Sec. 406.26 Prejudice to enrollment rights because of Federal Government error. Subpart D-Special Circumstances that Affect Entitlement to Hospital Insurance 406.30 Nonpayment of benefits on behalf of certain aliens. 406.31 Conviction of subversive activities. AUTHORITY: Secs. 202(t), 202(u), 226, 226A, 1102, 1818, and 1871 of the Social Security Act (42 U.S.C. 402(t) 402(u), 426, 426–1, 1302, 13951-2, and 1395hh) and 3103 of Pub. L. 8997 (42 U.S.C. 426a) unless otherwised noted. SOURCE: 48 FR 12536, Mar. 25, 1983, unless otherwise noted. Redesignated at 51 FR 41338, Nov. 14, 1986. Subpart A-Hospital Insurance Eligibility and Entitlement: General Provisions § 406.1 Statutory basis. Sections 226, 226A, and 1818 of the Social Security Act and section 103 of Pub. L. 89-97 establish the conditions for entitlement to hospital insurance benefits. Sections 202 (t) and (u) of the Act specify limitations that apply to certain aliens and to persons convicted of certain offenses. § 406.2 Scope. Subparts A through D of this part specify the conditions of eligibility for hospital insurance and set forth certain specific conditions that affect entitlement to benefits. Hospital insurance is authorized under Part A of Title XVIII and is also referred to as Medicare Part A. It includes inpatient hospital care, posthospital SNF care, home health services, and hospice care. [48 FR 56026, Dec. 16, 1983, as amended at 50 FR 33033, Aug. 16, 1985. Redesignated and amended at 51 FR 41338, Nov. 14, 1986] § 406.3 Definitions. First month of eligibility means the first month in which an individual meets all the requirements for entitlement to hospital insurance except application or enrollment if that is required. First month of entitlement means the first month for which the individ ual meets all the requirements for entitlement to Part A benefits. Insured individual means an individual who has the number of quarters of coverage required for monthly social security benefits. Quarter of coverage means a calendar quarter that is counted toward the number of covered quarters required to make the individual eligible for monthly social security benefits. A quarter is counted if during that quarter (or that calendar year) the individual earned a required minimum amount of money. (For details, see 20 CFR part 404, subpart B.) § 406.5 Basis of eligibility and entitlement. (a) Hospital insurance without premiums. Hospital insurance is available to most individuals without payment of a premium if they: (1) Are age 65 or over, or (2) Have received social security or railroad retirement disability benefits for 25 months; or (3) Have end-stage renal disease. Subpart B of this part explains the requirements such individuals must meet to obtain hospital insurance without premiums. (b) Premium hospital insurance. Many individuals who are age 65 or over, but do not meet the requirements set forth in subpart B of this part, may obtain the benefits by paying a premium. Section 406.20 of this part explains the requirements individuals must meet to obtain premium hospital insurance. [48 FR 12536, Mar. 25, 1983, as amended at 50 FR 33033, Aug. 16, 1985] § 406.6 Application or enrollment for hospital insurance. (a) Basic provision. In most cases, eligibility for Medicare Part A is a result of entitlement to monthly social security or railroad retirement cash benefits or eligibility for monthly social security cash benefits. This section specifies the individuals who need not file an application to become entitled to hospital insurance, those who must file an application, and those who must enroll. (b) Individuals who need not file an application for hospital insurance. An individual who is already entitled to monthly social security or railroad retirement benefits when he or she attains age 65 or who establishes entitlement to those benefits after age 65 need not file a separate application to become entitled to hospital insurance. (See 20 CFR part 404, subpart D for eligibility requirements for social security cash benefits, and Subpart G for requirements for filing applications for cash benefits.) (c) Individuals who must file an application for hospital insurance. An individual must file an application for hospital insurance if he or she seeks entitlement to hospital insurance on the basis of— (1) The transitional provisions set forth in § 406.11; (2) Deemed entitlement to disabled widow's or widower's benefit under certain circumstances as provided in § 406.12; (3) A diagnosis of end-stage renal disease, as specified in § 406.13; (4) Effective January 1, 1981, eligibility for social security cash benefits, as specified in § 406.10(a)(3), if the individual has attained age 65 without applying for those benefits; or (5) The special provisions applicable to government employment as set forth in § 406.15. (d) When application is deemed to be filed. (1) An application based on the transitional provisions or on ESRD is deemed to be filed in the first month of eligibility if it is filed not more than 3 months before the first month, and is retroactive to that month if filed within 12 months after the first month. An application filed more than 12 months after the first month of eligibility is retroactive to the 12th month before the month it is filed. (2) An application for deemed entitlement to disabled widow's or widower's benefits, that is filed before the first month in which the individual meets all conditions of entitlement for this benefit, will be deemed a valid application if those conditions are met before an initial determination, reconsideration, or hearing decision is made on the application. If the conditions are met after the date of any hearing decision, a new application will have to be filed. An application validly filed within 12 months after the first month of eligibility is retroactive to that first month. If filed more than 12 months after that first month, it is retroactive to the 12th month before the month of filing. (3) Effective June 8, 1980, an application based on eligibility for social security benefits at or after age 65, that is filed before the first month in which the individual meets all eligibility conditions for this benefit, will be deemed a valid application if those conditions are met before an initial determination, reconsideration, or hearing decision is made on the application. If the conditions are met after the date of any hearing decision, a new application will have to be filed. (4) Effective March 1, 1981, an application under § 406.10 that is validly filed within 6 months after the first month of eligibility is retroactive to that first month. If filed more than 6 months after that first month, it is retroactive to the 6th month before the month of filing. (e) Individuals who must enroll for hospital insurance. An individual who must pay a monthly premium for hospital insurance must enroll in accordance with the procedures set forth in § 406.21. [48 FR 12536, Mar. 25, 1983, as amended at 50 FR 33033, Aug. 16, 1985; 53 FR 47202, Nov. 22, 1988] § 406.7 Forms to apply for entitlement under Medicare Part A. The following forms, available free of charge by mail from HCFA or at any Social Security branch or district office, are used to apply for Medicare entitlement under the circumstances indicated: HCFA-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.) HCFA-43-Application for Health Insurance Benefits under Medicare for Individuals with End Stage Renal Disease (ESRD). (An initial application for entitlement by individuals with ESRD). Sec. 406.26 Prejudice to enrollment rights because of Federal Government error. Subpart D-Special Circumstances that Affect Entitlement to Hospital Insurance 406.30 Nonpayment of benefits on behalf of certain aliens. 406.31 Conviction of subversive activities. AUTHORITY: Secs. 202(t), 202(u), 226, 226A, 1102, 1818, and 1871 of the Social Security Act (42 U.S.C. 402(t) 402(u), 426, 426–1, 1302, 13951-2, and 1395hh) and 3103 of Pub. L. 8997 (42 U.S.C. 426a) unless otherwised noted. SOURCE: 48 FR 12536, Mar. 25, 1983, unless otherwise noted. Redesignated at 51 FR 41338, Nov. 14, 1986. Subpart A-Hospital Insurance Eligibility and Entitlement: General Provisions § 406.1 Statutory basis. Sections 226, 226A, and 1818 of the Social Security Act and section 103 of Pub. L. 89-97 establish the conditions for entitlement to hospital insurance benefits. Sections 202 (t) and (u) of the Act specify limitations that apply to certain aliens and to persons convicted of certain offenses. § 406.2 Scope. Subparts A through D of this part specify the conditions of eligibility for hospital insurance and set forth certain specific conditions that affect entitlement to benefits. Hospital insurance is authorized under Part A of Title XVIII and is also referred to as Medicare Part A. It includes inpatient hospital care, posthospital SNF care, home health services, and hospice care. [48 FR 56026, Dec. 16, 1983, as amended at 50 FR 33033, Aug. 16, 1985. Redesignated and amended at 51 FR 41338, Nov. 14, 1986] 8 406.3 Definitions. First month of eligibility means the first month in which an individual meets all the requirements for entitlement to hospital insurance except application or enrollment if that is required. First month of entitlement means the first month for which the individ ual meets all the requirements for entitlement to Part A benefits. Insured individual means an individual who has the number of quarters of coverage