CMS Pub. 100-01, ch. 2
Table of Contents (Rev. 12046, 05-18-23)
10 - Hospital Insurance Entitlement 10.1 - Insured Status 10.2 - Hospital Insurance for the Aged 10.3 - Hospital Insurance for Disability Beneficiaries 10.4 - Hospital Insurance for Persons Needing Kidney Transplant or Dialysis 10.4.1 - Effective Date of Entitlement for Persons on Dialysis 10.4.2 - Entitlement Based on Transplant 10.4.3 - Effect on Self-dialysis Training on Entitlement 10.4.4 - End of Coverage Based on ESRD 10.4.5 - Reentitlement for Beneficiaries with ESRD 20 - Hospital Insurance Obtained by Premium Payment 20.1 - Eligibility Requirements 20.2 - Premiums for Hospital Insurance 20.2.1 - Premiums Paid by Other Than Enrollee 20.2.1.1 - Part A Buy-in States 20.2.1.2 - Part A Group Payer States 20.3 - Beginning of Coverage 20.3.1 - Initial Enrollment Period (IEP) 20.3.2 - General Enrollment Period (GEP) 30 - End of Coverage for Hospital Insurance 40 - Supplementary Medical Insurance (SMI) 40.1 - Eligibility for Enrollment 40.2 - Automatic Enrollment in SMI 40.3 - Enrollment Periods 40.3.1 - Enrollment During the Individual's Initial Enrollment Period
40.9.6 - Termination of Part B-ID
40.9.7 - Part B-ID Premiums
40.9.8 - Procedure for Termination of Part B-ID
40.9.9 - Medicare Savings Programs for Part B-ID Premiums
50 - Identifying the Patient's Health Insurance Record Using the Medicare Card
50.1 - Medicare Beneficiary Identifier (MBI)
60 - Medicare Part C, Medicare+Choice
(Rev. 1, 09-11-02)
Hospital insurance (HI), as well as supplementary medical insurance (SMI), is available to three basic groups of 'insured individuals'- the aged, the disabled, and those with end stage renal disease. Following is an explanation of how an individual becomes 'insured' as well as an explanation of the eligibility requirements for each group.
(Rev. 1, 09-11-02)
To be eligible for premium-free HI, an individual must be 'insured' based on his or her own earnings or those of a spouse, parent, or child. To be insured, the worker must have a specific number of quarters of coverage (QCs); the exact number required is dependent upon whether the person is filing for HI on the basis of age, disability, or end stage renal disease. QCs are earned through payment of payroll taxes under the Federal Insurance Contributions Act (FICA) during the person's working years. QCs earned by an individual who pays the full FICA tax are usable to insure the person for both monthly social security benefits and HI.
Federal employees were exempt from payment of FICA taxes prior to January 1983. However, beginning in January 1983, Federal employees became subject to the HI portion of the FICA tax (those actually employed in January 1983 were also deemed to have earned HI quarters of coverage for their Federal service prior to January 1983). Also, Government employees who pay only the HI portion of the FICA tax are only insured for HI; they are not insured for monthly social security benefits.
State and local Government employees hired after March 31, 1986, are eligible for Medicare coverage and must pay the HI portion of the FICA tax. A State may elect to cover employees hired prior to April 1986 for the Medicare portion of the FICA tax by requesting an agreement or modification of its existing agreement under section 218 of the Social Security Act.
(Rev. 1, 09-11-02)
To be eligible for HI on the basis of age, a person must be age 65 or older and either eligible for monthly social security or railroad retirement cash benefits, or would be eligible for such benefits if the worker's Government QCs were regular social security QCs. An individual who is insured for monthly benefits need not actually file for benefits to receive HI benefits. If such a person continues to work beyond age 65, he or she may instead elect to file an application for HI only.
Premium-free HI for the aged begins with the month in which the individual attains age 65, provided he or she files an application for HI or for cash benefits and HI within 6 months of the month in which he or she attains age 65. If the application is filed later
than that, HI entitlement can be retroactive for only 6 months. An individual attains age 65 on the day before his or her 65th birthday. For example, if an individual is born on August 1, the attainment date is July 31, and HI begins with July 1. Entitlement generally does not end until death.
A disabled person who is entitled to social security or railroad retirement benefits on the basis of disability is automatically entitled to HI after 24 months of entitlement to such benefits. Since there is a 5-month disability benefits waiting period, the person actually becomes entitled to HI after being disabled for 29 months.
In addition, disabled persons who are not insured for monthly Social Security disability benefits but would be insured for such benefits if Government QCs were treated as social security QCs, are deemed to be entitled to disability benefits and automatically entitled to HI after being disabled for 29 months.
The months in the Medicare qualifying period need not be consecutive so that months from a previous period of disability benefit entitlement generally may be counted in determining when the qualifying period requirement is met. HI entitlement on the basis of disability is available not only to the worker, but to the widow, widower, or child of a deceased, disabled, or retired worker if any of them become disabled within the meaning of the Social Security or Railroad Retirement Acts.
If an individual recovers from a disability, HI entitlement ends with the month after the month he or she is notified of the disability termination. For example, if notification is November 15, entitlement ends December 31. However, if the individual's disability benefit entitlement ends only because he or she was working, HI entitlement may continue for up to 78 additional months.
