24

2.

governing the Federal Hospital Insurance Trust Fund) and replace the two Medicare programs with a single, comprehensive health insurance program for the aged and for

those persons who are disabled and presently covered for purposes of Medicare.

Entitlement and Duration of Entitlement

a. Present Law

Under Section 226 of the Social Security Act, Hospital
Insurance benefits are provided for an individual who is
age 65 or over and who is entitled to monthly Old Age or
Survivors Insurance benefits under Section 20223 of Title
II of the Social Security Act or who is a "qualified rail-
24
road retirement beneficiary. Entitlement to Hospital

Insurance benefits begins with the first day of the month
in which he reaches age 65 and ends with the month he
ceases to be entitled to social security section 202
benefits or ceases to be a qualified railroad retirement
25
beneficiary. In the case of an individual who is not

or ceases to be entitled to social security 202 cash
benefits and is not or ceases to be a qualified railroad
retirement beneficiary, entitlement to Hospital Insurance
benefits will depend upon his meeting the requirements

23 Not included are transitionally insured or uninsured persons age 72 and over who are entitled to special monthly cash benefits under Soc. Sec. Act §§227, 228.

24 Soc. Sec. Act $8226 (a)(1).

25 But see, Soc. Sec. Act §§226 (c) (2) under which an individual will be deemed entitled to social security 202 benefits or qualified railroad retirement beneficiary status for purposes of Hospital Insurance entitlement for the month in which he died if he would have otherwise been so entitled.

for "transitional entitlement"26 or, failing that, the

requirements for voluntary enrollment.

27

An uninsured individual will be deemed entitled to social security 202 benefits for purposes of entitlement to Hospital Insurance benefits (transitional entitlement) provided he attained the age of 65 before 1968 or attained the age of 65 after 1967 and has not less than three social security or railroad retirement quarters of coverage for each year elapsing after 1966 and before the year in which he reached age 65. Hospital insurance protection begins with the month in which the requirements are met and ends with the month before the first month in which the individual is entitled to social security 202 benefits, or becomes certifiable as a qualified railroad retirement beneficiary, or with the month of his death.

28

Hospital insurance is available to an individual under the age of 65 who has been entitled for not less than 24 consecutive months to social security or railroad retirement benefits on the basis of a disability. In this case, Hospital Insurance protection would begin with the 25th consecutive month of entitlement to social security or railroad retirement disability benefits or July, 1973 whichever is later. Entitlement continues until the end of the month following the month in which notice of

26 See Soc. Sec. Amendments of 1965, §§103, Pub. L. 89-97. 27 Soc. Sec. Act $81818.

28 Soc. Sec. Act §§226 (b).

termination of disability status is mailed or, with the

end of the month before the month of attainment of age
29

65, whichever is earlier.

Hospital Insurance benefits are also available to

an individual under age 65 and medically determined to
have chronic renal disease and to require hemodialysis
or renal transplantation, who is either fully or currently
insured for social security benefits or entitled to
monthly social security benefits or is the spouse or

dependent child of an individual who is so insured or
30

so entitled.

Eligibility begins with the third month

after the month in which a course of renal dialysis is initiated and ends with the twelfth month after the month in which the individual has a renal transplant or the

course of dialysis is terminated.

31

Finally, Hospital Insurance protection is available

on a voluntary basis to an individual who is 65 or over,
and not otherwise entitled under the regular or transi-
32
tional provisions of the law? However, he must be a
resident of the United States, a citizen of the United
States or an alien lawfully admitted for permanent

residence who has continuously resided here for not less 29See Soc. Sec. Act §§226 (b) under which the individual will be deemed entitled to social security or railroad retirement disability benefits for purposes of Hospital Insurance entitlement for the month in which he died if he would have otherwise been so entitled.

30Soc. Sec. Act §§226 (e).

31Soc. Sec. Act $8226 (f) [Pub. L. 92-603, section 2991, redesig

nated subsection (e) as subsection (f) and added new subsections (e), (f) and (g) resulting in more than one subsection (f)]. 32Soc. Sec. Act §§1818.

than five years immediately preceeding the month of ap-
In addition, he must also be enrolled under

plication.

the Supplementary Medical Insurance program. In general,
the provisions governing enrollment and coverage under
the Supplementary Medical Insurance program are also
applicable to enrollment in the Hospital Insurance pro-
gram. 33

An individual eligible to enroll in the Supplementary Medical Insurance program or deemed to have automatically enrolled is limited to an individual entitled to Hospital Insurance benefits or to one age 65 or over who is a resident of the United States and a citizen of the United States or an alien lawfully admitted for permanent residence or a resident for a five year period immediately preceeding the month of application.34

Except in the case of enrollment under a federalstate agreement, an individual may enroll in the Supplementary Medical Insurance program, only during an enrollment period. In the case of an individual meeting the enrollment requirements before March 1, 1966, the "ini

tial general enrollment period" began on September 1,

33 However, the "initial general enrollment period "for an individual meeting the eligibility requirements before June 1, 1973 began on December 1, 1972 and ended August 31, 1973. The coverage period for an individual enrolling for Hospital Insurance benefits during this period began with the month following the month of enrollment, July, 1973, or the month in which the eligibility requirements were met.

34While no one could become entitled to Supplementary Medical Insurance benefits before July, 1973 without enrolling in the program, as of July, 1973, an individual entitled to Hospital Insurance benefits would be automatically enrolled and covered for Supplementary Medical Insurance benefits, unless he indicated that he did not wish to be enrolled for such coverage.

- 28

1965 and ended May 31, 1966.

Otherwise, the "initial

enrollment period" for an individual begins with the third
month before the month in which the eligibility require-
ments are met and ends seven months later. In the case
of an individual who failed to enroll in the "initial
general enrollment period" or in his "initial enrollment
period" or in the case of an individual who wants to re-
35

enroll, there was "a general enrollment period" from

October 1, 1967, to March 31, 1968, and beginning with
1969 there was and will be a general enrollment period
from July 1 to March 31 of each year.

In the case of an individual who voluntarily enrolls, or is automatically enrolled in the Supplemental Medical Insurance program, coverage begins in accordance with the provisions of Section 1837 of the Social Security Act, but in no event before July 1, 1966 (or July 1, 1973 in the case of a disabled individual).

Entitlement to benefits under the Supplementary

Medical Insurance program continues until the individual's
enrollment is terminated. Such termination will be ef-
fected by the death of the individual, the filing of a
termination notice, or as a result of non-payment of pre-
miums, whichever first occurs. The termination of cover-
age by notice will take effect at the close of the

35Under Soc. Sec. Act $1837 (b) no individual may enroll more
than twice.