42 C.F.R. Subpart B—Individual Enrollment and Entitlement for SMI
Title 42 - Public Health
(a) Basic rule. Except as specified in paragraph (b) of this section, an individual is eligible to enroll for SMI if he or she— (1) Is entitled to hospital insurance under any of the rules set forth in §§406.10 through 406.15 of this chapter; or (2) Meets the following requirements: (i) Has attained age 65. (An individual is considered to have attained age 65 on the day before the 65th anniversary of his or her birth.) (ii) Is a resident of the United States. (iii) Is a citizen of the United States, or an alien lawfully admitted for permanent residence who has resided continuously in the United States during the 5 years preceding the month in which he or she applies for enrollment. (b) Exception. An individual is not eligible to enroll for SMI if he or she has been convicted of— (1) Spying, sabotage, treason, or subversive activities under chapter 37, 105, or 115 of title 18 of the United States Code; or (2) Conspiracy to establish dictatorship under section 4 of the Internal Security Act of 1950. The following forms, available free of charge by mail from CMS, or at any Social Security branch or district office, are used to apply for enrollment under the supplementary medical insurance program.
CMS–4040—Application for Enrollment in the Supplementary Medical Insurance Program. (This form is used for enrollment by individuals who are not eligible for monthly benefits or for hospital insurance.) CMS–40–B—Application for Medical Insurance. (For general use by the SSA District Office in requesting medical insurance protection during the general enrollment period or during the initial enrollment period if the enrollee is not subject to automatic enrollment is SMI.) CMS–40–D—Application for Enrollment in the Supplementary Medical Insurance Program. (This form is mailed to individuals who do not have current supplementary medical insurance because of prior refusals, voluntary withdrawal, or premium default from prior coverage. It is used during the annual general enrollment period.) CMS–40–F—Application for Medical Insurance. (For use by beneficiaries residing outside the United States.) CMS–18–F–5—Application for Hospital Insurance Entitlement. (For use by individuals who are not eligible for retirement benefits under Title II of the Social Security Act or under the Railroad Retirement Act. This form may also be used for enrollment in the supplementary medical insurance program.) As an alternative, the individual may request enrollment by answering the Part B enrollment questions on an application for monthly Social Security benefits, or by signing a simple statement of request, if he or she is eligible to enroll at that time. (a) Opportunity to enroll. (1) An individual who is eligible to enroll for SMI may do so during an initial enrollment period or a general enrollment period as specified in §§407.14, and 407.15. An individual who meets the conditions specified in §407.20 may enroll during a special enrollment period, as provided in that section. (2) An individual who fails to enroll during his or her initial enrollment period or whose enrollment has been terminated may enroll or reenroll during a general enrollment period, or, if he or she meets the specified conditions, during a special enrollment period. (b) Enrollment periods ending on a nonworkday. (1) If an enrollment period ends on a Federal nonworkday, that period is automatically extended to the next succeeding workday. (2) A Federal nonworkday is any Saturday, Sunday, or Federal legal holiday or a day that is declared by statute or executive order to be a day on which Federal employees are not required to work. (a) Duration. (1) The initial enrollment period is the 7-month period that begins 3 months before the month an individual first meets the eligibility requirements of §407.10 and ends 3 months after that first month of eligibility. (2) In determining the initial enrollment period of an individual who is age 65 or over and eligible for enrollment solely because of entitlement to hospital insurance, the individual is considered as first meeting the eligibility requirements for SMI n the first day he or she becomes entitled to hospital insurance or would have been entitled if he or she filed an application for that program. (b) Deemed initial enrollment period. (1) SSA or CMS will establish a deemed initial enrollment period for an individual who fails to enroll during the initial enrollment period because of a belief, based on erroneous documentary evidence, that he or she had not yet attained age 65. The period will be established as though the individual had attained age 65 on the date indicated by the incorrect information. (2) A deemed initial enrollment period established under paragraph (b)(1) of this section is used to determine the individual's premium and right to enroll in a general enrollment period if that is advantageous to the individual. (a) Except as specified in paragraph (b) of this section, the general enrollment period is January through March of each calendar year. (b) An unlimited general enrollment period existed between April 1 and September 30, 1981. Any eligible individual whose initial enrollment period had ended, or whose previous period of entitlement had terminated, could have enrolled or reenrolled during any month of that 6-month period. (a) Who is automatically enrolled. An individual is automatically enrolled for SMI if he or she: (1) Resides in the United States, except in Puerto Rico; (2) Becomes entitled to hospital insurance under any of the provisions set forth in §§406.10 through 406.15 of this chapter; and (3) Does not decline SMI enrollment. (b) Opportunity to decline automatic enrollment. (1) SSA will notify an individual that he or she is automatically enrolled under paragraph (a) of this section and grant the individual a specified period (at least 2 months after the month the notice is mailed) to decline enrollment. (2) The individual may decline enrollment by submitting to