Individuals of any age with end stage renal disease (ESRD) who receive dialysis on a regular basis or a kidney transplant are eligible for HI (and are deemed enrolled for Supplementary Medical Insurance (SMI) unless such coverage is refused) if they file an application. They must also meet certain work requirements for insured status under the social security or railroad retirement programs, or be entitled to monthly social security benefits or an annuity under the Railroad Retirement Act, or be the spouse or dependent child of an insured or entitled person.
Entitlement usually begins after a 3-month waiting period has been served, i.e., with the first day of the third month after the month in which a course of regular dialysis begins. Entitlement begins before the waiting period has expired if the individual receives a transplant or participates in a self-dialysis training program during the waiting period.
(Rev. 1, 09-11-02)
Entitlement begins with the month the individual is admitted as an inpatient to a hospital for procedures in preparation for or in anticipation of a kidney transplant, provided the transplant surgery takes place within the following 2 months. If the transplant is delayed more than 2 months after the preparatory hospitalization, entitlement begins with the second month prior to the month of transplant. Under the Medicare, Medicaid, and State Children's Health Insurance Program (SCHIP) Benefits Improvement and Protection Act of 2000, Congress extended immunosuppressive drug benefits to lifetime, as long as the beneficiary is entitled to Medicare and was entitled to Medicare when his/her transplant took place.
(Rev. 1, 09-11-02)
Entitlement begins with the first month of the course of dialysis if the individual is expected to complete the self-dialysis training program and self-dialyze thereafter.
(Rev. 1, 09-11-02)
HI coverage based on ESRD ends with the earliest of the following dates:
(Rev. 1, 09-11-02)
If a person whose entitlement based on ESRD has ended begins a new course of regular dialysis or has a kidney transplant, reentitlement begins without a waiting period.
(Rev. 1, 09-11-02)
(Rev. 1, 09-11-02)
Individuals who want hospital insurance coverage but who are not otherwise eligible (i.e., do not qualify under either the regular or deemed insured provisions, in §§10.1, 10.2, 10.3, 10.4 in this chapter) may obtain such coverage by enrolling timely, paying a monthly premium, and upon meeting the following three requirements:
(Rev. 1, 09-11-02)
Each year, the Secretary of the Department of Health and Human Services announces the amount of the hospital insurance premium payable for each month in the following calendar year. The applicable premium amount is 33/76 (about 43.4 percent) of the hospital insurance deductible for that calendar year. The premium is rounded to the nearest $1. An individual who is not entitled to free Part A and wishes this type of coverage must enroll him/herself during the appropriate enrollment period. A premium is due for each month of entitlement under Premium HI.
(Rev. 11764; Issued 12-22-22; Implementation: 01-01-2023; Effective 01-03-23)
The following subsections describe Medicare Part A premiums paid by other than the enrollee.
(Rev .11764; Issued 12-22-22; Implementation: 01-01-2023; Effective 01-03-23)
States that include the payment of Medicare Part A premiums for Qualifying Medicare Beneficiaries (QMBs) in their state buy-in agreements are known as Part A buy-in states. Individuals in Part A buy-in states can file for Premium Part A at any time, without regard to enrollment periods. Late enrollment penalties do not apply. Please see the Manual for State Payment of Medicare Premiums, chapter 1, sections 1.7 and 1.11 for additional information about Part A buy-in states.
(Rev. 11764; Issued 12-22-22; Implementation: 01-01-2023; Effective 01-03-23)
States that do not include the payment of Medicare Part A premiums for QMBs in their state buy-in agreements are known as group payer states. To become entitled to Part A, individuals in group payer states can file for premium Part A during their Initial Enrollment Period (IEP) or the General Enrollment Period (GEP). Part A premiums and any applicable late enrollment penalties are paid under a group payer arrangement. Please see the Manual for State Payment of Medicare Premiums, chapter 1, section 1.7 and 1.11 for additional information about Part A group payer states.
(Rev. 1, 09-11-02)
(Rev. 1, 09-11-02)
Persons may enroll for premium hospital insurance by filing a request during the IEP which begins the third month before the month of first eligibility and lasts for 7 months. The individual's IEP for premium hospital insurance is in most cases the same 7-month period as the IEP for SMI.
The individual may enroll for hospital insurance when he or she enrolls for SMI, or later during his or her IEP. The beginning date of an individual's premium hospital insurance coverage period is determined by the rules applicable to SMI coverage based on an SMI enrollment during an IEP. (See chapter 2 §40 in this chapter.)
(Rev. 1, 09-11-02)
Eligible persons who have not enrolled for premium hospital insurance during their IEP, or whose premium hospital insurance has been terminated, may enroll during a GEP (January 1 - March 31 of each year) if they are enrolling or have enrolled for SMI. As with SMI, an eligible person who enrolls for hospital insurance during a GEP will have hospital insurance coverage beginning the following July.
The same restrictions on enrollment and reenrollment apply as in the SMI program. Individuals who enroll late may pay a 10 percent premium penalty.
(Rev. 1, 09-11-02)
A beneficiary's entitlement under the provision terminates:
(Rev. 1, 09-11-02)
Unlike the HI benefits program, which is largely financed by compulsory taxes on employers, employees, and the self-employed, the SMI benefits program is a voluntary program financed from premium payments by enrollees, together with contributions from funds appropriated by the Federal Government, and certain deductible and cost-sharing provisions.