required for monthly social security benefits. Quarter of coverage means a calendar quarter that is counted toward the number of covered quarters required to make the individual eligible for monthly social security benefits. A quarter is counted if during that quarter (or that calendar year) the individual earned a required minimum amount of money. (For details, see 20 CFR part 404, subpart B.) § 406.5 Basis of eligibility and entitlement. (a) Hospital insurance without premiums. Hospital insurance is available to most individuals without payment of a premium if they: (1) Are age 65 or over, or (2) Have received social security or railroad retirement disability benefits for 25 months; or (3) Have end-stage renal disease. Subpart B of this part explains the requirements such individuals must meet to obtain hospital insurance without premiums. (b) Premium hospital insurance. Many individuals who are age 65 or over, but do not meet the requirements set forth in subpart B of this part, may obtain the benefits by paying a premium. Section 406.20 of this part explains the requirements individuals must meet to obtain premium hospital insurance. [48 FR 12536, Mar. 25, 1983, as amended at 50 FR 33033, Aug. 16, 1985] § 406.6 Application or enrollment for hospital insurance. (a) Basic provision. In most cases, eligibility for Medicare Part A is a result of entitlement to monthly social security or railroad retirement cash benefits or eligibility for monthly social security cash benefits. This section specifies the individuals who need not file an application to become entitled to hospital insurance, those who must file an application, and those who must enroll. (b) Individuals who need not file an application for hospital insurance. An individual who is already entitled to monthly social security or railroad retirement benefits when he or she attains age 65 or who establishes entitlement to those benefits after age 65 need not file a separate application to become entitled to hospital insurance. (See 20 CFR part 404, subpart D for eligibility requirements for social security cash benefits, and Subpart G for requirements for filing applications for cash benefits.) (c) Individuals who must file an application for hospital insurance. An individual must file an application for hospital insurance if he or she seeks entitlement to hospital insurance on the basis of (1) The transitional provisions set forth in § 406.11; (2) Deemed entitlement to disabled widow's or widower's benefit under certain circumstances as provided in § 406.12; (3) A diagnosis of end-stage renal disease, as specified in § 406.13; (4) Effective January 1, 1981, eligibility for social security cash benefits, as specified in § 406.10(a)(3), if the individual has attained age 65 without applying for those benefits; or (5) The special provisions applicable to government employment as set forth in § 406.15. (d) When application is deemed to be filed. (1) An application based on the transitional provisions or on ESRD is deemed to be filed in the first month of eligibility if it is filed not more than 3 months before the first month, and is retroactive to that month if filed within 12 months after the first month. An application filed more than 12 months after the first month of eligibility is retroactive to the 12th month before the month it is filed. (2) An application for deemed entitlement to disabled widow's or widower's benefits, that is filed before the first month in which the individual meets all conditions of entitlement for this benefit, will be deemed a valid application if those conditions are met before an initial determination, reconsideration, or hearing decision is made on the application. If the conditions are met after the date of any hearing decision, a new application will have to be filed. An application validly filed within 12 months after the first month of eligibility is retroactive to that first month. If filed more than 12 months after that first month, it is retroactive to the 12th month before the month of filing. (3) Effective June 8, 1980, an application based on eligibility for social security benefits at or after age 65, that is filed before the first month in which the individual meets all eligibility conditions for this benefit, will be deemed a valid application if those conditions are met before an initial determination, reconsideration, or hearing decision is made on the application. If the conditions are met after the date of any hearing decision, a new application will have to be filed. (4) Effective March 1, 1981, an application under § 406.10 that is validly filed within 6 months after the first month of eligibility is retroactive to that first month. If filed more than 6 months