approved under title XVI of the Social Security Act (see paragraph (b)(1) of this section) and the State has a plan approved under title XIX of the Social Security Act in effect as of December 31, 1973, the State's coverage group shall be deemed to consist of individuals who (i) receive supplemental security income under title XVI of the Social Security Act or State supplementary payments (as the term is used in section 1616(a) of the Social Security Act and in section 212 of Pub. L. 9366), and (ii) are categorically needy (as the term is used in 42 CFR 448.1) under the plan of such State approved under title XIX of the Social Security Act.

(2) Where the State's coverage group as of December 31, 1973, consists of individuals receiving money payments under the plans of the State approved under titles I, X, XIV, XVI, and part A of title IV of the Social Security Act (see paragraph (b)(2) of this section) and the State has a plan approved under title XIX in effect on December 31, 1973, the State's coverage group shall be deemed to consist of individuals who (i) receive supplemental security income under title XVI of the Social Security Act, or State supplementary payments (as the term is used in section 1616(a) of the Social Security Act and in section 212 of Pub. L. 93-66), or money payments under a plan of the State approved under part A of title IV of the Social Security Act, and (ii) are categorically needy (as the term is used in 42 CFR 448.1) under the plan of such State approved under title XIX of the Social Security Act.

(3) Where a State had an agreement as of December 31, 1973, but it had no plan approved under title XIX of the Social Security Act in effect on December 31, 1973, the State's coverage group shall be deemed to consist of individuals receiving supplemental security income under title XVI of the Social Security Act, State supplementary payments (as the term is used in section 1616(a) of the Social Security Act and in section 212 of Pub. L. 9366), or money payments under a plan of the State approved under Part A of title IV of the Social Security Act.

(4) For purposes of this section and § 405.222, an individual will be treated as receiving supplemental security income under title XVI of the Social Security Act or State supplementary payments if he receives or the State reports to the Social Security Administration in accordance with prescribed procedures that he receives such income or payments for January 1974 or for any month thereafter.

(5) For purposes of this section and § 405.222, an individual will be treated as categorically needy (as the term is used in 42 CFR 448.1) under a plan of the State approved under title XIX of the Social Security Act, if, for January 1974, or for any month thereafter, he has been determined or the State reports to the Social Security Administration in accordance with prescribed procedures that he has been determined to be categorically needy under such plan.

(h) Where a State's agreement has not been modified, pursuant to a request made by it before 1970, to provide that individuals entitled to monthly benefits under title II of the Social Security Act or entitled to receive an annuity or pension under the Railroad Retirement Act of 1937, as amended, shall be members of the coverage group, such State shall be deemed to have so modified its coverage group, except with respect to individuals receiving money payments under a plan of the State approved under Part A of title IV of the Social Security Act, effective with the month following the effective date of these amendments to regulations.

(i) Except as provided in paragraph (c) of this section, any individual is inIcluded in the State's coverage group for any month after August 1972 and before July 1975 if: (1) For August 1972 he was eligible for money payments under any of the plans of the State included in the coverage group of the State under its agreement under this section, and was eligible for medical assistance under a plan of the State approved under title XIX of the Social Security Act, and was entitled to monthly insurance benefits under title II of the Social Security Act; and (2) for such month after August 1972 and before July 1975 the individual

would have been eligible for such money payments had the 20 percent increase in monthly insurance benefits under title II of the Social Security Act provided by Pub. L. 92-336 not been applicable for such individual and, in the case of the fifty States and the District of Columbia after December 31, 1973, had the plan of such state approved under titles I, X, IV, and XVI continued in effect.

[36 FR 16647, Aug. 25, 1971, as amended by 40 FR 43211, Sept. 19, 1975. Redesignated at 42 FR 52826, Sept. 30, 1977]

§ 405.220 Coverage period; general.

Payment is made under the supplementary medical insurance plan only for covered expenses incurred during an individual's "coverage period." Subject to the provision that an individual's coverage period continues through the month of death or until such earlier time as his enrollment is terminated, an individual's coverage period begins and terminates as described in §§ 405.221 and 405.223 (a) and (b) or, in the case of an individual enrolled pursuant to a State agreement, in accordance with the provisions of §§ 405.222 and 405.223 (c) and (d).

