI, the beneficiary should probably postpone filing for R-HI, as discussed in HI 00801.191 B.2.)

R-HI claimants are deemed to have enrolled in R-SMI in the first 3 months of their initial enrollment period (IEP) except as provided in B. Therefore, unless R-SMI is refused, R-SMI entitlement generally begins with the first month of R-HI entitlement.

2. Automatic enrollment

Claimants are notified of their deemed enrollment and its effective date. They are also given at least 2 full calendar months from the date of notice to refuse deemed SMI enrollment. If the individual declines SMI enrollment, he or she may later enroll by filing a request for SMI during the remainder of the IEP or during a GEP, with coverage based on the month of filing (see HI 00805.165). If the claimant files a voluntary request for termination of SMI coverage effective with any month after the end of the IEP, he/she can re-enroll only during a GEP with coverage beginning the following July.

Puerto Rican residents and persons outside the U.S. who qualify for R-HI, like other

R-HI beneficiaries, have SMI beginning immediately after the qualifying period, under the terms of the ESRD provision, unless they refuse SMI timely.

3. Refusal of SMI

Only the beneficiary (or, if he/she is unable to transact business, his/ her representative) can refuse SMI. If an R-HI beneficiary wants to decline SMI before being awarded HI, explain the effect of such a decision. Document when SMI is refused to show that the beneficiary understands the consequences of his/her action.

4. State Buy-in

If, during the enrollment process, there is an indication of welfare involvement, develop possible State buy-in coverage per HI 00815.030.

5. SMI termination

R-SMI is subject to termination under the same general rules that govern termination of D-SMI. These are:

• for nonpayment of premiums;

• by voluntary request;

• termination of the enrollee's HI; and

• upon the enrollee's death.

B. Policy - Premium arrearage of 6 months or more involved

Many people would have difficulty in paying a large premium arrearage, and might either refuse SMI or lose their SMI due to the inability to pay their premiums on time.

When talking with the claimant or his/her responsible representative and there appears to be 6 or more months of premium arrearage, tell him/her that SMI coverage is prospective only (i.e., coverage begins with the month in which the enrollment is processed). If the claimant is willing and able to pay all premiums for coverage beginning with the earliest possible (specified) month, or prefers to have SMI begin with the month of filing, he/she may choose to have coverage begin with either of those months.

Unless there is a statement in file showing that the claimant wants to have SMI retroactive to the specified month or the month of filing, SMI should be awarded prospectively, and the claimant notified of his/her right to have earlier coverage. The SMI award can be amended to give retroactive coverage if a timely request and payment are received.

C. Example

Mr. Henderson, born 12/50, begins a course of renal dialysis for ESRD 9/8/00. The first month of Medicare eligibility is 12/00, but he delays filing until 8/01. His award is processed in 10/01. He is entitled to R-HI retroactive to 12/1/00 and R-SMI effective 10/01 (unless the file shows he did not want R-SMI, or wanted it effective 12/00 or 8/01). He will be billed for premiums from that date. If, when notified of the award, he states that he wants retroactive SMI and encloses the necessary payment, coverage will be made effective 12/00 or 08/01 as requested.