PART 406—HOSPITAL INSURANCE ELIGIBILITY AND ENTITLEMENT Authority: 42 U.S.C. 1302, 1395i-2, 1395i-2a, 1395p, 1395q and 1395hh. Source: 48 FR 12536, Mar. 25, 1983, unless otherwise noted. Redesignated at 51 FR 41338, Nov. 14, 1986. Subpart A—General Provisions § 406.1 Statutory basis. Sections 226, 226A, 1818 and 1818A of the Social Security Act and section 103 of Public Law 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. [48 FR 12536, Mar. 25, 1983. Redesignated at 51 FR 41338, Nov. 14, 1986, as amended at 56 FR 38078, Aug. 12, 1991] § 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 First month of entitlement Insured individual Quarter of coverage § 406.5 Basis of eligibility and entitlement. (a) Hospital insurance without premiums. (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. [48 FR 12536, Mar. 25, 1983, as amended at 50 FR 33033, Aug. 16, 1985; 56 FR 38078, Aug. 12, 1991] § 406.6 Application or enrollment for hospital insurance. (a) Basic provision. (b) Individuals who need not file an application for hospital insurance. (1) Is under age 65 and has been entitled, for more than 24 months, to monthly social security or railroad retirement benefits based on disability. (2) At the time of attainment of age 65, is entitled to monthly social security or railroad retirement benefits. (3) Establishes entitlement to monthly social security or railroad retirement benefits at any time after attaining age 65. (c) Individuals who must file an application for hospital insurance. (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. (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. [48 FR 12536, Mar. 25, 1983, as amended at 50 FR 33033, Aug. 16, 1985; 53 FR 47202, Nov. 22, 1988; 61 FR 40345, Aug. 2, 1996] § 406.7 Forms to apply for entitlement under Medicare Part A. Forms used to apply for Medicare entitlement are available free of charge by mail from CMS or at any Social Security branch or district office or online at the CMS and SSA websites. An individual who files an application for monthly social security cash benefits as defined in § 400.200 of this chapter also applies for Medicare entitlement if he or she is eligible for hospital insurance at that time. [87 FR 66503, Nov. 3, 2022] Subpart B—Hospital Insurance Without Monthly 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. (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. (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. (b) Requirements. (1) Age and quarters of coverage. (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. (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. (c) Bases for exclusion. (1) Has been convicted of spying, sabotage, or treason, sedition, and subversive action under chapter 37, 105, or 115 of title 18 of the United States Code; (2) Has been convicted of conspiracy to establish a dictatorship under section 4 of the Internal Security Act of 1950; (3) On February 16, 1965, was or could have been covered under the Federal Employees Health Benefits Act (FEHBA) of 1959; or (4) In his or her first month of eligibility; (i) Is covered by an enrollment under the FEHBA; or (ii) Could have been covered by an enrollment under that Act if he or she (or any other person who could provide him or her with coverage) was a Federal employee at any time after February 15, 1965, and had enrolled and retained coverage under that Act. (d) End of exclusion. (e) Beginning and end of entitlement. (i) In the first month of eligibility if the application is filed no later than 12 months after the first month of eligibility: (ii) In the 12th month before the month of application if the application is filed more than 12 months after the first month of eligibility. (2) Entitlement continues until death or until the month before the month in which the individual becomes entitled under § 406.10 or § 406.15. [48 FR 12536, Mar. 25, 1983, as amended at 50 FR 33033, Aug. 16, 1985; 53 FR 47202, Nov. 22, 1988] § 406.12 Individual under age 65 who is entitled to social security or railroad retirement disability benefits. (a) Basic requirements. (1) Entitled or deemed entitled to social security disability benefits as an insured individual, child, widow, or widower who is “under a disability” or (2) A disabled qualified beneficiary certified under Section 7(d) of the Railroad Retirement Act. (b) Previous periods of disability benefits entitlement. (1) Entitlement was as an insured individual or a disabled qualified railroad retirement beneficiary, and the previous period ended within the 60 months preceding the month in which the current disability began. (2) Entitlement was as a disabled child, widow, or widower, and the previous period ended within the 84 months preceding the month in which the current disability began. (3) The previous period ended on or after March 1, 1988 and the current impairment is the same as, or directly related to, the impairment on which the previous period of entitlement was based. (c) Deemed entitlement to disabled widow's or widower's monthly benefits Purpose. (i) To meet