42 U.S.C. § 426 : US Code - Section 426: Entitlement to hospital insurance benefits

Search 42 U.S.C. § 426 : US Code - Section 426: Entitlement to hospital insurance benefits

(a) Individuals over 65 years
Every individual who -
(1) has attained age 65, and
(2)(A) is entitled to monthly insurance benefits under section
402 of this title, would be entitled to those benefits except
that he has not filed an application therefor (or application has
not been made for a benefit the entitlement to which for any
individual is a condition of entitlement therefor), or would be
entitled to such benefits but for the failure of another
individual, who meets all the criteria of entitlement to monthly
insurance benefits, to meet such criteria throughout a month,
and, in conformity with regulations of the Secretary, files an
application for hospital insurance benefits under part A of
subchapter XVIII of this chapter,
(B) is a qualified railroad retirement beneficiary, or
(C)(i) would meet the requirements of subparagraph (A) upon
filing application for the monthly insurance benefits involved if
medicare qualified government employment (as defined in section
410(p) of this title) were treated as employment (as defined in
section 410(a) of this title) for purposes of this subchapter,
and (ii) files an application, in conformity with regulations of
the Secretary, for hospital insurance benefits under part A of
subchapter XVIII of this chapter,
shall be entitled to hospital insurance benefits under part A of
subchapter XVIII of this chapter for each month for which he meets
the condition specified in paragraph (2), beginning with the first
month after June 1966 for which he meets the conditions specified
in paragraphs (1) and (2).
(b) Individuals under 65 years
Every individual who -
(1) has not attained age 65, and
(2)(A) is entitled to, and has for 24 calendar months been
entitled to, (i) disability insurance benefits under section 423
of this title or (ii) child's insurance benefits under section
402(d) of this title by reason of a disability (as defined in
section 423(d) of this title) or (iii) widow's insurance benefits
under section 402(e) of this title or widower's insurance
benefits under section 402(f) of this title by reason of a
disability (as defined in section 423(d) of this title), or
(B) is, and has been for not less than 24 months, a disabled
qualified railroad retirement beneficiary, within the meaning of
section 231f(d) of title 45, or
(C)(i) has filed an application, in conformity with regulations
of the Secretary, for hospital insurance benefits under part A of
subchapter XVIII of this chapter pursuant to this subparagraph,
and
(ii) would meet the requirements of subparagraph (A) (as
determined under the disability criteria, including reviews,
applied under this subchapter), including the requirement that he
has been entitled to the specified benefits for 24 months, if -
(I) medicare qualified government employment (as defined in
section 410(p) of this title) were treated as employment (as
defined in section 410(a) of this title) for purposes of this
subchapter, and
(II) the filing of the application under clause (i) of this
subparagraph were deemed to be the filing of an application for
the disability-related benefits referred to in clause (i),
(ii), or (iii) of subparagraph (A),
shall be entitled to hospital insurance benefits under part A of
subchapter XVIII of this chapter for each month beginning with the
later of (I) July 1973 or (II) the twenty-fifth month of his
entitlement or status as a qualified railroad retirement
beneficiary described in paragraph (2), and ending (subject to the
last sentence of this subsection) with the month following the
month in which notice of termination of such entitlement to
benefits or status as a qualified railroad retirement beneficiary
described in paragraph (2) is mailed to him, or if earlier, with
the month before the month in which he attains age 65. In applying
the previous sentence in the case of an individual described in
paragraph (2)(C), the "twenty-fifth month of his entitlement"
refers to the first month after the twenty-fourth month of
entitlement to specified benefits referred to in paragraph (2)(C)
and "notice of termination of such entitlement" refers to a notice
that the individual would no longer be determined to be entitled to
such specified benefits under the conditions described in that
paragraph. For purposes of this subsection, an individual who has
had a period of trial work which ended as provided in section
422(c)(4)(A) of this title, and whose entitlement to benefits or
status as a qualified railroad retirement beneficiary as described
in paragraph (2) has subsequently terminated, shall be deemed to be
entitled to such benefits or to occupy such status (notwithstanding
the termination of such entitlement or status) for the period of
consecutive months throughout all of which the physical or mental
impairment, on which such entitlement or status was based,
continues, and throughout all of which such individual would have
been entitled to monthly insurance benefits under this subchapter
or as a qualified railroad retirement beneficiary had such
individual been unable to engage in substantial gainful activity,
but not in excess of 78 such months. In determining when an
individual's entitlement or status terminates for purposes of the
preceding sentence, the term "36 months" in the second sentence of
section 423(a)(1) of this title, in section 402(d)(1)(G)(i) of this
title, in the last sentence of section 402(e)(1) of this title, and
in the last sentence of section 402(f)(1) of this title shall be
applied as though it read "15 months".
