TN 22 (04-09)

A. Policy - general

The 1972 amendments extended HI coverage, both Part A, Hospital Benefits, and Part B, Medical Benefits, to disability beneficiaries, including disabled widow(er)s (DWBs). (See policy in HI 00801.146, Entitlement to HI for the Disabled.)

A claimant who has been entitled to DWB for 24 months and is currently entitled will automatically be entitled to health insurance (HI) beginning with the 25th month of entitlement (MOET) (but not before 7/1973). For credit of months of Social Security Insurance (SSI) payment and/or State Supplementary Payment (SSP) for payments after 12/1990, see DI 11015.020 and HI 00801.154.

In counting the 24-month period, certain months in which a claimant was not actually entitled as a DWB will be included if he or she can be deemed to have been entitled as a DWB for HI purposes only as explained below.

Entitlement to supplementary medical insurance (SMI) would begin effective the same month as HI, unless the claimant declines the former. (See HI 00805.005, Eligibility for SMI.) When retroactive SMI is involved, follow existing equitable relief procedures in Enrollment Not Processed Timely, HI 00805.195 and in Granting Equitable Relief, HI 00830.001.

EXCEPTION: Effective July 1, 2001, a disability beneficiary diagnosed with Amyotrophic Lateral Sclerosis (ALS), better known as Lou Gehrig’s disease, will not have to serve the 24-month Medicare waiting period. The date of entitlement to Medicare is the date of entitlement to disability (DOED) benefits or July 1, 2001, whichever is later. The Diagnosis code (either primary (DIG) or secondary (SDIG)) will be 3350. (See DI 45605.001, Amyotrophic Lateral Sclerosis (ALS) – Medicare Waiting Period Waived – Processing Center (PC) and DI 11036.001, Amyotrophic Lateral Sclerosis (ALS) – Medicare Waiting Period Waived – Field Office (FO).)

B. Policy - deemed entitled to HI

1. Conditions

For HI purposes only, a claimant, although not actually entitled to DWB, will be deemed entitled to DWB in each of the following situations:

1. Claimant entitled to mother's or father's benefits, who is age 50 or over and applies for HI, is deemed to have filed for DWB (see RS 00207.020B.2. in this section).

2. A claimant, between ages 62 and 65 entitled to a retirement insurance benefit (RIB), who, in the month before he or she became so entitled, was entitled as a disabled widow(er) is deemed to continue to be entitled (for HI purposes) for months of RIB entitlement prior to age 65.

3. A claimant entitled as an aged widow(er) whose benefits were changed from a disabled widow(er) to an aged widow(er) is deemed entitled as a disabled widow(er) (for HI purposes) for months of aged widow(er)'s entitlement.

4. A claimant who:

   • became entitled to widow(er)'s benefits no earlier than the month in which he or she attained age 60 and,

   • meets all requirements for DWB, except for age, will be deemed to be entitled as a disabled widow(er) for months of aged widow(er)'s entitlement prior to age 65 as long as he or she remains disabled.

2. Mother or father beneficiary

Prior to 5/83, only a mother beneficiary could be entitled to HI because she met the requirements to be deemed entitled as a DWB for HI purposes only.

The Social Security Amendments of 1983 provided that a disabled father beneficiary could also be deemed to be entitled as a DWB for HI purposes only, but could not be entitled to HI until 5/83. Therefore, a father beneficiary who meets the requirements may be deemed to be entitled as a DWB for up to 24 months prior to 5/83, but his first MOET to HI can be no earlier than 5/83.

A disabled individual between ages 50-65 who is entitled to mother's (or father's effective 5/83) insurance benefits and who elects HI is deemed, for HI purposes only, to have filed as a disabled widow(er) upon furnishing proof of disability and meeting all other requirements for eligibility to DWB (see RS 00207.007, FO Processing of Initial Disabled Widow(er)’s Claims). He or she is deemed to have been entitled to these benefits, for HI purposes only, beginning with the first month for which he or she could have been entitled based on deemed filing as a disabled widow(er).

3. Reduced RIB beneficiary

An individual entitled to DWB may, if he or she is otherwise qualified, elect to receive a reduced RIB at any time between age 62 and full retirement age (FRA). For HI purposes only, a claimant who was entitled to DWB for the month before the first MOET to reduced RIB is deemed to continue to be entitled to benefits as a disabled widow(er). Such a claimant may count months of disabled widow(er)'s entitlement and subsequent months of RIB entitlement prior to age 65 in order to meet the requirement of 24 months of entitlement as disabled widow(er).

4. Aged widow(er) beneficiary

A widow(er) over age 60 and under 65 may (for HI purposes) be deemed entitled to DWB if, except for age, he or she meets all other requirements for DWB and either:

• became entitled as a DWB prior to age 60, and benefits were changed to aged widow(er)'s benefits; or

• was never awarded benefits as a disabled widow(er) based on the current claim because the first possible MOET to widow(er)'s benefits was no earlier than the month in which he or she attained age 60.

A claimant entitled to widow(er)'s benefits based on age, who becomes disabled before age 65, will be deemed for HI purposes to be entitled as a disabled widow(er) beginning with the first month after the waiting period. The claimant must have actual entitlement on the same record for which he or she is claiming deemed entitlement to DWB.

The aged widow(er)s will be considered to continue to be entitled to DWB for months of entitlement prior to age 65, unless and until an event occurs which terminates his or her status as a DWB.

5. Termination of HI protection

Entitlement to HI ends with the month following the month in which notice is sent to the disabled widow(er) indicating that he or she is no longer entitled as a DWB.

Where evidence establishes that a terminating event (remarriage or cessation of disability) for disabled widow(er)s occurred in an earlier month, the beneficiary's HI-SMI entitlement will not terminate until the end of the month following the month in which the notice of termination was mailed.

If a beneficiary attains age 65 in the month immediately following the last month during which he or she is entitled to HI as a disabled widow(er), HI entitlement will continue for the beneficiary as a 65-year-old beneficiary.

Although a disabled widow(er)'s entitlement to benefits may end before age 65, if he or she becomes entitled to a higher reduced RIB, for HI purposes, entitlement as a disabled widow(er) is deemed to continue as long as he or she remains under a disability. (See RS 00207.020B.3. in this section.)

C. Reference

HI 00801.155, Deemed Entitlement to DWB for Medicare