the 25-month requirement of paragraph (a) of this section; or (ii) To retain hospital insurance entitlement when they are no longer entitled to monthly disability benefits. (2) Deemed entitlement for certain individuals entitled to old-age insurance benefits. (3) Deemed entitlement for certain individuals entitled to mother's benefits. (4) Deemed entitlement for certain individuals entitled to father's benefits. (i) If he applied for hospital insurance benefits before May 1984, he was deemed entitled to disabled widower's benefits for any month after April 1981 for which he would have been entitled to those benefits if he had filed an application for them. (ii) If he applies for hospital insurance benefits in or after May 1984, he is deemed entitled to disabled widower's benefits for any month, up to 12 months before the month of application, for which he would have been entitled to those benefits if he had filed an application for them. (iii) Hospital insurance entitlement under this paragraph (c)(4) could not begin before May 1983. (5) Deemed retroactive entitlement for certain disabled widows and widowers. (d) When entitlement begins and ends. (2) Except as provided in paragraph (e) of this section, entitlement to hospital insurance ends with the earliest of the following: (i) The last day of the last month in which he or she was entitled or deemed entitled to disability benefits or was qualified as a disabled railroad retirement beneficiary, if he or she was notified of the termination of entitlement before that month. (ii) The last day of the month following the month in which he or she is mailed a notice that his or her entitlement or deemed entitlement to disability benefits, or his or her status as a qualified disabled railroad retirement beneficiary, has ended. (iii) The last day of the month before the month he or she attains age 65. (An individual who is entitled to social security or railroad retirement cash benefits for the month of attainment of age 65 is automatically entitled to hospital insurance under § 406.10.) (iv) The day of death. (e) Continuation of Medicare entitlement when disability benefit entitlement Definitions. Trial work period Reentitlement period (2) Duration of continued Medicare entitlement. (i) The last day of the 78th month following the first month of substantial gainful activity occurring after the 15th month of the individual's reentitlement period or, if later, the end of the month following the month the individual's disability benefit entitlement ends. (ii) The last day of the month following the month in which notice is mailed to the individual indicating that he or she is no longer entitled to hospital insurance because of an event or circumstance (for example, there has been medical improvement, or the disabled widow has remarried) that would terminate disability benefit entitlement if it had not already been terminated because of substantial gainful activity. [48 FR 12536, Mar. 25, 1983. Redesignated at 51 FR 41338, Nov. 14, 1986, as amended at 53 FR 47202, Nov. 22, 1988; 56 FR 38078, Aug. 12, 1991; 56 FR 50058, Oct. 3, 1991; 61 FR 40345, Aug. 2, 1996; 69 FR 57225, Sept. 24, 2004] § 406.13 Individual who has end-stage renal disease. (a) Statutory basis and applicability. (b) Definitions. End-stage renal disease Child spouse Dependent child (1) Is under age 22; (2) Is under a disability that began before age 22; or (3) Is under age 26, is receiving at least one-half support from that parent, and has continuously received at least one-half support from that parent since the day before attaining age 22. One-half support (c) Requirements. (1) He or she is medically determined to have ESRD; (2) He or she is: (i) Fully or currently insured under the social security program (title II of the Act) or would be fully or currently insured if his or her employment (after 1936) as defined under the Railroad Retirement Act were considered “employment” under the Social Security Act; (ii) Entitled to monthly social security or railroad retirement benefits; or (iii) The spouse or dependent child of a person who meets the requirements of paragraph (c)(2)(i) or (c)(2)(ii) of this section; (3) He or she has filed an application for Medicare Part A; and (4) He or she has satisfied the waiting period explained in paragraph (e) of this section. (d) Filing an application. (2) An application is not valid if it is filed earlier than the third month before the month in which the individual meets the conditions of paragraphs (c)(1), (c)(2), and (c)(4) of this section. (3) If an individual who has ESRD dies before he or she has filed an application, or is unable to file because of physical or mental condition, a relative or other person responsible for his or her affairs may file in his or her behalf. If a responsible person is not available, the hospital or dialysis facility that furnished treatment may file the application. (e) Beginning of entitlement Basic limitations. (2) Waiting period. (3) Exceptions: Early kidney transplant. (i) On the first day of the month in which