DI 11040: Deemed Medicare Cases
TN 1 (04-09)
A. Medicare qualifications for a mother, father, or widow(er)
To qualify for Medicare, a mother, father, or widow(er) must establish that he or she meets all the requirements for Disabled Widow(er)’s Benefits (DWB). Therefore, a mother, father, or widow(er) seeking Medicare based on deemed DWB entitlement must submit proof of age (POA) and evidence of disability. The claimant must be found disabled before the end of the prescribed period. The disability must begin at least 5 full calendar months before the month in which the widow(er) attains age 60 (before age 62 years and 7 months if disability is being established for “Medicare only” purposes) and no later than 84 months after the latest of the following months:
The month of the Number Holder’s (NH) death;
The month in which previous entitlement to disabled widow(er) benefits (DWB) terminated because the disability had ceased;
For a widow(er) or surviving divorced spouse, the last month of entitlement to mother's or father's benefits based on the NH’s record.
A disability which began before the worker died or while the claimant was entitled to mother’s or father’s insurance benefits, based on the worker’s record meets the above requirements.
See also:
DI 10135.001 - Deemed Entitlement to DWB for Medicare – General
DI 11015.001 - Disabled Widow(er)’s Benefits – General
DI 25501.360 - Established Onset in Deemed Entitlement to Disabled Widow(er)’s Benefits for Medicare Claims
RS 00208.110 - Medicare-Requirements for Entitlement-Mothers/Fathers
RS 00208.115 - Medicare-Development and Forwarding of Claims-Mothers/Fathers
HI 00801.155 - Deemed Entitlement to DWB for Medicare
DI 81010.025 – Completing Electronic Disability Collect System (EDCS) Forms for Initial Claims
B. Onset dates
Many disabled widow(er) cases involve onset dates long past; however, establishing a precise date of onset will not be necessary for all cases. For example, if the evidence establishes that the individual was disabled more than 5 full months prior to the beginning of the prescribed period, that determination would eliminate the need to establish the precise month, day, or year of onset.
See also:
DI 11005.050 - Prescribed Period and Controlling Date
DI 11015.001 - Disabled Widow(er)’s Benefits – General
DI 25501.350 - Establishing an Established Onset Date (EOD) for Disabled Widow(er) (DWB) Cases (Not Medicare)
DI 25501.360 - Established Onset in Deemed Entitlement to Disabled Widow(er)’s Benefits for Medicare Claims
C. Development and transmitting of claims
For information on the development of DWB cases, see RS 00208.115 - Medicare - Development and Forwarding of Claims - Mothers/Fathers
For information on folder preparation for transmittal of DWB cases, see:
DI 11010.205 - Completing the SSA-831
DI 11015.001 - Disabled Widow(er)’s Benefits (DWB) General
DI 70005.001 - Introduction to the Modular Disability Folder (MDF)
D. Special situations for subsequent claims for mother, father, or widow(er)
1. Mother beneficiary under age 50 filing for disability determination for Medicare purposes or widow(er) beneficiary age 60-64 alleging disability after the prescribed period ends
The Field Office (FO) will make a determination of disallowance and notify the claimant.
NOTE: The prescribed period for Medicare purposes is extended to age 65 rather than age 60 for DWB cases.
See also:
DI 11015.030 - FO Authorization of a Disabled Widow(er)’s Benefit (DWB) Technical or Non-Medical Denial
DI 25501.360 - Established Onset in Deemed Entitlement to Disabled Widow(er)’s Benefits for Medicare Claims
DI 40101.010 - Technical Denials and Withdrawals
2. Mother, father, or widow(er) title II beneficiary age 50 to 64 filing for entitlement for Medicare purposes alleging disability before the end of the prescribed period
The Disability Determination Services (DDS) will make a determination, if not otherwise excluded from DDS jurisdiction.
NOTE: The prescribed period for Medicare purposes is extended to age 65 rather than age 60 for DWB cases.
See also:
DI 25501.360 - Established Onset in Deemed Entitlement to Disabled Widow(er)’s Benefits for Medicare Claims
NOTE: If a Medicare only claimant alleges an onset before the end of the prescribed period, but dies prior to adjudication and before expiration of the 24-month qualifying period for Medicare, no medical determination by the DDS is required.