SSA or CMS a signed statement that he or she does not wish SMI. (3) The statement must be submitted before entitlement begins, or if later, within the time limits set in the notice of enrollment. (a) An individual who is automatically enrolled in SMI under §407.17 will have the month of enrollment determined in accordance with paragraphs (b) through (f) of this section. The month of enrollment determines the month of entitlement. (b) An individual is automatically enrolled in the third month of the initial enrollment period if he or she— (1) Is entitled to social security benefits under section 202 of the Act on the first day of the initial enrollment period; (2) Is entitled to hospital insurance based on end-stage renal disease; on entitlement to disability benefits as a social security or railroad retirement beneficiary; or on deemed entitlement to disability benefits on the basis of Medicare-qualified government employment; or (3) Establishes entitlement to hospital insurance by filing an application and meeting all other requirements (as set forth in subpart B of part 406 of this chapter) during the first 3 months of the initial enrollment period. (c) If an individual establishes entitlement to hospital insurance on the basis of an application filed in the last 4 months of the SMI initial enrollment period, he or she is automatically enrolled for SMI in the month in which the application is filed. (d) If an individual establishes entitlement to hospital insurance on the basis of an application filed after the SMI initial enrollment period but not during a general enrollment period in effect before April 1, 1981, or after September 30, 1981, he or she is automatically enrolled for SMI on the first day of the next general enrollment period. (e) If the individual establishes entitlement to hospital insurance on the basis of an application filed during a SMI general enrollment period in effect before April 1, 1981 or after September 30, 1981, he or she is automatically enrolled on the first day of that period. (f) If an individual established entitlement to hospital insurance on the basis of an application filed during the general enrollment period of April 1, 1981, through September 30, 1981, he or she was automatically enrolled for SMI on the first day of the month in which the application was filed. (a) Terminology—(1) Group health plan (GHP) and large group health plan (LGHP). These terms have the meanings given them in §411.101 of this chapter except that the “former employee” language of those definitions does not apply with respect to SEPs for the reasons specified in §406.24(a)(3) of this chapter. (2) Special enrollment period (SEP). This term has the meaning set forth in §406.24(a)(4) of this chapter. In order to use a SEP, an individual must meet the conditions of paragraph (b) and of paragraph (c) or (d) of this section, as appropriate. (b) General rule. All individuals must meet the following conditions: (1) They are eligible to enroll for SMI on the basis of age or disability, but not on the basis of end-stage renal disease. (2) When first eligible for SMI coverage (4th month of their initial enrollment period), they were covered under a GHP or LGHP on the basis of current employment status or, if not so covered, they enrolled in SMI during their initial enrollment period; and (3) For all months thereafter, they maintained coverage under either SMI or a GHP or LGHP. (Generally, if an individual fails to enroll in SMI during any available SEP, he or she is not entitled to any additional SEPs. However, if an individual fails to enroll during a SEP because coverage under the same or a different GHP or LGHP was restored before the end of that particular SEP, that failure to enroll does not preclude additional SEPs.) (c) Special rule: Individual age 65 or over. For an individual who is or was covered under a GHP, coverage must be by reason of the current employment status of the individual or the individual's spouse. (d) Special rules: Disabled individual.4 4 Under the current statute, the SEP provision applicable to disabled individuals covered under an LGHP expires on September 1998. Unless Congress changes that date, the last SEP available under those provisions will begin with June 1998. (1) For a disabled individual who is or was covered under a GHP, coverage must be on the basis of the current employment status of the individual or the individual's spouse. (2) For a disabled individual who is or was covered under an LGHP, coverage must be as follows: (i) Before August 10, 1993, as an “active individual”, that is, as an employee, employer, self-employed individual (such as the employer), individual associated with the employer in a business relationship, or as a member of the family of any of those persons. (ii) On or after August 10, 1993, by reason of current employment status of the individual or a member of the individual's family. (e) Effective date of coverage. The rule set forth in §406.24(d) for Medicare Part A applies equally to Medicare Part B. [61 FR 40346, Aug. 2, 1996] (a) A request for enrollment is required of an individual who meets the eligibility requirements of §407.10 and desires SMI, if the individual— (1) Is not entitled to hospital insurance; (2) Has previously declined enrollment in SMI; (3) Has had a previous period of SMI entitlement which terminated; (4) Resides in Puerto Rico or outside the United States; or (5) Is enrolling or reenrolling during a special enrollment period under §407.20. (b) A request for enrollment under paragraph (a) of this section must: (1) Be signed by the individual or someone acting in his or her behalf; and (2) Be filed with SSA or CMS during the initial enrollment period, a general enrollment period, or a special enrollment period as provided in §407.20. The following apply whether an individual is self-enrolled or automatically enrolled in SMI: (a) Enrollment during initial enrollment period. (1) If an individual enrolls during the first three months of the initial enrollment period, entitlement begins with