(Rev. 1, 09-11-02)
To obtain SMI coverage, eligible individuals must enroll in the plan during an enrollment period open to them and pay the required premiums. They are eligible to enroll if they are entitled to premium-free HI, or are age 65 and resident citizens or resident aliens. To qualify as a resident alien, an individual must have been lawfully admitted for permanent residence and have resided continuously in the United States during the 5 years immediately preceding the month of enrollment.
(Rev. 1, 09-11-02)
Beneficiaries (except those residing in foreign countries or Puerto Rico) are deemed to have enrolled in SMI in the month before the month for which they are entitled to HI so that HI and SMI coverage start in the same month. Thus, monthly beneficiaries other than disability beneficiaries are deemed to enroll in the month before attainment of age 65. Disability beneficiaries are deemed to enroll in the 24th consecutive month of entitlement to disability benefits.
Every potential "deemed" enrollee is given a reasonable opportunity (at least 2 months) to decline SMI enrollment by filing notice to this effect. He or she is deemed not to have enrolled and does not incur any premium liability. A refusal of SMI not timely filed is
treated as a request for voluntary termination under existing disenrollment rules once it has been established that the individual does not wish to have SMI.
(Rev. 12046, Issued:05-18-23, Effective:01-01-23, Implementation:06-21-23)
Enrollment is possible only during specified enrollment periods:
(Rev. 12046, Issued:05-18-23, Effective:01-01-23, Implementation:06-21-23)
Coverage begins on the first day of:
(Rev. 12046, Issued:05-18-23, Effective:01-01-23, Implementation:06-21-23)
Coverage begins the first day of the month following the month of enrollment.
(Rev. 12046, Issued:05-18-23, Effective:01-01-23, Implementation:06-21-23)
If an individual enrolls in SMI or premium HI while still covered under a GHP or LGHP or during the first full month when not enrolled in a GHP/LGHP based on current employment status, coverage begins either with:
If the individual enrolls during any of the 7 remaining months of the special enrollment period, coverage begins with the first day of the month following the month of enrollment.
(Rev. 12046, Issued:05-18-23, Effective:01-01-23, Implementation:06-21-23)
Individuals who do not enroll in Part B or Premium Part A when first eligible because they were performing volunteer service outside of the United States may enroll during this SEP.
Eligible Individuals may enroll if:
The SEP for volunteers is the 6-month period that begins the earlier of the first day of the month following the month for which the:
Coverage begins the first day of the month following enrollment.
(Rev. 12046, Issued:05-18-23, Effective:01-01-23, Implementation:06-21-23)
Individuals who enroll in Part A based on disability or ESRD, but do not enroll in Part B because they were eligible for TRICARE standard or TRICARE prime, may enroll during this SEP. Eligible individuals are those who are:
A military retiree or military retiree family member, or
On active duty or a family member of an active duty service member with Medicare based on ESRD.
Eligible individuals may enroll:
Coverage begins:
If notified of Medicare entitlement during the IEP:
If notified of Medicare entitlement after the IEP:
If entitlement is based on ESRD, coverage begins:
(Rev. 12046, Issued:05-18-23, Effective:01-01-23, Implementation:06-21-23)
Individuals entitled to Medicare Part A based on disability, but who did not enroll in Part B because Medicare was the secondary payer for covered services, may enroll using this 7-month SEP.
Eligible individuals may enroll with the later of:
Coverage begins either:
(Rev. 12046, Issued:05-18-23, Effective:01-01-23, Implementation:06-21-23)
Effective January 1, 2023, the following SEPs for exceptional conditions are available for Premium Part A and Part B, respectively.
(Rev. 12046, Issued:05-18-23, Effective:01-01-23, Implementation:06-21-23)
Individuals who do not enroll in Part B or Premium Part A when first eligible due to having an emergency or disaster as declared by a federal, state, or local government entity may enroll during this SEP.
Eligible Individuals may enroll as early as:
NOTE: they may also be able to use this SEP if the disaster or emergency takes place where their authorized representative, legal guardian, or person who makes health care decisions on their behalf resides.
The SEP begins the date an emergency or disaster is declared, or the start date identified in the emergency declaration, whichever is earlier. The SEP ends six months after the end of the date which is the later of:
Coverage begins the first day of the month following enrollment.
(Rev. 12046, Issued:05-18-23, Effective:01-01-23, Implementation:06-21-23)
Individuals who do not enroll in Part B or Premium Part A when first eligible due to misrepresentation or reliance on incorrect information provided by their employer or GHP, agents or brokers of health plans, or any person authorized to act on behalf of such entity may enroll during this SEP.
An eligible person must demonstrate (by documentation or written attestation) both of the following:
The SEP begins the day an individual notifies the Social Security Administration and ends six months later.
Coverage begins the first day of the month following enrollment.
(Rev. 12046, Issued:05-18-23, Effective:01-01-23, Implementation:06-21-23)
Individuals who do not enroll in Part B or Premium Part A when first eligible because they were incarcerated may enroll during the SEP.
An eligible person can sign up anytime within the 12 months after their release from incarceration.
