TN 26 (11-93)

CITATIONS:

ACT AS AMENDED—SECTION 1818A

Regulations—42 CFR 406.20(c)

A. Policy — General

A disabled individual who loses premium-free D-HI solely because he/she is working may enroll in hospital insurance (and medical insurance) by paying monthly premiums for as long as he/she continues to have a disabling impairment. This provision is referred to as Premium-HI for the Working Disabled.

Although the first possible month of entitlement to Premium-HI for the Working Disabled is 7/90, any individual who lost premium-free D-HI prior to 7/90 solely because of work and has continuously been under a disabling impairment is eligible to enroll under the provision.

B. Policy — Eligibility requirements

To enroll in Premium-HI for the Working Disabled, an individual must be under age 65, and:

• have lost entitlement to premium-free D-HI solely because he/she was engaging in substantial gainful activity (SGA);

• continue to have a disabling physical or mental impairment; and

• be ineligible for HI on any other basis.

An individual may not enroll in SMI under this provision unless he/ she also enrolls in Premium-HI.

NOTE: A re-entitled disability beneficiary who is required to serve a new 24-month D-HI qualifying period and who meets the above requirements is eligible to enroll in Premium-HI for the Working Disabled during a general enrollment period or special enrollment period (see C. below for a discussion of enrollment periods). Premium-HI eligibility continues until the individual becomes re-entitled to D-HI.

C. Policy — Enrollment periods

An individual may enroll in Premium-HI (and SMI) for the Working Disabled during the following enrollment periods:

• Initial Enrollment Period (IEP): this is the 8-month period beginning with the month an individual is notified about the loss of premium-free HI

• General Enrollment Period (GEP): GEPs occur during January through March of each year (for 1990, the GEP was extended through 7/2/90)

• Special Enrollment Period (SEP): SEPs occur as described in HI 00805.265

D. Policy — When coverage begins

1. IEP enrollments

2. GEP enrollment

Coverage begins July 1, following the GEP in which the
individual enrolls.

3. SEP enrollment

See HI 00805.275 for a discussion of the SEP provisions.

E. Policy—Premiums

1. General

Individuals who enroll in Premium-HI for the Working Disabled pay the same HI and SMI premium as aged Premium-HI enrollees. See HI 01005.005 and HI 01005.007 for HI premium amounts.

The HI premium for the Working Disabled is not subject to increase for late enrollment. This differs from the rule applicable to individuals who enroll in Premium-HI for the Aged and are subject to a 10 percent increase payable for twice the number of full twelve month periods they could have been but were not enrolled. The SMI premium under the Premium-HI for the Working Disabled provision is subject to increase for late enrollment following normal SMI premium increase rules. No months prior to 7/90 are counted in determining the number of months to assess for SMI premium increase purposes.

If an individual was paying an increased SMI premium during the last month of premium-free HI entitlement, but enrolls for SMI under the Working Disabled provision during his/her IEP, the SMI premium reverts to the standard rate.

States are required to pay HI (but not SMI) premiums for “qualified disabled and working individuals (QDWI).” QDWIs are individuals enrolled in Premium-HI for the Working Disabled who meet the requirements in SI 01715.005. States pay HI premiums through the Part A Group Payer System.

2. Premium reduction

Beginning 1/1/94, a disabled Premium-HI enrollee may qualify for a reduction in the amount of his/her HI premium. A disabled Premium-HI enrollee (including a disabled worker, a disabled widow(er) or a disabled adult child) is eligible for HI premium reduction if he /she:

• Has 30 or more QCs on his/her own E/R;

• Has been married for at least 1 year to a number holder (NH) with 30 or more QCs;

• Was married for at least 1 year to a deceased NH with 30 or more QCs;

• Is divorced, after at least 10 years of marriage, from a NH who had acquired 30 or more QCs at the time the divorce became final.

NOTE: Although a disabled adult child can qualify for HI premium reduction based on his/her own earnings or on the earnings of a spouse (including a divorced spouse), a disabled adult child cannot qualify for premium reduction based on the earnings of his/her parent (including the NH on whose earnings the child's premium-free HI entitlement was based).

F. Examples of HI premium reduction

1. Disabled worker

John lost his entitlement to premium-free HI solely because he was working. He enrolls in Premium-HI for the Working Disabled during his IEP. John has 26 QCs on his own record. His wife, to whom John has been married for 8 years, has 32 QCs. John is eligible for HI premium reduction since he is married to a NH with at least 30 QCs.

2. Disabled adult child

Amy is a disabled adult child who returned to work and lost her premium-free HI entitlement. Her disability benefit and premium-free HI entitlement was based on her 67 year old father's earnings. Amy enrolls for Premium-HI for the Working Disabled during her IEP. She has 20 QCs on her own record. Her father and mother each have more than 40 QCs. Amy is not eligible for HI premium reduction. However, if she continues to work and subsequently acquires 30 QCs, she will be eligible for HI premium reduction at that time. Also, if she marries a NH with 30 or more QCs, she will be eligible for HI premium reduction after she has been married to the NH for 1 year.

3. Disabled widow(er)

Tom is a disabled widower who loses his premium-free HI solely because of work. Tom's deceased wife had a total of 28 QCs. Tom has 31 QCs on his own E/ R. Tom is eligible for HI premium reduction.