he or she initially enters the hospital, if the transplant is performed in that month or in either of the next 2 months; or (ii) On the first day of the second month before the month of kidney transplantation, if the transplant is delayed more than 2 months after the month of initial hospital stay. For example, if an individual enters the hospital in January, and the transplant is performed in January, February, or March, entitlement would begin January 1. However, if the transplant is performed in April, entitlement would begin February 1. (4) Exceptions: Self-dialysis training. (i) Before the end of the waiting period, the individual participates in a self-dialysis training program offered by a participating Medicare facility that is approved to provide such training; (ii) The patient's physician has certified that it is reasonable to expect the individual will complete the training program and will self-dialyze on a regular basis; and (iii) The regular course of dialysis is maintained throughout the time that would otherwise be the waiting period (unless it is terminated earlier because the individual dies). (f) End of entitlement. (1) The end of the 12th month after the month in which a regular course of dialysis ends; or (2) The end of the 36th month after the month in which the individual received a kidney transplant. Beginning January 1, 2023, an individual who is no longer entitled to Part A benefits due to this paragraph may be eligible to enroll in Part B solely for purposes of coverage of immunosuppressive drugs as described in § 407.55 of this subchapter. (g) Resumption of entitlement. (1) An individual who initiates a regular course of renal dialysis or has a kidney transplant during the 12-month period after the previous course of dialysis ended is entitled to Part A benefits and eligible to enroll in Part B with the month the regular course of dialysis is resumed or the month the kidney is transplanted. (2) An individual who initiates a regular course of renal dialysis or has a kidney transplant during the 36-month period after an earlier kidney transplant is entitled to Part A benefits and eligible to enroll in Part B with the month the regular course of dialysis begins or with the month the subsequent kidney transplant occurs. (3) An individual who initiates a regular course of renal dialysis more than 12 months after the previous course of regular dialysis ended or more than 36 months after the month of a kidney transplant is eligible to enroll in Part A and Part B with the month in which the regular course of dialysis is resumed. If he or she is otherwise entitled under the conditions specified in paragraph (c) of this section, including the filing of an application, entitlement begins with the month in which dialysis is initiated or resumed, without a waiting period, subject to the limitations of paragraph (e)(1) of this section. [48 FR 12536, Mar. 25, 1983, as amended at 60 FR 22535, May 8, 1995; 87 FR 66503, Nov. 3, 2022] § 406.15 Special provisions applicable to Medicare qualified government employment. (a) Definition. Medicare-qualified government employment (1) Wages paid for Federal employment after December 1982. (2) Wages paid to State and local government employees hired after March 31, 1986. (3) Wages paid to State and local government employees hired before April 1, 1986 but whose employment after March 31, 1986 is covered, for Medicare purposes only, under an agreement under section 218 of the Act. (b) Crediting of wages that are taxable only for Medicare purposes. (c) Required quarters of coverage. (2) An individual who has worked in Medicare qualified government employment may qualify for hospital insurance on the basis of Medicare qualified government employment exclusively, or a combination of Medicare qualified government employment and social security covered employment. (d) Transitional provision for Federal employment. (e) Conditions of entitlement. (1) Would meet the requirements of § 406.10, § 406.12, or § 406.13 if Medicare qualified government employment were social security covered employment; and (2) Has filed an application for hospital insurance. For purposes of this section not more than 12 months before the month of application may be counted towards the 25-month qualifying period specified in § 406.12(a). (f) Beginning and end of entitlement Basic rule. (2) Limitations: Federal government employment. (ii) No months before January 1983 may be used to satisfy the qualifying period required for entitlement based on disability. (3) Limitations: State and local government employment. (ii) No months before April 1986 may be used to satisfy the qualifying period required for entitlement based on disability. [53 FR 47202, Nov. 22, 1988] Subpart C—Premium Hospital Insurance § 406.20 Basic requirements. (a) General provisions. (b) Eligibility of individuals age 65 or over to enroll for premium hospital insurance. (1) Has attained age 65; (2) Is a resident of the United States and is either— (i) A citizen of the United States; or (ii) An alien lawfully