The SEP begins the day an individual is released from the custody of penal authorities. However, individuals have the option to select a retroactive effective date (not to begin prior to their release date and not to exceed 6 months). If individuals choose this retroactive option, they will be responsible for paying Medicare premiums back to the date of coverage.
Coverage begins the first day of the month following enrollment or up to six months retroactive.
(Rev. 12046, Issued:05-18-23, Effective:01-01-23, Implementation:06-21-23)
Individuals whose Medicaid eligibility terminated may enroll during this SEP.
A person may be eligible based on this condition if they have:
The SEP begins when an individual is notified of an upcoming termination of Medicaid eligibility and ends six months after the Medicaid termination. Medicare benefits start the month after Medicare enrollment unless the individual elects a start date back to the first
day of the month the individual lost Medicaid and agrees to pay all prior premiums.
Note: Individuals who are still eligible for Medicaid, including a Medicare Savings Program, and have not received notice of an upcoming Medicaid termination are not eligible for this SEP.
(Rev. 12046, Issued:05-18-23, Effective:01-01-23, Implementation:06-21-23)
Individuals who do not enroll in Part B or Premium Part A when first eligible because conditions beyond their control caused them to miss an enrollment period may enroll during the SEP. This SEP is available for individuals whose unique conditions do not qualify for other SEPs.
An eligible person must demonstrate (by documentation or written attestation) that conditions outside of their control that occurred on or after January 1, 2023, caused them to miss an enrollment period.
An individual’s request for this SEP will only be granted in conditions that are truly exceptional in nature, and will not be used to grant individual’s enrollment due to forgetfulness, lack of knowledge, or failure to make premium payments.
SSA will determine when this SEP begins on a case-by-case basis, but the SEP will end no less than 6 months after it begins.
Coverage begins the first day of the month following enrollment.
(Rev. 11764; Issued 12-22-22; Implementation: 01-01-2023; Effective 01-03-23)
Under the State Buy-in program, states, the District of Columbia, and the U.S. territories may enter into buy-in agreements with CMS to enroll certain individuals who are dually eligible for Medicare and Medicaid into Medicare Part B and pay the premiums on their behalf.
Most states have expanded their buy-in agreements to also include payments of Part A premiums for individuals who must pay a premium to enroll in Medicare Part A and who are eligible for the Qualified Medicare Beneficiary (QMB) eligibility group. State buy-in agreements maximize the number of full-benefit Medicaid recipients enrolled in Medicare, which ensures that Medicare pays primary to Medicaid. State buy-in agreements also facilitate enrollment in Medicare for low income individuals who are not eligible for full-benefit Medicaid coverage by paying Medicare premiums and cost sharing. Please see the Manual for State Payment of Medicare Premiums, chapter 1, section 1.2 for additional state buy-in information.
(Rev. 1, 09-11-02)
An individual may notify CMS in writing, at any time, that he or she no longer wishes to participate in the supplementary medical insurance plan. Termination of coverage takes effect at the close of the calendar month following the calendar month in which the request for termination was filed.
Enrollment under medical insurance is terminated because of nonpayment of premiums. Termination is effective with the end of the grace period provided for payment of premiums. (See chapter 2, §40.7.4 of this manual.)
For individuals under age 65, enrollment is terminated because HI entitlement ended. SMI terminates at the same time as HI.
If not terminated sooner, coverage ends with the beneficiary's death.
(Rev. 1, 09-11-02)
An individual whose enrollment has terminated may reenroll only in a general enrollment period or a special enrollment period if the requirements are met.
(Rev. 1, 09-11-02)
A premium is due for each month of entitlement under SMI. The SMI premium covers about one-fourth of the cost of the Part B program.
(Rev. 1, 09-11-02)
In the third quarter of each calendar year, the Secretary of the Department of Health and Human Services announces the base premium for SMI coverage that is payable as of the following January 1. The SMI premium is the same for all enrollees even though the cost to the program is greater for ESRD enrollees and the disabled than it is for the aged. The SMI premium is refigured each year and is based on the lower of one-half of SMI program costs per aged enrollee or the general percentage by which social security benefits were increased during the calendar year in which the announcement occurs. (During the 5-year period, January 1984 through December 1988, the formula for computing the SMI premium has been modified to provide that the Part B premium reflects exactly one-fourth of the cost of the Part B program. Beginning with the premium announced for the period beginning January 1989, however, the method of computing the SMI premium reverts back to the pre-January 1984 rules.)
The base premium that is announced by the Secretary is paid by most enrollees. However, it is increased for those who enroll late or reenroll after a prior termination of entitlement. The amount of the increase is 10 percent of the base rate for each full 12-month period during which the individual could have been but was not enrolled in the program. However, months in which an individual has GHP coverage based on current employment status are not counted as months in which the individual 'could have been, but was not enrolled.' This exception does not apply to individuals who are entitled to Medicare on the basis of ESRD.
SMI premiums are collected from benefits payable (in order of priority) by the Railroad Retirement Board, SSA, or Office of Personnel Management (Civil Service) unless the individual is covered under a State buy-in agreement. If the individual is entitled to such benefits but the payments are in suspense, e.g., due to work deductions, he or she is billed for the amounts due. Uninsured beneficiaries are also billed directly for the premiums due.