§ 405.221 Individual enrollment; coverage period beginning date.

An individual's "coverage period" can begin no earlier than July 1, 1966, and begins on a day as determined in accordance with this section (or in the case of an individual enrolled pursuant to a State agreement, in accordance with the provisions of § 405.222):

(a) Enrollment during initial enrollment period; first eligibility before March 1966. (1) The coverage period of an individual who first meets the eligibility requirements for enrollment (see § 405.205) prior to March 1966, and who enrolls during his initial enrollment period of September 1965 through May 1966, begins on July 1, 1966.

(2) The coverage period of an individual who first meets the eligibility enrollment requirements for (see § 405.205) prior to March 1966, who fails to enroll prior to June 1966, but who is authorized to enroll at a subsequent time not later than September

30, 1966, under the "good cause" provisions described in § 405.224, begins on the first day of the 6th month after the month in which he so enrolls.

(b) Enrollment during initial enrollment period; first eligibility in March 1966. (1) The coverage period of an individual who first meets the eligibility requirements for enrollment during the month of March 1966, and who enrolls before June 1966, begins on July 1, 1966.

(2) The coverage period of an individual who first meets the eligibility requirements for enrollment during March 1966, and who enrolls during the month of June 1966, begins on September 1, 1966.

(c) Enrollment during initial enrollment period; first eligibility after March 1966. The coverage period of an individual who first meets the eligibility requirements for enrollment after March 1966, and who enrolls during his initial enrollment period (including a deemed initial enrollment period under the provisions of § 405.212(e)), begins on whichever is later, July 1, 1966, or the first day of:

(1) The month in which the eligibility requirements are first met, if he enrolls during the 3 preceding months; (2) The month following the month in which the eligibility requirements are first met, if he enrolls in the month such requirements are first met;

(3) The third month following the month in which the eligibility requirements are first met, if he enrolls in the month following the month in which such requirements are first met;

(4) The fifth month following the month in which the eligibility requirements are first met, if he enrolls in the second month following the month in which such requirements are first met; (5) The sixth month following the month in which the eligibility requirements are first met, if he enrolls in the third month following the month such requirements are first met.

Example. An individual first meets the eligibility requirements for enrollment in April of 1967. Therefore, his initial enrollment period runs from January through July 1967. Depending upon the month in which he enrolls, his coverage period will begin as follows:

(4) April............

(5) May.

(6) June

(7) July.

Do. Do.

May 1 (month following month eligibility requirements first met). July 1 (third month following month eligibility

requirements first met). September 1 (fifth month following month eligibility requirements first met). October 1 (sixth month following month eligibilty requirements first met).

(d) Enrollment during general enrollment period. The coverage period of an individual who enrolls after his initial or deemed initial enrollment period or reenrolls during a general enrollment period applicable in his case (see §§ 405.213 and 405.214) begins on July 1 following the month in which he so enrolls, or reenrolls.

(e) Enrollment between December 1, 1972, and August 31, 1973, inclusive. An individual who is enrolled for supplementary medical insurance between December 1, 1972, and August 31, 1973, inclusive, pursuant

to

§ 405.213(b) will have supplementary medical insurance coverage beginning on the same date as his premium hospital insurance coverage unless his supplementary medical insurance coverage would begin earlier under paragraph (c) or (d) of this section.

[36 FR 16647, Aug. 25, 1971, as amended at 40 FR 18166, Apr. 25, 1975. Redesignated at 42 FR 52826, Sept. 30, 1977]

§ 405.222 Enrollment pursuant to a State agreement; coverage period beginning date.