admitted for permanent residence who has resided in the United States continuously for the 5-year period immediately preceding the month in which he or she meets all other requirements; (3) Is not eligible for Part A benefits under subpart B of this part; and (4) Is entitled to supplementary medical insurance (Part B of Medicare) or is eligible and has enrolled for it during an enrollment period. (c) Eligibility of individuals under age 65 to enroll for premium hospital insurance. (1) Has been entitled to Medicare Part A (under § 406.12 or § 406.15) on the basis of entitlement or deemed entitlement to social security disability benefits, as provided under section 226(b) of the Act. (2) Continues to have a disabling physical or mental impairment. (3) Loses entitlement to disability benefits (and therefore also loses entitlement to Medicare Part A under § 406.12) solely because his or her earnings exceed the amount allowed under the social security regulations pertaining to “substantial gainful activity” (20 CFR 404.1571-404.1574); and (4) Is not otherwise entitled to Medicare Part A. [56 FR 38078, Aug. 12, 1991; 56 FR 50058, Oct. 3, 1991] § 406.21 Individual enrollment. (a) Basic provision. (1) Initial enrollment period as set forth in paragraph (b) of this section; (2) A general enrollment period as set forth in paragraph (c) of this section; (3) A special enrollment period as set forth in §§ 406.24, 406.25, and 406.27; or (4) For HMO/CMP enrollees, a transfer enrollment period as set forth in paragraph (f) of this section. (b) Initial enrollment periods Initial enrollment period for individual age 65 or over. (2) Initial enrollment period of individual under age 65. (c) General enrollment period. (2) General enrollment periods are for individuals who do not enroll during the special enrollment period, who failed to enroll during the initial enrollment period, or whose previous period of entitlement had terminated. (3) If the individual enrolls or reenrolls during a general enrollment period— (i) Before January 1, 2023, his or her entitlement begins on July 1 of the calendar year; or (ii) On or after January 1, 2023, his or her entitlement begins on the first day of the month after the month of enrollment. (4) During the period April 1 through September 30, 1981, the general enrollment period was any time after the end of the individual's initial enrollment period. Any eligible individual whose initial enrollment period has ended, or whose previous period of entitlement had terminated, could enroll or reenroll during that 6-month period. (5) If an individual resides in a State that pays premium hospital insurance for Qualified Medicare Beneficiaries under § 406.32(g) and enrolls or reenrolls during a general enrollment period after January 1, 2023, QMB coverage is effective the month entitlement begins (if the individual is determined eligible for QMB before the month following the month of enrollment), or a month later than the month entitlement begins (if the individual is determined eligible for QMB the month entitlement begins or later). (d) “Deemed” initial enrollment period for individual age 65 or over. (2) The deemed initial enrollment period will be used to determine the individual's premium and right to enroll in a general enrollment period if such use is advantageous to the individual. (e) [Reserved] (f) Transfer enrollment period for HMO/CMP enrollees Terminology. HMO CMP (2) Basic rule. (3) Effective date of coverage. (ii) If the individual enrolls in premium hospital insurance during any of the last 7 months of the transfer enrollment period, coverage will begin on the first day of the month after the month of enrollment. [48 FR 12536, Mar. 25, 1983. Redesignated at 51 FR 41338, Nov. 14, 1986, as amended at 53 FR 47203, Nov. 22, 1988; 56 FR 38079, Aug. 12, 1991; 57 FR 36014, Aug. 12, 1992; 61 FR 40345, Aug. 2, 1996; 87 FR 66503, Nov. 3, 2022; 88 FR 65269, Sept. 21, 2023] § 406.22 Effect of month of enrollment on entitlement. (a) Individual age 65 or over. (1) If the individual enrolls during the 3 months before the first month of eligibility, entitlement begins with the first month of eligibility. (2) If the individual enrolls in the first month of eligibility, entitlement begins with the following month. (3) If the individual enrolls during the month after the first month of eligibility, entitlement begins with the second month after the month of enrollment. (4) If the individual enrolls in either of the last 2 months of the enrollment period, entitlement begins with the third month after the month of enrollment. (b) Individual age 65 or over. (1) If the individual enrolls during the first 3 months of their initial enrollment period, entitlement begins with the first month of eligibility. (2) If an individual enrolls during the last 4 months of their initial enrollment period, entitlement begins with the month following the month of enrollment. (c) Individual under age 65. (1) If the individual enrolls before the month in which he or she meets the requirements of § 