Premium bills are sent every 3 months unless the individual specifically requests a monthly bill or is also entitled to Premium - HI (in which case a monthly combined SMI-Premium-HI bill is sent).
A grace period has been provided for payment of premiums by those who are billed directly. The period extends for 90 days after the month in which the bill is mailed. If the premiums are not received in that prescribed time, entitlement terminates at the end of the grace period. This 90-day grace period for paying overdue SMI premiums and continuing SMI coverage may be extended by CMS for good cause for up to an additional 90 days. Good cause, for example, is found if the enrollee was mentally or physically incapable of paying his or her premiums timely, or had some reasonable basis to believe that payment had been made, or the failure to pay was due to administrative error.
If an extension to the grace period (additional 90 days; a total not to exceed 180 days) has been granted, an enrollee may retain SMI entitlement by paying all past due premiums if there was a good cause for his/her failure to pay premiums within the initial grace period.
(Rev. 1, 09-11-02)
The following subsections describe premiums paid by other than the enrollee.
(Rev. 1, 09-11-02)
Enrollees who are being billed directly for Medicare premiums may turn over their premium bills to a friend, relative, employer lodge, union or other organization to pay premiums on their behalf. The third party payer forwards the proper amount of payment for each enrollee to CMS's Premium Collection Center. Enrollees participating in this type of informal arrangement continue to receive their premium notice (Form CMS-500), and remain responsible for assuring that premiums paid on their behalf are paid timely in order to avoid termination of Medicare coverage.
(Rev. 1, 09-11-02)
Individuals may be designated as the premium payer for an enrollee and receive the enrollee's premium bills, if it is judged to be in the enrollee's best interest (e.g., the enrollee is competent, but too physically ill or infirm to be able to handle such matters). The individual receiving the premium bill must be a relative or friend showing personal interest in the welfare of the enrollee.
(Rev. 1, 09-11-02)
Employers, religious orders, lodges, unions or other organizations may enter into a formal agreement with CMS in order to receive a single bill and pay a lump sum for the premiums due from a group of individuals. Group payments under a formal group agreement may be made only on behalf of individuals who are already enrolled and are being billed for direct remittance. This type of arrangement is referred to as a "Formal Group Payer" arrangement. While included in a formal group payer arrangement, enrollees will no longer receive a premium notice (Form CMS-500). This arrangement is available only where the number of enrollees in the group is large enough to make it practicable to send one bill to the group payer and where the following conditions are also met:
The enrollee authorizes the formal group payer to pay premiums on his/her behalf;
The formal group payer has a minimum of 20 enrollees; and
If the formal group payer agreement is terminated, or if the group payer alerts CMS to remove an individual from the group payer arrangement, CMS will resume collection of premiums from the individual through the direct billing process.
(Rev. 1, 09-11-02)
States or local Governments may pay a lump sum for the total amount of the SMI late enrollment premium surcharge for a group of individuals. In order to pay the premium surcharge, States or local Governmental entities are required to enter into a formal agreement with CMS. An individual is not billed for the premium surcharge portion of his/her SMI premium while under a premium surcharge agreement, however, he/she is billed for the base premium amount. If the enrollee is receiving a Social Security, Railroad Retirement, or Civil Service annuity, the agencies responsible for these programs will continue to withhold the base premium amount from the annuity. Enrollees who are billed directly for premiums will continue to receive a premium bill for the base premium amount.
The ultimate responsibility for paying premiums rests with the enrollees.
(Rev. 12046, Issued:05-18-23, Effective:01-01-23, Implementation:06-21-23)
States pay the Part B premiums for any eligible individual specified in the state's buy-in agreement. Under buy-in agreements, states can enroll individuals in Part B at any time without regard to Medicare enrollment periods or late enrollment penalties. Please see the Manual for State Payment of Medicare Premiums, chapter 1, section 1.4 for additional information about state payment of premiums under a buy-in agreement.
(Rev. 12046, Issued:05-18-23, Effective:01-01-23, Implementation:06-21-23)
If an individual did not enroll in premium Part A when first eligible, they may have to pay a higher monthly premium if they decide to enroll later. The monthly premium for Part A may increase up to 10%. The individual will have to pay the higher premium for twice the number of years the individual could have had Part A, but did not sign up.
For individuals enrolling using the SEP Related to Coverage Under Group Health Plans, the premium Part A LEP is calculated by adding the months that have elapsed between the close of the individual's IEP and the end of the month in which the individual
enrolls. For enrollments after your IEP has ended, months where you had group health plan coverage are excluded from the LEP calculation.
For individuals enrolling using an Exceptional Conditions SEP, the International Volunteers SEP, or the SEP for Certain TRICARE Beneficiaries, no LEP will be applied.
(Rev. 12046, Issued:05-18-23, Effective:01-01-23, Implementation:06-21-23)
If an individual did not sign up for Part B when first eligible, the individual may have to pay a late enrollment penalty for as long as the individual has Medicare. The individual’s monthly premium for Part B may go up 10% for each full 12-month period that the individual could have had Part B, but did not sign up for it.
For individuals enrolling using the SEP Related to Coverage Under Group Health Plans, the Part B LEP is calculated by adding the months that have elapsed between the close of the individual’s IEP and the end of the month in which the individual enrolls. For enrollments after your IEP has ended, months where you had group health plan coverage are excluded from the LEP calculation.