the first month of eligibility. (2) If an individual enrolls during the fourth month of the initial enrollment period, entitlement begins with the following month. (3) If an individual enrolls during the fifth month of the initial enrollment period, entitlement begins with the second month after the month of enrollment. (4) If an individual enrolls in either of the last two months of the initial enrollment period, entitlement begins with the third month after the month of enrollment. (5) Example. An individual first meets the eligibility requirements for enrollment in April. The initial enrollment period is January through July. The month in which the individual enrolls determines the month that begins the period of entitlement, as follows: (b) Enrollment on reenrollment during general enrollment period. (1) if an individual enrolls or reenrolls during a general enrollment period before April 1, 1981 or after September 30, 1981, entitlement begins on July 1 of that calendar year. (2) If an individual enrolled or reenrolled during the general enrollment period between April 1, 1981 and September 20, 1981, entitlement began with the third month after the month in which the enrollment request was filed. (c) Enrollment or reenrollment during a SEP. The rules set forth in §406.24(d) of this chapter apply. [53 FR 47204, Nov. 22, 1988, as amended at 61 FR 40347, Aug. 2, 1996] An individual's entitlement will terminate for any of the following reasons: (a) Death. Entitlement to SMI ends on the last day of the month in which the individual dies. (b) Termination of hospital insurance benefits. If an individual's entitlement to hospital insurance ends before the month in which he or she attains age 65, entitlement to SMI will end on the same day unless it has been previously terminated in accordance with paragraph (c) or (d) of this section. (c) Request by individual. An individual may at any time give CMS or SSA written notice that he or she no longer wishes to participate in SMI, and request disenrollment. (1) Before July 1987, entitlement ended at the end of the calendar quarter after the quarter in which the individual filed the disenrollment request. (2) For disenrollment requests filed in or after July 1987, entitlement ends at the end of the month after the month in which the individual files the disenrollment request. (d) Nonpayment of premiums. If an individual fails to pay the premiums, entitlement will end as provided in the rules for SMI premiums, set forth in part 408 of this chapter. (a) Initial enrollment periods—(1) Individual under age 65. An individual who has not attained age 65 may have one or more periods of entitlement to hospital insurance, based on disability. Since each period of disability entitlement entitles the individual to hospital insurance and since entitlement to hospital insurance makes the individual eligible for SMI enrollment, an individual may have an SMI initial enrollment period for each continous period of entitlement to hospital insurance. (2) Individuals who have attained age 65. An individual who has attained age 65 may not have more than one initial enrollment period on the basis of age. However, if the individual develops ESRD after age 65, he or she may have another initial enrollment period based on meeting the requirements of §406.13 of this chapter. (b) Number of enrollments. There is no limitation on the number of enrollments. (c) Coverage under buy-in agreements. For purposes of paragraph (a) of this section, the continued enrollment of an individual following the end of coverage under a State buy-in agreement in considered an initial enrollment. If an individual's enrollment or nonenrollment in SMI is unintentional, inadvertent, or erroneous because of the error, misrepresentation, on inaction of a Federal employee or any person authorized by the Federal Government to act in its behalf, the Social Security Administration or CMS may take whatever action it determines is necessary to provide appropriate relief. The action may include: (a) Designation of a special initial or general enrollment period; (b) Designation of an entitlement period based on that enrollment period; (c) Adjustment of premiums; (d) Any combination of actions under paragraphs (a) through (c) of this section; or (e) Any other remedial action that may be necessary to correct or eliminate the effects of the error, misrepresentation, or inaction.
Title 42: Public Health
PART 407—SUPPLEMENTARY MEDICAL INSURANCE (SMI) ENROLLMENT AND ENTITLEMENT
Subpart B—Individual Enrollment and Entitlement for SMI
§ 407.10 Eligibility to enroll.
§ 407.11 Forms used to apply for enrollment under Medicare Part B.
§ 407.12 General enrollment provisions.
§ 407.14 Initial enrollment period.
§ 407.15 General enrollment period.
§ 407.17 Automatic enrollment.
§ 407.18 Determining month of automatic enrollment.
§ 407.20 Special enrollment period related to coverage under group health plans.
§ 407.22 Request for individual enrollment.
§ 407.25 Beginning of entitlement: Individual enrollment.
------------------------------------------------------------------------ Enrolls in initial enrollment period Entitlement begins on_------------------------------------------------------------------------January............................... April 1 (month eligibility requirements first met).February.............................. April 1.March................................. April 1.April................................. May 1 (month following month of enrollment).May................................... July 1 (second month after month of enrollment).June.................................. September 1 (third month after month of enrollment).July.................................. October 1 (third month after month of enrollment).------------------------------------------------------------------------
§ 407.27 Termination of entitlement: Individual enrollment.
§ 407.30 Limitations on enrollment.
§ 407.32 Prejudice to enrollment rights because of Federal Government misrepresentation, inaction, or error.