406.20(c), entitlement begins with the month in which the individual meets those requirements. (2) If the individual enrolls in the month in which he or she first meets the requirements of § 406.20(c), entitlement begins with the following month. (3) If the individual enrolls in the month following the month in which he or she meets the requirements of § 406.20(c), entitlement begins with the second month after the month of enrollment. (4) If the individual enrolls more than one month after the month in which he or she first meets the requirements of § 406.20(c), entitlement begins with the third month after the month of enrollment. (d) Individual under age 65. (1) For individuals who enroll during the first 3 months of their IEP, entitlement begins with the first month of eligibility. (2) If an individual enrolls during the month in which they first become eligible or any subsequent month of their IEP, entitlement begins with month following the month of enrollment. [56 FR 38079, Aug. 12, 1991, as amended at 87 FR 66503, Nov. 3, 2022] § 406.24 Special enrollment period related to coverage under group health plans. (a) Terminology. (1) Current employment status (2) Family member (3) Group health plan (GHP) large group health plan (LGHP) (i) Section 1837(i)(1)(A) of the Act explicitly requires that GHP coverage of an individual age 65 or older, be by reason of the individual's (or the individual's spouse's) current employment status; and (ii) The sentence following section 1837(i)(1)(B), of the Act refers to “large group health plan”. Under section 1862(b)(1)(B)(i), as amended by OBRA '93, LGHP coverage of a disabled individual must be “by virtue of the individual's or a family member's current employment status with an employer”. (4) Special enrollment period (SEP) (b) Duration of SEP. 2 2 (i) An individual over age 65 is enrolled in a GHP by reason of the current employment status of the individual or the individual's spouse; or (ii) An individual under age 65 and disabled— (A) Is enrolled in a GHP by reason of the current employment status of the individual or the individual's spouse; or (B) Is enrolled in an LGHP by reason of the current employment status of the individual or a member of the individual's family. (2) The SEP ends on the last day of the eighth consecutive month during which the individual is at no time enrolled in a GHP or an LGHP by reason of current employment status. (c) Conditions for use of a SEP. 3 3 (1) When first eligible to enroll for premium hospital insurance under § 406.20(b) or (c), the individual was— (i) Age 65 or over and covered under a GHP by reason of the current employment status of the individual or the individual's spouse; (ii) Under age 65 and covered under an LGHP by reason of the current employment status of the individual or a member of the individual's family ; or (iii) Under age 65 and covered under a GHP by reason of the current employment status of the individual or the individual's spouse. (2) For all the months thereafter, the individual has maintained coverage either under hospital insurance or a GHP or LGHP. (d) Special rule: Additional SEPs. (2) However, if an individual fails to enroll during a SEP, because coverage under the same or a different GHP or LGHP was restored before the end of that particular SEP, that failure to enroll does not preclude additional SEPs. (e) Effective date of coverage. (2) If the individual enrolls in any month of the SEP other than the months specified in paragraph (e)(1) of this section, coverage begins on the first day of the month following the month of enrollment. [61 FR 40346, Aug. 2, 1996] § 406.25 Special enrollment period for volunteers outside the United States. (a) General rule. (1) The individual is serving as a volunteer outside of the United States in a program that covers at least a 12-month period. (2) The individual is in a program that is sponsored by an organization described in section 501(c)(3) of the Internal Revenue Code of 1986 and is exempt from taxation under section 501(a) of Internal Revenue Code of 1986. (3) The individual can demonstrate that he or she has health insurance that covers medical services that the individual receives outside the United States while serving in the program. (4) The individual— (i) At the time he or she first met the requirements of § 406.10 through 406.15 or § 406.20(b), elected not to enroll in premium hospital insurance during the individual's initial enrollment period; or (ii) Terminated enrollment in premium hospital insurance during a month in which the individual met the requirements of this section for a SEP. (b) Duration of SEP. (c) Effective date of coverage. [73 FR 36468, June 27, 2008] § 406.26 Enrollment under State buy-in. (a) Enrollment of QMBs under a State buy-in agreement Effective date. (i) Any State that has a buy-in agreement in effect must participate in daily exchanges of enrollment data with CMS. (ii) [Reserved] (2) Amount of premium. (3) Enrollment without discrimination. (b) Beginning of coverage under buy-in. (1) The third month following