For individuals enrolling using an Exceptional Conditions SEP, the International Volunteers SEP, or the SEP for Certain TRICARE Beneficiaries, no LEP will be applied.
For individuals enrolling using the D-SEP, the Part B LEP is calculated by adding all months during which the large group health plan (LGHP) was secondary payer beginning with the end of the IEP, or the date LGHP coverage began.
(Rev. 1, 09-11-02)
CMS and SSA are authorized to take necessary action to correct an erroneous SMI or premium hospital insurance enrollment or nonenrollment which was based upon the action, inaction, or error of a Government officer, employee, or agent. The action may include designating special individual enrollment periods and premium adjustments.
For the purpose of this provision, an individual's enrollment or nonenrollment in SMI is considered to have been prejudiced and due to the 'action, inaction, or error' of an officer, employee, or agent of the Government, if there is an official record or other evidence showing that:
The individual took reasonable appropriate and timely measures to assert his or her rights, and
Due to administrative fault or other action, which may or may not have been erroneous at the time taken, his or her rights have been or are likely to be impaired unless relief is given.
This authority applies to all Part B cases which have arisen since the Medicare program began on July 1, 1966. It is applied to cases that come to CMS's or SSA's attention; however, MACs should not search their files.
(Rev. 11646; Issued:10-19-22; Effective:01-01-23; Implementation:01-03-23)
The Consolidated Appropriations Act of 2021 amended section 1836(b) of the Social Security Act to add a new form of coverage that provides solely for coverage of immunosuppressive drugs beginning January 1, 2023, for eligible individuals whose entitlement to Medicare based on End-Stage Renal Disease (ESRD) ends the 36th month after the month in which the individuals receive a successful kidney transplant.
This new benefit is referred to as the Part B immunosuppressive drug benefit or "Part B-ID."
Beneficiaries enrolled in Part B-ID will not be covered for any other Medicare benefit or for any items or services other than Part B Immunosuppressive Drugs.
(Rev. 11764; Issued 12-22-22; Implementation: 01-01-2023; Effective 01-03-23)
An individual is eligible for Part B-ID if he or she:
1. Is or was entitled to Medicare Part A based on ESRD that ends 36 months after a successful kidney transplant; and
2. Attests that he or she is not enrolled in other health coverage that would make them ineligible for Part B-ID, as outlined in section 40.9.2. Every individual enrolling in Part B-ID must: i. Attest that they are not enrolled in other health coverage and do not expect to enroll in other coverage which would make them ineligible for Part B-ID; and ii. Agree to notify SSA within 60 days of enrolling in other health coverage.
NOTE: An individual can inform SSA of other health coverage up to 6 months in advance
(Rev. 11764; Issued 12-22-22; Implementation: 01-01-2023; Effective 01-03-23)
An individual who has other certain health coverage is not eligible for Part B-ID. Other health coverage includes:
(Rev. 11646; Issued:10-19-22; Effective:01-01-23; Implementation:01-03-23)
The effective date of an individual’s eligibility for the Part B-ID benefit depends on when their entitlement to Medicare Part A based on ESRD ends and when they submit the attestation described in section 40.9.1 of this chapter.
When an individual’s Medicare Part A entitlement based on ESRD ends on or after January 1, 2023:
When an individual’s Medicare Part A entitlement based on ESRD ends prior to January 1, 2023:
(Rev. 11764; Issued 12-22-22; Implementation: 01-01-2023; Effective 01-03-23)
There are no enrollment periods associated with Part B-ID. Therefore, eligible individuals can enroll at any time without regard to Medicare enrollment periods. The earliest date on which they may initially enroll depends on when their Medicare Part A entitlement based on ESRD ends, under the following two scenarios:
1. When an individual's Medicare Part A entitlement based on ESRD ends on or after January 1, 2023, they may enroll in Part B-ID any time after their Medicare Part A on the basis of ESRD entitlement ends.
2. When an individual's Medicare Part A entitlement based on ESRD ends prior to January 1, 2023, they may enroll in Part B-ID beginning October 1, 2022 and their coverage will start the later of January 2023 or the month after they enroll.
Individuals who had previously enrolled in Part B-ID can reenroll at any time if they meet the eligibility requirements in section 40.9.1.
NOTE: Late enrollment penalties are not applicable to Part B-ID enrollment. Additional information is outlined under subsection 40.9.7 (Part B-ID Premiums).
(Rev. 11764; Issued 12-22-22; Implementation: 01-01-2023; Effective 01-03-23)
Eligible individuals may enroll by:
1. calling SSA at 1-877-465-0355 and providing an oral attestation, or
2. completing and filing the Application for Enrollment in Part B-ID. Immunosuppressive Drug Coverage Form CMS-10798 and mailing it to the following address:
SOCIAL SECURITY ADMINISTRATION OFFICE OF CENTRAL OPERATIONS PO Box 32914 BALTIMORE, MARYLAND 21298
Note: The Office of Central Operations Office of Disability Operations teleservice center (ODO TSC) will only be handling the telephonic enrollments and PC 7 will process the enrollment for Part B-ID.
