TN 19 (03-93)

Citations:

Section 1837 of the Social Security Act

Social Security Act

Social Security Amendments of 1965 - Section 103(b)

P.L. 89-732, P.L. 90-97, P.L. 90-248, P.L. 92-603, P.L. 96-499

Policy

1. Specific times for enrollment

The law provides specific times for an individual to enroll (or to be deemed enrolled) in SMI.

The initial enrollment period (IEP) is explained in HI 00805.015. If the individual does not enroll in the IEP, or if SMI enrollment is terminated, he /she can only enroll in a GEP (See HI 00805.025), with coverage beginning the following July.

EXCEPTION: Individuals with employer group health plan coverage may be eligible for an SEP if they meet the requirements of HI 00805.265ff.

If coverage under a State buy-in agreement terminates, SMI coverage continues on an individual basis as though the individual had enrolled in the IEP, i.e., with no penalty.

2. Filing occurs outside enrollment period

Unless automatic enrollment applies (see HI 00805.040), an enrollment request filed outside an applicable enrollment period is not valid and must be denied.

If an individual files an enrollment request shortly before an enrollment period and the request has not been denied by the beginning of the period, the individual should be asked to file again as soon as the enrollment period begins. The premature request need not be formally denied if he/she files in the enrollment period.

If an individual's request for enrollment will be denied because it is not filed in an IEP or GEP, he/she should be advised that he/she may enroll during a subsequent GEP.

NOTE: See HI 00805.205 where there is failure to advise the individual to file a valid enrollment request during a prescribed enrollment period.

3. SMI rights for those with HI who develop ESRD

A beneficiary on Medicare when he/she contracts ESRD has a second IEP, beginning 3 months before and ending 3 months after the first month of R-HI eligibility. (See HI 00801.258 C.)