the month in which the agreement modification covering QMBs is effectuated. (2) The first month in which the individual is entitled to premium hospital insurance under § 406.20(b) and has QMB status. Under a State buy-in agreement, as defined in § 407.40 of this subchapter, QMB-eligible individuals can enroll in premium hospital insurance at any time of the year, without regard to Medicare enrollment periods. (3) The date specified in the agreement modification. (c) End of coverage under buy-in. (1) Death. (2) Loss of QMB status. (3) Termination of buy-in agreement. (4) Entitlement to premium-free Part A. (d) Continuation of coverage: Individual enrollment following termination of buy-in coverage Deemed enrollment. (i) Is considered to have enrolled during his or her initial enrollment period; and (ii) Is entitled to Part A benefits and liable for Part A premiums beginning with the first month for which he or she is no longer covered under the buy-in agreement. (2) Voluntary termination. (ii) Voluntary disenrollment is effective as follows: (A) If the individual files a request within 30 days after the date of CMS's notice that buy-in coverage has ended, the individual's entitlement ends on the last day of the last month for which the State paid the premium. (B) If the individual files the request more than 30 days but not more than 6 months after buy-in coverage ends, entitlement ends on the last day of the month in which the request is filed. (C) If the individual files the request later than the 6th month after buy-in coverage ends, entitlement ends at the end of the month after the month in which request is filed. [56 FR 38080, Aug. 12, 1991, as amended at 85 FR 25632, May 1, 2020; 87 FR 66504, Nov. 3, 2022] § 406.27 Special enrollment periods for exceptional conditions. (a) General rule. (b) Special enrollment period for individuals impacted by an emergency or disaster. (1) SEP parameters. (2) SEP duration. (3) Entitlement. (c) Special enrollment period for individuals affected by a health plan or employer misrepresentation. (1) SEP parameters. (i) He or she did not enroll in premium Part A during another enrollment period in which they were eligible based on information received from an employer or GHP, agents or brokers of health plans, or any person authorized to act on such organization's behalf. (ii) An employer, GHP, agent or broker of a health plan, or their representative materially misrepresented information or provided incorrect information relating to enrollment in premium Part A. (2) SEP duration. (3) Entitlement. (d) SEP for formerly incarcerated individuals. (1) SEP parameters and duration before January 1, 2025 Eligibility. (ii) SEP duration. (2) SEP parameters and duration beginning January 1, 2025 Eligibility. (ii) SEP duration. (3) Entitlement General rule. (ii) Special rule. (e) Special enrollment period for termination of Medicaid coverage. (1) SEP parameters. (i) They are eligible for premium Part A under § 406.5(b); and (ii) Their Medicaid eligibility is terminated on or after January 1, 2023, or is terminated after the last day of the Coronavirus Disease 2019 public health emergency (COVID-19 PHE) as determined by the Secretary, whichever is earlier. (2) SEP duration. (i) After the last day of the COVID-19 PHE and before January 1, 2023, the SEP starts on January 1, 2023 and ends on June 30, 2023. (ii) On or after January 1, 2023, the SEP starts when the individual is notified of termination of Medicaid eligibility and ends 6 months after the termination of eligibility. (3) Entitlement General rule. (ii) Special COVID-19 PHE rule. (iii) Other special rule. (4) Effect on previously accrued late enrollment penalties. (f) Special enrollment period for other exceptional conditions. (1) SEP parameters. (i) The individual demonstrates that they missed an enrollment period in which they were eligible because of an event or circumstance outside of the individual's control which prevented them from enrolling in premium Part A. (ii) It is determined that the conditions were exceptional in nature. (2) SEP duration. (3) Entitlement. [87 FR 66504, Nov. 3, 2022, as amended at 89 FR 94586, Nov. 27, 2024; 90 FR 2635, Jan. 13, 2025] § 406.28 End of entitlement. Any of the following actions or events ends entitlement to premium hospital insurance: (a) Filing of request for termination. (1) If he or she files the notice before entitlement begins, he or she will be deemed not to have enrolled. (2) If he or she files the notice after entitlement begins, that entitlement will end at the close of the month following the month in which he or she filed the notice. (b) Eligibility for hospital insurance without premiums. (2) If an individual meets the requirements of § 406.10, § 406.11, § 406.13, or § 406.15, he or she will be deemed to have filed the required application for hospital insurance benefits in his or her first month of eligibility under that section. (c) End of entitlement to supplementary medical insurance (SMI) for individual who has attained age 65. (d) Nonpayment of