(Rev. 11646; Issued:10-19-22; Effective:01-01-23; Implementation:01-03-23)
1. Individuals enrolled in other health coverage are required to notify SSA and terminate Part B-ID a. When a Part B-ID covered individual notifies SSA that they have enrolled in other coverage, and if not otherwise specified, Part B-ID terminates effective with the first day of the month following the month SSA receives the notification.
b. If the individual states that their other health insurance begins in the future, the individual may request a termination date up to 6 months in the future.
Example: If an individual enrolls in employer health coverage during an employer's open enrollment period in October, for a January 1st effective date, the individual can submit their request for termination of the Part B-ID benefit in October or November, and not lose their Part B-ID benefit prior to the January 1st effective date.
c. When a state ends buy-in for Part B-ID because an individual gained full Medicaid eligibility that includes immunosuppressive drug coverage, the individual must report this new eligibility to SSA and terminate Part B-ID coverage.
If a Part B-ID covered individual fails to notify SSA of their enrollment in other health coverage, including employer and Medicaid, Part B-ID will terminate effective the first day of the month after the month in which SSA discovers the individual has other health coverage.
2. Voluntary termination request – In general, Part B-ID terminates effective with the first day of the month following the month in which we receive the request.
There is an exception to this general rule for individuals who had state payment of their Part B-ID premium under a Medicare Savings Program (as described in section 40.9.9) and who are notified by SSA that their state will no longer pay their Medicare Part B-ID premiums. For these individuals the following entitlement end dates apply:
a. If the individual files a voluntary termination request within 30 days after the date of the notice that state payment of premiums will end or has ended, the individual's Part B-ID entitlement ends on the last day of the last month for which the state paid the premium.
b. If the individual files the voluntary termination request more than 30 days but not more than 6 months after state payment of Medicare Part B-ID premiums ends, Part B-ID entitlement ends on the last day of the month in which the request is filed.
c. If the individual files the voluntary termination request later than the 6th month after state payment of Medicare Part B-ID premiums
ends, entitlement ends at the end of the month after the month in which request is filed.
We note that individuals who lose eligibility for state payment of Medicare Part B-ID premiums through a Medicare Savings Program will continue to be eligible for the Part B-ID benefit without interruption with the individual assuming responsibility for paying the Part B-ID premiums, unless they voluntarily terminate. The options for financial relief from Part B billing in SSA's Program Operations Manual System (POMS), section HI.00815.042, also apply for the Part B-ID coverage here.
3. Death - Entitlement to Part B-ID continues into the month of death, up to and including the date of death.
4. Non-payment of premiums – Part B-ID coverage will terminate for non-payment of premiums following the same rules, including grace periods, used for Medicare Part B for monthly billing in sections 40.5 and 40.7.4 of this manual. Note that section 40.5 provides end of coverage information, and section 40.7.4 provides grace period payment information.
5. Individual becomes entitled to Medicare on another basis – In cases where a Part B-ID enrollee becomes eligible for Medicare based on age, disability, or ESRD, Part B-ID will terminate effective with the last day of the month prior to the month in which they become entitled on the other basis. Equitable relief for retroactivity may apply.
(Rev. 11764; Issued 12-22-22; Implementation: 01-01-2023; Effective 01-03-23)
Part B-ID premiums may be adjusted based on rounding, the income-related monthly adjusted amounts (IRMAA), and the hold harmless provision, but will not be increased based on late enrollment.
If the individual is directly billed for premiums, billing will be on a monthly basis.
(Rev. 11764; Issued 12-22-22; Implementation: 01-01-2023; Effective 01-03-23)
Individuals enrolled in the Part B-ID benefit can report other coverage and request to terminate their enrollment by either:
1. calling SSA at 1-877-465-0355 to disenroll over the phone to verbally request termination, or
2. completing and submitting Form CMS-1763, Request for Termination of Premium Hospital and/or Supplementary Medical Insurance, and mailing it to:
SOCIAL SECURITY ADMINISTRATION OFFICE OF CENTRAL OPERATIONS
3. any other request to SSA that shows the unequivocal desire to end coverage.
Note: The Office of Central Operations Office of Disability Operations teleservice center (ODO TSC) only will handle the telephonic disenrollment and PC 7 will process the disenrollment for Part B-ID.
When the individual is reporting other coverage and choosing a future termination date, a termination effective date that is more than 6 months in the future cannot be processed
(Rev. 11764; Issued 12-22-22; Implementation: 01-01-2023; Effective 01-03-23)
Individuals enrolled in Part B-ID with limited income and resources may be eligible for assistance through the Medicare Savings Programs (MSPs). The MSPs include three eligibility groups that cover Part B-ID premiums and sometimes cost sharing, including:
There are two ways to enroll in the MSPs for the payment of the Part B-ID premiums. First, once enrolled in Part B-ID, individuals may apply for the MSPs and be determined eligible by their state for an MSP eligibility group based on Part B-ID.
Second, individuals who are enrolled in an MSP group and lose Medicare entitlement based on ESRD 36 months after the month in which they receive a kidney transplant can transition to an MSP based on Part B-ID enrollment without a break in coverage if: (1) they attest that they do not have other health coverage as described in 40.9.1 by the end of the 36th month after the month in which they receive a kidney transplant; and (2) the state redetermines the individual's Medicaid eligibility on all bases and does not otherwise find the individual ineligible for the MSP group.