(c) Conditions
For purposes of subsection (a) of this section -
(1) entitlement of an individual to hospital insurance benefits
for a month shall consist of entitlement to have payment made
under, and subject to the limitations in, part A of subchapter
XVIII of this chapter on his behalf for inpatient hospital
services, post-hospital extended care services, and home health
services (as such terms are defined in part E of subchapter XVIII
of this chapter) furnished him in the United States (or outside
the United States in the case of inpatient hospital services
furnished under the conditions described in section 1395f(f) of
this title) during such month; except that (A) no such payment
may be made for post-hospital extended care services furnished
before January 1967, and (B) no such payment may be made for post-
hospital extended care services unless the discharge from the
hospital required to qualify such services for payment under part
A of subchapter XVIII of this chapter occurred (i) after June 30,
1966, or on or after the first day of the month in which he
attains age 65, whichever is later, or (ii) if he was entitled to
hospital insurance benefits pursuant to subsection (b) of this
section, at a time when he was so entitled; and
(2) an individual shall be deemed entitled to monthly insurance
benefits under section 402 or section 423 of this title, or to be
a qualified railroad retirement beneficiary, for the month in
which he died if he would have been entitled to such benefits, or
would have been a qualified railroad retirement beneficiary, for
such month had he died in the next month.
(d) "Qualified railroad retirement beneficiary" defined
For purposes of this section, the term "qualified railroad
retirement beneficiary" means an individual whose name has been
certified to the Secretary by the Railroad Retirement Board under
section 231f(d) of title 45. An individual shall cease to be a
qualified railroad retirement beneficiary at the close of the month
preceding the month which is certified by the Railroad Retirement
Board as the month in which he ceased to meet the requirements of
section 231f(d) of title 45.
(e) Benefits for widows and widowers
(1)(A) For purposes of determining entitlement to hospital
insurance benefits under subsection (b) of this section in the case
of widows and widowers described in paragraph (2)(A)(iii) thereof -

(i) the term "age 60" in sections 402(e)(1)(B)(ii), 402(e)(4),
402(f)(1)(B)(ii), and 402(f)(4) of this title shall be deemed to
read "age 65"; and
(ii) the phrase "before she attained age 60" in the matter
following subparagraph (F) of section 402(e)(1) of this title and
the phrase "before he attained age 60" in the matter following
subparagraph (F) of section 402(f)(1) of this title shall each be
deemed to read "based on a disability".
(B) For purposes of subsection (b)(2)(A)(iii) of this section,
each month in the period commencing with the first month for which
an individual is first eligible for supplemental security income
benefits under subchapter XVI of this chapter, or State
supplementary payments of the type referred to in section 1382e(a)
of this title (or payments of the type described in section 212(a)
of Public Law 93-66) which are paid by the Secretary under an
agreement referred to in section 1382e(a) of this title (or in
section 212(b) of Public Law 93-66), shall be included as one of
the 24 months for which such individual must have been entitled to
widow's or widower's insurance benefits on the basis of disability
in order to become entitled to hospital insurance benefits on that
basis.