premium. (2) CMS may reinstate entitlement if the individual shows good cause for failure to pay on time, and pays all overdue premiums within 3 calendar months after the date specified in paragraph (d)(1) of this section. (e) Death. (f) End of disabling impairment for individual under age 65. [48 FR 12536, Mar. 25, 1983. Redesignated at 51 FR 41338, Nov. 14, 1986, as amended at 53 FR 47204, Nov. 22, 1988. Redesignated and amended at 56 FR 38080, Aug. 12, 1991] § 406.32 Monthly premiums. (a) Promulgation and effective date. (b) Monthly premiums: Determination of dollar amount. (2) Before 1989, the dollar amount was determined by multiplying $33 by the ratio of the next year's inpatient deductible to $76, which was the inpatient deductible determined for 1973. (Because of cost controls, the deductible actually charged for that year was $72.) (3) Effective for months beginning January 1994, if an individual meets the requirements in paragraph (c) of this section, the monthly premium determined under paragraph (b)(1) of this section is reduced in each month in which the individual meets the requirements by 25 percent in 1994, 30 percent in 1995, 35 percent in 1996, 40 percent in 1997 and 45 percent in 1998 and thereafter. (4) The amount determined under paragraphs (b) (1), (2), or (3) of this section is rounded to the next nearest multiple of $1. (Fifty cents is rounded to the next higher dollar.) (c) Qualifying for a reduction in monthly premium. (1) Has 30 or more quarters of coverage (QCs) as defined in 20 CFR 404.140 through 404.146; (2) Has been married for at least the previous one year period to a worker who has 30 or more QCs; (3) Had been married to a worker who had 30 or more QCs for a period of at least one year before the death of the worker; (4) Is divorced from, after at least 10 years of marriage to, a worker who had 30 or more QCs at the time the divorce became final; or (5) Is divorced from, after at least 10 years of marriage to, a worker who subsequently died and who had 30 or more QCs at the time the divorce became final. (d) Monthly premiums: Increase for late enrollment and for reenrollment. (e) Collection of monthly premiums. (2) The enrollee must pay by check or money order that is payable to “CMS Medicare Insurance,” and shows his or her name and the claim number that appears on his or her Medicare card. He or she must return the bill with the check or money order. (f) Months for which payment is due. (2) A premium is due for the month of death if coverage is still in effect, even if the individual dies on the first day of the month. (g) Option for group payments. [48 FR 12536, Mar. 25, 1983. Redesignated at 51 FR 41338, Nov. 14, 1986, as amended at 53 FR 47203, Nov. 22, 1988; 56 FR 8839, Mar. 1, 1991. Redesignated and amended at 56 FR 38079, 38080, Aug. 12, 1991; 57 FR 36014, Aug. 12, 1992; 57 FR 58717, Dec. 11, 1992; 59 FR 26959, May 25, 1994] § 406.33 Determination of months to be counted for premium increase: Enrollment. (a) Enrollment before April 1, 1981 or after September 30, 1981 and before January 1, 2023. (1) Any months before September 1973. (2) For premiums due for months after May 1986, any months beginning with January 1983 during which the individual was enrolled in an employer group health plan based on the current employment of the individual or the individual's spouse. (3) Any months during the SEP under § 406.24 of this subpart, during which premium hospital insurance coverage is in effect. (4) Any months that the individual was enrolled in an HMO or CMP under part 417, subpart K of this chapter as described in § 406.21(f). (5) For premiums due for months after December 2006, any months during which the individual met the requirements for a SEP under § 406.25(a) of this subpart. (6) Any months during the 6-month SEP described in § 406.25(b) of this subpart during which premium hospital insurance coverage is in effect. (b) Enrollment during the period April 1 through September 30, 1981. (c) Enrollment on or after January 1, 2023. (1) The months described in paragraphs (a)(1) through (6) of this section. (2) Any months of non-coverage in accordance with an individual's use of an exceptional conditions SEP under § 406.27 provided the individual enrolls within the duration of the SEP. (d) Examples. (2) Mary T's initial enrollment period ended in April 1980 but she did not enroll until May 1981. The months to be counted are May 1980 through May 1981. Since 13 months has elapsed, the premium would be increased by 10 percent. (3) Effective with July 1986, Mary T, in Example 2, would no longer have to pay an increased premium because she had paid it for twice the number of full 12-month periods during which she could have been, but was not, enrolled in the program. (4) Vincent C's initial enrollment period ended August 31, 1986. He was covered under his wife's employer group health plan until she retired on May 31, 1989. He enrolled during June 1989, the first month of the special enrollment period under § 406.21(e). No months are countable for premium increase