TN 14 (08-92)

A. Policy

A CDR conducted for entitlement to Premium-HI must not consider the performance of SGA in evaluating continuing disability. A finding that the individual is not disabled for Premium-HI must be based on medical improvement.

ODIO/PSCs initiate the CDR and process all disability continuances to completion. Cases involving medical improvement or other medical issues for which a cessation is probable are referred to the DDS for processing.

The interim award notice must inform the applicant for Premium-HI that continuing entitlement to benefits is subject to a medical review, and serves as the prereview notice normally sent to a disability beneficiary when a CDR is initiated.

B. Procedure

When conducting a CDR for an initial Premium-HI enrollment period, follow the instructions below:

1. Notice

Do not send a prereview notice. The interim award notice will inform the applicant for Premium-HI that continuing entitlement to benefits is subject to a medical review.

2. Determination

Follow the CDR evaluation process including the MIRS as covered in
DI 28005.000. Do not consider SGA when evaluating Premium-HI cases.

a. Currently disabled

If the individual can be found currently disabled for Premium-HI:

• Complete an SSA-831-U3 as required by DI 40510.165. Be sure that the identifying Medicare remark is displayed in item 34, and that an entry of “S” appears in item 29.

• Establish a future medical review diary per DI 40510.160.

• Route the folder to the typist for preparation and release of the final award notice, Exhibit 4, DI 40510.185.

b. CDR raises an issue of MI/different allegation

• Forward the case to the DDS under cover of an SSA-847-U3 for a decision if the CDR raises an issue of MI, or the original impairment is no longer disabling and individual has alleged a different impairment than the one on which the most recent favorable determination was based.

• Check block l.b. and block 3 “Other” and annotate the form “Section 6012 - Premium Medicare Case.”

• Advise the DDS to follow the continuing impairment severity adjudication procedure set out in DI 28055.025. Emphasize that SGA should not be considered in evaluating these cases.