(2) For purposes of determining entitlement to hospital insurance
benefits under subsection (b) of this section in the case of an
individual under age 65 who is entitled to benefits under section
402 of this title, and who was entitled to widow's insurance
benefits or widower's insurance benefits based on disability for
the month before the first month in which such individual was so
entitled to old-age insurance benefits (but ceased to be entitled
to such widow's or widower's insurance benefits upon becoming
entitled to such old-age insurance benefits), such individual shall
be deemed to have continued to be entitled to such widow's
insurance benefits or widower's insurance benefits for and after
such first month.
(3) For purposes of determining entitlement to hospital insurance
benefits under subsection (b) of this section, any disabled widow
aged 50 or older who is entitled to mother's insurance benefits
(and who would have been entitled to widow's insurance benefits by
reason of disability if she had filed for such widow's benefits),
and any disabled widower aged 50 or older who is entitled to
father's insurance benefits (and who would have been entitled to
widower's insurance benefits by reason of disability if he had
filed for such widower's benefits), shall, upon application for
such hospital insurance benefits be deemed to have filed for such
widow's or widower's insurance benefits.
(4) For purposes of determining entitlement to hospital insurance
benefits under subsection (b) of this section in the case of an
individual described in clause (iii) of subsection (b)(2)(A) of
this section, the entitlement of such individual to widow's or
widower's insurance benefits under section 402(e) or (f) of this
title by reason of a disability shall be deemed to be the
entitlement to such benefits that would result if such entitlement
were determined without regard to the provisions of section
402(j)(4) of this title.
(f) Medicare waiting period for recipients of disability benefits
For purposes of subsection (b) of this section (and for purposes
of section 1395p(g)(1) of this title and section 231f(d)(2)(ii) of
title 45), the 24 months for which an individual has to have been
entitled to specified monthly benefits on the basis of disability
in order to become entitled to hospital insurance benefits on such
basis effective with any particular month (or to be deemed to have
enrolled in the supplementary medical insurance program, on the
basis of such entitlement, by reason of section 1395p(f) of this
title), where such individual had been entitled to specified
monthly benefits of the same type during a previous period which
terminated -
(1) more than 60 months before the month in which his current
disability began in any case where such monthly benefits were of
the type specified in clause (A)(i) or (B) of subsection (b)(2)
of this section, or
(2) more than 84 months before the month in which his current
disability began in any case where such monthly benefits were of
the type specified in clause (A)(ii) or (A)(iii) of such
subsection,
shall not include any month which occurred during such previous
period, unless the physical or mental impairment which is the basis
for disability is the same as (or directly related to) the physical
or mental impairment which served as the basis for disability in
such previous period.
(g) Information regarding eligibility of Federal employees
The Secretary and Director of the Office of Personnel Management
shall jointly prescribe and carry out procedures designed to assure
that all individuals who perform medicare qualified government
employment by virtue of service described in section 410(a)(5) of
this title are fully informed with respect to (1) their eligibility
or potential eligibility for hospital insurance benefits (based on
such employment) under part A of subchapter XVIII of this chapter,
(2) the requirements for and conditions of such eligibility, and
(3) the necessity of timely application as a condition of
entitlement under subsection (b)(2)(C) of this section, giving
particular attention to individuals who apply for an annuity under
chapter 83 (!1) of title 5 or under another similar Federal
retirement program, and whose eligibility for such an annuity is or
would be based on a disability.
(h) Waiver of waiting period for individuals with ALS
For purposes of applying this section in the case of an
individual medically determined to have amyotrophic lateral
sclerosis (ALS), the following special rules apply:
(1) Subsection (b) of this section shall be applied as if there
were no requirement for any entitlement to benefits, or status,
for a period longer than 1 month.
(2) The entitlement under such subsection shall begin with the
first month (rather than twenty-fifth month) of entitlement or
status.
(3) Subsection (f) of this section shall not be applied.
(i) Continuing eligibility of certain terminated individuals
For purposes of this section, each person whose monthly insurance
benefit for any month is terminated or is otherwise not payable
solely by reason of paragraph (1) or (7) of section 425(c) (!2) of
this title shall be treated as entitled to such benefit for such
month.
(j) Certain uninsured individuals
For entitlement to hospital insurance benefits in the case of
certain uninsured individuals, see section 426a of this title.