(Rev. 124, Issued: 05-17-19, Effective: 06-18-19, Implementation: 06-18-19)
As part of health insurance electronic data processing, Medicare cards are issued by CMS to individuals who have established entitlement to health insurance.
Below is an example of the Medicare card.
New Medicare Card
You may be asked to show this card when you get health care services. Only give your personal Medicare information to health care providers, your insurers, or people you trust who work with Medicare on your behalf. WARNING: Intentionally misusing this card may be considered fraud and/or other violation of federal law and is punishable by law.
Es posible que le pidan que muestre esta tarjeta cuando reciba servicios de cuidado médico. Solamente dé su información personal de Medicare a los proveedores de salud, sus aseguradores o personas de su confianza que trabajan con Medicare en su nombre.
¡ADVERTENCIA! El mal uso intencional de esta tarjeta puede ser considerado como fraude y/u otra violación de la ley federal y es sancionada por la ley.
1-800-MEDICARE (1-800-633-4227 / TTY: 1-877-486-2048); Medicare.gov
The Medicare card is used to identify the individual as being entitled and also serves as a source of information required to process Medicare claims or bills. It displays the beneficiary's name, Medicare number, and effective date of entitlement to hospital insurance and/or medical insurance. The Social Security Administration's Social Security Office assists in replacing a lost or destroyed Medicare cards.
(Rev. 12046, Issued:05-18-23, Effective:01-01-23, Implementation:06-21-23)
The term Medicare beneficiary identifier (MBI) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.
Medicare Part C, which is also known as Medicare+Choice, is a Medicare program that gives beneficiaries more choices among health plans. Everyone who has Medicare Parts A and B is eligible, except those who have end stage renal disease, and were not in a Medicare+Choice plan at the onset of this condition.
Public Law 105-33, the Balanced Budget Act of 1997, establishes a new authority permitting contracts between CMS and a variety of different managed care and fee-for-service entities. The types of entities that may be granted contracts under this new authority include:
(PSOs). A PSO is defined as a public or private entity established by health care providers, which provide a substantial proportion of health care items and services directly through affiliated providers who share, directly or indirectly, substantial financial risk.
In addition to the Medicare+Choice contractors, beginning in January, 1999, up to 390,000 beneficiaries will have the choice (on a demonstration basis ending January 1, 2003) of enrolling in a Medical Savings Account (MSA) option. Under this option, beneficiaries would obtain high deductible health policies that pay for at least all Medicare-covered items and services after an enrollee meets the annual deductible of up to $6,000. The difference between the premiums for such high deductible policies and the applicable Medicare+Choice premium amount would be placed into an account for the beneficiary to use in meeting his or her deductible expenses.
Past 1876 Contracts - HMO/CMP risk plans that remain in compliance with current contracting standards and comply with new requirements established under this statutory authority automatically transitioned into the Part C Medicare+Choice program. Section 1876 risk-based contractors were paid under a new Medicare+Choice payment methodology rather than the prior method in section 1876(a), and were subject to certain other Medicare+Choice provisions. The Secretary no longer accepts new 1876 risk applications. As of January 1, 1999, existing 1876 risk-based contracts were terminated, and plans in good standing transitioned to the Medicare+Choice program.
Repeal of Cost Option - As of August 5, 1997, the Secretary is prohibited from entering into any new 1876 cost-based contracts, unless the plan is a Health Care Prepayment Plan with an agreement under section 1833 of the Social Security Act. The 1876 cost-based payment authority is repealed and all cost contracts are terminated as of December 31, 2002.
Limited HCPP Option - Beginning January 1, 1999, the Secretary may only contract with those HCPPs that are sponsored by Union or Employer groups, or HCPPs that do not "provide, or arrange for the provision of, any inpatient hospital services ..." This amendment will result in the termination of section 1833 agreements with any organization that does not meet the new definition. CMS will establish transition rules for 1876 risk-based contractors that currently receive reimbursement on a cost basis for enrollees remaining under a previous HCPP agreement.
For more information, see the Managed Care Manual.
| Rev # | Issue Date | Subject | Impl Date | CR# |
|---|---|---|---|---|
| R12046GI | 05/18/2023 | Update to the Internet Only Manual (IOM) Publication (Pub.) 100-01, IOM Chapter 2 Hospital Insurance and Supplementary Medical Insurance | 06/21/2023 | 13189 |
| R11764BP | 12/22/2022 | New Medicare Part B Immunosuppressant Drug Benefit (PBID) - Implementation | 01/03/2023 | 12804 |
| R11646GI | 10/19/2022 | New Medicare Part B Immunosuppressant Drug Benefit (PBID) – Implementation – Rescinded and Replaced by Transmittal 11764 | 01/03/2023 | 12804 |
| 07/28/2022 | New Medicare Part B Immunosuppressant Drug Benefit (PBID) – Implementation SENSITIVE/CONTOVERSIAL DO NOT POST- Rescinded and Replaced by Transmittal 11646 | 01/03/2023 | 12804 | |
| R124GI | 05/17/2019 | Update to Publication (Pub.) 100-01 to Provide Language-Only Changes for the New Medicare Card Project | 06/18/2019 | 11240 |
| R01MGI | 09/11/2002 | Initial Publication of Manual | NA | NA |
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