after that first month, it is retroactive to the 6th month before the month of filing. (e) Individuals who must enroll for hospital insurance. An individual who must pay a monthly premium for hospital insurance must enroll in accordance with the procedures set forth in § 406.21. [48 FR 12536, Mar. 25, 1983, as amended at 50 FR 33033, Aug. 16, 1985; 53 FR 47202, Nov. 22, 1988] § 406.7 Forms to apply for entitlement under Medicare Part A. The following forms, available free of charge by mail from HCFA or at any Social Security branch or district office, are used to apply for Medicare entitlement under the circumstances indicated: HCFA-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.) HCFA-43-Application for Health Insurance Benefits under Medicare for Individuals with End Stage Renal Disease (ESRD). (An initial application for entitlement by individuals with ESRD). As an alternative, an individual may use the application for monthly social benefits to apply also for Medicare entitlement if he or she is eligible for hospital insurance at that time. [53 FR 6633, Mar. 2, 1988] Subpart B-Hospital Insurance Without Premiums § 406.10 Individual age 65 or over who is entitled to social security or railroad retirement benefits, or who is eligible for social security benefits. (a) Requirements. An individual is entitled to hospital insurance benefits under section 226 of the Act if he or she has attained aged 65 and is: (1) Entitled to monthly social security benefits under section 202 of the Social Security Act; (2) A qualified railroad retirement beneficiary who has been certified as such to the Social Security Administration by the Railroad Retirement Board in accordance with section 7(d) of the Railroad Retirement Act of 1974; or (3) Effective January 1, 1981, eligible for monthly social security benefits under section 202 of the Act and has filed an application for hospital insurance. (b) Beginning and end of entitlement. (1) Entitlement begins with the first day of the first month in which the individual meets the requirements of paragraph (a) of this section. (2) Entitlement continues until the individual dies or no longer meets the requirements of paragraph (a) of this section. An individual is not entitled to railroad retirement benefits and is neither entitled to, nor eligible for, monthly social security benefits in the month in which he or she dies. However, an individual who meets all other requirements for hospital insurance entitlement is entitled to hospital insurance in the month in which he or she dies if he or she (i) Would have been entitled to monthly railroad retirement benefits or social security benefits in that month if he or she had not died; or (ii) Has filed an application for hospital insurance and would have been eligible for monthly social security benefits in that month if he or she had not died. § 406.11 Individual age 65 or over who is not eligible as a social security or railroad retirement benefits beneficiary, or on the basis of government employment. (a) Basis. Section 103 of the law that established the Medicare program in 1965 (Pub. L. 89-97) provided for eligibility for certain individuals who were age 65 or would soon attain age 65 but would not be able to qualify for social security or railroad retirement benefits. (b) Requirements. Unless he or she is excluded under paragraph (c) of this section, an individual age 65 or over who does not meet the requirements of § 406.10 or § 406.15 (and who would not meet those requirements if he or she filed an application), is entitled to Medicare Part A benefits if he or she meets the following requirements: (1) Age and quarters of coverage. (i) He or she attained age 65 before 1968; or (ii) If he or she attained age 65 in 1968 or later, he or she must have at least 3 quarters of coverage for each year that elapsed after 1966 and before the year in which he or she attained age 65. (The quarters of coverage may have been acquired at any time, not necessarily during the elapsed years.) (2) Residence and citizenship. He or she is a resident of the United States and (i) A citizen of the United States; or (ii) An alien lawfully admitted for permanent residence who has continuously resided in the United States for 5 years immediately preceding the first month in which he or she meets all other requirements for entitlement to hospital insurance. (3) Application. He or she has filed an application for Medicare Part A no earlier than the third month before the first month of eligibility. (c) Bases for exclusion. An individual who meets the requirements of paragraph (b) of this section is excluded from Medicare Part A if he or she (1) Has been convicted of spying, sabotage, or treason, sedition, and sub |