purposes because the exclusions of paragraph (a) of this section apply to all months. (5) Terry P enrolled in the 1987 general enrollment period, with coverage effective July 1987. There were 28 months after the end of his initial enrollment period through the end of the 1987 general enrollment period. His premium is increased by 10 percent. The increase will be eliminated after he has paid the additional 10 percent for 48 months. [48 FR 12536, Mar. 25, 1983. Redesignated at 51 FR 41338, Nov. 14, 1986, as amended at 53 FR 47203, Nov. 22, 1988. Further redesignated and amended at 57 FR 36014, Aug. 12, 1992; 73 FR 36468, June 27, 2008; 87 FR 66505, Nov. 3, 2022] § 406.34 Determination of months to be counted for premium increase: Reenrollment. (a) First reenrollment before April 1, 1981 or after September 30, 1981 and before January 1, 2023. (1) The months specified in § 406.33(a) or (b); plus (2) The months from the end of the first period of entitlement through the end of the general enrollment period in which the individual reenrolled. (b) First reenrollment during the period April 1, 1981 (1) The months specified in § 406.33(a); plus (2) The months from the end of the first period of entitlement through the month in which the individual reenrolled. (c) Subsequent reenrollment during the period April 1, 1981 through September 30, 1981. (1) The months specified in paragraph (a) of this section; plus (2) The months from April 1981 through the month in which the individual reenrolled for the second time. (Since only one reenrollment was permitted before April 1981, any months from the end of the individual's first enrollment period of entitlement through March 1981 are not counted.) (d) Subsequent reenrollment after September 30, 1981. (1) The months specified in paragraph (a) or (b) of this section, for the first and second periods of coverage; plus (2) The months from the end of each subsequent period of entitlement through the end of the general enrollment period in which the individual reenrolled, excluding any months before April 1981. (e) Reenrollments on or after January 1, 2023. (i) The months specified in § 406.33(c). (ii) The months specified in paragraphs (b) and (d) of this section (if applicable). (iii) The months from the end of the first period of entitlement through the end of the month during the general enrollment period in which the individual reenrolled. (2) The months excluded from premium increase are the months of non-coverage in accordance with an individual's use of an exceptional conditions SEP under § 406.27, provided the individual enrolls within the duration of the SEP. (f) Example. [48 FR 12536, Mar. 25, 1983. Redesignated at 51 FR 41338, Nov. 14, 1986. Further redesignated and amended at 57 FR 58717, Dec. 11, 1992; 87 FR 66505, Nov. 3, 2022] § 406.38 Prejudice to enrollment rights because of Federal Government error. (a) If an individual's enrollment or nonenrollment for premium hospital insurance is unintentional, inadvertent, or erroneous because of the error, misrepresentation, or inaction of a Federal employee, or any person authorized by the Federal Government to act on its behalf, the Social Security Administration or CMS may take whatever action it determines is necessary to provide appropriate relief. (b) The action may include— (1) Designation of a special initial or general enrollment period; (2) Designation of an entitlement period; (3) Adjustment of premiums; (4) Any combination of the actions specified in paragraph (b) (1) through (3) of this section; or (5) Any other remedial action which may be necessary to correct or eliminate the effects of such error, misrepresentation, or inaction. [48 FR 12536, Mar. 25, 1983. Redesignated at 51 FR 41338, Nov. 14, 1986. Further redesignated at 56 FR 38080, Aug. 12, 1991] Subpart D—Special Circumstances That Affect Entitlement to Hospital Insurance § 406.50 Nonpayment of benefits on behalf of certain aliens. (a) Hospital insurance benefit payments may not be made for services furnished to an alien in any month in which his or her monthly social security benefits are suspended (or would be suspended if he or she were entitled to those benefits) because the alien remains outside the United States for more than 6 months. (b) Benefits will be payable beginning with services furnished in the first full calendar month the alien is back in the United States. [48 FR 12536, Mar. 25, 1983. Redesignated at 51 FR 41338, Nov. 14, 1986. Further redesignated at 57 FR 58717, Dec. 11, 1992] § 406.52 Conviction of certain offenses. (a) Penalty that affects entitlement. (2) The additional penalty is that the individual's income (or the income of the insured individual on whose earnings record he or she became or seeks to become entitled) for the year of conviction and any previous year may not be counted in determining the insured status necessary for entitlement to hospital insurance. (b) Effect of pardon. [48 FR 12536, Mar. 25, 1983. Redesignated at 51 FR 41338, Nov. 14, 1986. Further redesignated at 57 FR 58717, Dec. 11, 1992]