The coverage period of an individual enrolled pursuant to an agreement with a State under the provisions set forth in § 405.217 begins (without regard to any prior enrollment or termination of enrollment) on whichever of the following is the latest:

(a) July 1, 1966;

(b) The first day of the third month following the month in which the State agreement is entered into (or in the case of individuals covered by virtue of a modification described in § 405.217(c) (1) or (2), as of the first day of the third month following the

month such modification is entered into);

(c) The first day of the first month in which he is both an eligible individual (see § 405.205) and a member of the coverage group that is specified in such agreement, except that, if an individual is a member of such group solely by virtue of a modification described in § 405.217(c)(2) (i.e., he does not receive money payments under a plan of the State approved under titles I, X, XIV, XVI or part A of title IV; is not both receiving supplemental security income under title XVI or State supplementary payments and determined to be categorically needy (as the term is used in 42 CFR 448.1) under the plan of the State approved under title XIX; and he is not included in the coverage group by virtue of § 405.217(h)), his coverage period may not begin before the first day of the second month following the month in which he is both an eligible individual and the State has made the determination (without regard to the retroactivity of such determination) that he is eligible to receive medical assistance under the plan of such State approved under title XIX of the Social Security Act, or

(d) Such date as may be specified in the agreement, or, where the individual is covered by virtue of a modification described in § 405.217(c), as may be specified in such modification.

[36 FR 16647, Aug. 25, 1971, as amended at 40 FR 43212, Sept. 19, 1975. Redesignated at 42 FR 52826, Sept. 30, 1977]

§ 405.223 Individual enrollments; State enrollments; manner and time of termination of enrollment and coverage period.

Subject to the provision that an individual's coverage period attributable to a State agreement may be terminated only as provided in paragraph (c) of this section and is not subject to termination by the individual, an enrollment and the coverage period may be terminated only as described in this section:

(a) Individual requests termination. An individual may at any time after September 1967 notify the Social Security Administration or the Health Care Financing Administration in

writing that he no longer wishes to participate in the supplementary medical insurance plan. In such case, his enrollment and coverage period terminate effective with the close of the calendar quarter following the calendar quarter in which such notice is submitted to the Social Security Administration or the Health Care Financing Administration except that:

(1) Where such notice is submitted during the period October through December 1967, such individual's enrollment and coverage period shall terminate on December 31, 1967;

(2) Where such notice is submitted during the period January through March 1968, such individual's enrollment and coverage period shall terminate on March 31, 1968;

(3) Where an individual entitled to monthly benefits under title II of the Act or to an annuity or pension under the Railroad Retirement Act of 1937, whose coverage attributable to a Federal-State agreement containing the provisions described in § 405.217(c) is terminated or who ceases to be a member of the coverage group before his coverage under such agreement begins, files a written notice with the Social Security Administration or the Health Care Financing Administration before the first day of the fourth month which begins after the date of . ich termination, his coverage period is terminated effective with the last day of the third month which begins after the date his coverage period under a Federal-State agreement is terminated.

(b) Nonpayment of premiums. Enrollment under the supplementary medical insurance plan shall be terminated because of nonpayment of premiums. In such case, an individual's enrollment and coverage period is terminated at such time as is provided in Subpart I of this part.

(c) Enrollees pursuant to State agreement. In the case of an individual enrolled pursuant to a Federal-State agreement (see § 405.217), the coverage period attributable to the agreement terminates (subject to the provisions of paragraph (d) of this section) on:

(1) The last day of the last month for which he is eligible for inclusion in the coverage group provided that,

where the State makes the determination of ineligibility, the State sends notice to the Social Security Administration of such ineligibility within a reasonable time. Such notice shall be given in such form and in accordance with such instructions as prescribed by the Health Care Financing Administration. The notice is considered to be given within a reasonable period of time if the Social Security Administration receives such notice by the 25th day of the second month after the calendar month in which the individual becomes ineligible for inclusion in the coverage group or, where the individual's State enrollment coverage period began on the basis of a Social Security Administration determination and the State makes the determination of ineligibility after receiving notice from the Social Security Administration through the buy-in data exchange system that the individual is no longer receiving supplemental security income or Federally-administered State supplementary payments, by the 25th day of the second month after the calendar month in which the Social Security Administration so notifies the State. If, however, the Social Security Administration first receives prescribed notice of ineligibility from the State after such reasonable period of time, the individual's coverage attributable to the buy-in agreement will, instead, end on the last day of the second month before the month in which the Social Security Administration receives such notice and, for such purpose, notice received in a calendar month but after the 25th day of that month shall be deemed to have been received in the next following month. (2) If earlier than paragraph (c)(1) of this section, whichever of the following first occurs:

(i) The last day of the month preceding the first month in which the individual became entitled to monthly benefits under title II of the Social Security Act (see Subpart D of 20 CFR Part 404) or to an annuity or pension under the Railroad Retirement Act of 1937 without regard to the retroactivity of such entitlement unless the State agreement provides for the inclusion of such individuals entitled to such benefits in the coverage group, or

(ii) The last day of the month as of which the State agreement is terminated, or

(iii) The last day of the month in which he dies, or

(iv) If he is under 65, the last day of the last month for which he is entitled to hospital insurance benefits.

(d) Continuation of enrollees' coverage period pursuant to State agreements. Notwithstanding the provisions of paragraph (c) of this section, if an individual's coverage pursuant to enrollment under a State agreement is terminated under the provisions of paragraph (c) of this section, such individual is deemed to have enrolled for supplementary medical insurance benefits in the initial enrollment period described in § 405.212(b) and his coverage period continues until terminated for his failure to pay premiums or by his written notice to the Social Security Administration or the Health Care Financing Administration that he wishes to terminate his supplementary medical insurance coverage, as provided in paragraphs (a) and (b) of this section. An individual who is enrolled under a State agreement but who ceases to be a member of the coverage group before his coverage begins is also deemed to have so enrolled and his coverage as an individual begins on the date his coverage under the agreement would have begun had he continued in the coverage group.

(e) Termination of hospital insurance before individual attains age 65. If an enrollee's hospital insurance entitlement terminates before the month in which he attains age 65, his medical insurance coverage period, if it has not previously ended pursuant to paragraph (a) or (b) of this section, will terminate on the same date as his hospital insurance entitlement § 405.103(b)).

(see

[36 FR 16647, Aug. 25, 1971, as amended at 40 FR 18166, Apr. 25, 1975; 40 FR 43212, Sept. 19, 1975. Redesignated at 42 FR 52826, Sept. 30, 1977]

§ 405.224 Good cause for failure to enroll during the initial enrollment period ending May 31, 1966.

An individual who first meets the eligibility requirements for enrollment prior to March 1, 1966, and who fails

to enroll during the initial enrollment period ending May 31, 1966, may enroll at any time before October 1966 if such individual, or his representative, establishes to the satisfaction of the Social Security Administration that "good cause" exists because such failure was due to:

(a) Circumstances beyond the individual's control, such as extended illness, mental or physical impairment, communication difficulties;

(b) Incorrect or incomplete information furnished by official sources to the individual or another person acting on his behalf;

(c) Difficulty encountered by the individual in obtaining, within a reasonable time before the end of the initial enrollment period, an enrollment form and information about supplementary medical insurance and the manner and time limit in which enrollments may be made;

(d) Bona fide unawareness or misunderstanding of the need to enroll within the prescribed time period or of the nature of coverage under this Subpart B; or

(e) Other circumstances (as a result of which the individual was deterred fron enrolling) in the light of which it would be clearly inequitable to deny him a second chance to enroll.

§ 405.226 Equitable relief for individual whose enrollment rights have been prejudiced by government misrepresentation, inaction or error.

Notwithstanding any other provision of this subpart or Subpart I of this part, in any case where it is established that an individual's enrollment or nonenrollment in the supplementary medical insurance plan or in the hospital insurance plan pursuant to section 1818 of the Social Security Act, is unintentional, inadvertent, or erroneous, and is the result of the error, misrepresentation or inaction of an officer, employee, or agent of the Federal Government or its instrumentalities, the Social Security Administration may provide equitable relief to correct or eliminate the effects of such prejudicial misrepresentation, inaction, or error. Such equitable relief may include, but is not limited to, designation of a special initial or subse