TN 19 (03-93)
HI 00805.005 Eligibility for SMI
Sections 1836 and 1837 of the Social Security Act
Regulations 42 CFR 407.1 - 407.32
A. Policy - Requirements for eligibility
Subject to the limitations in C., below and in HI 00805.010, an individual is eligible to enroll for SMI if he/she meets either (or both) of the following requirements.
1. Entitlement to HI
If the individual is entitled to premium-free HI based on age, disability or end stage renal disease (ESRD), or is entitled to Premium-HI for the working disabled, he/she is eligible for SMI.
2. Alternate requirement
An individual is also eligible for SMI if he/she has attained age 65 and is a resident of the U.S., and is either:
a U.S. citizen, or
an alien lawfully admitted for permanent residence who has resided in the U.S. continuously for the 5-year period immediately preceding the month in which he/she effectively files for enrollment (i.e., the month when the alien will be entitled to SMI based on the enrollment request).
(Aliens lawfully admitted for permanent residence include special agricultural workers granted lawful temporary resident status. These workers, for all purposes other than immigration, must be considered as lawfully admitted for permanent residence under the Immigration Reform and Control Act of 1986.)
NOTE: The 5 years' continuous residence may begin prior to the date that the lawful admission for permanent residence is granted (e.g., where the original admission was illegal, or under color of law).
B. Policy - First month of eligibility for SMI
An individual's first month of eligibility for SMI is the month in which he/ she meets the requirements in A. above.
Where eligibility is based solely on entitlement to premium-free HI, the first month for which the individual is eligible for premium-free HI is the first month of eligibility for SMI.
The month of first eligibility for SMI is the fourth month of the initial enrollment period (IEP), which is explained in HI 00805.015.
NOTE: The first month of eligibility is not necessarily the first month of entitlement. The filing date controls the entitlement date.
C. Policy - Preclusion because of crimes against the U.S
An individual is not eligible for SMI if he/she has been convicted of a crime against the U.S. referred to in section 202(u) of the Act. (See HI 00801.086 for more information about preclusion because of such crimes.)
D. Policy - Additional considerations
1. Prescribed enrollment period
A person may enroll only during a prescribed enrollment period. (See HI 00805.010.)
2. No limit on number of enrollments
There is no limit on the number of times an individual may enroll and disenroll as long as the individual continues to meet the eligibility requirements for enrollment.
3. Earliest entitlement
For the earliest possible entitlement (coverage), an individual enrolls during the first 3 months of the IEP (i.e., during the 3 months before the first month of eligibility, as defined in B. above).
4. Prior enrollment
Eligibility need not be developed for a person previously enrolled who seeks to reenroll.
EXCEPTION: Eligibility must be developed if there is a basis for believing that the person is no longer eligible (e.g., he/she is a nonbeneficiary who has recently lived outside the U.S.).
5. Premium indebtedness
A person may reenroll even though he/she owes premiums for prior SMI coverage. (See HI 01001.345 concerning payment of past-due premiums for an earlier period of coverage.)
6. Monthly benefits are suspended
Non-coverage situations should not be confused with non-entitlement situations. For example, incarcerated felons whose social security benefits are suspended retain entitlement to monthly benefits and HI, as well as eligibility for SMI. Premiums must be paid to retain entitlement to SMI. However, health care services received while incarcerated may not be covered under Medicare due to the governmental entity exclusion. (See HI 00620.070C.)
U.S. residence, citizenship, and lawful admission for permanent residence, including the special agricultural workers' status, GN 00303.000.
When a former disability beneficiary can enroll for Premium-HI prior to age 65 and for SMI, as well, HI E00801.183.