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United States Code (Last Updated: May 24, 2014) |
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Title 42. THE PUBLIC HEALTH AND WELFARE |
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Chapter 7. SOCIAL SECURITY |
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SubChapter II. FEDERAL OLD-AGE, SURVIVORS, AND DISABILITY INSURANCE BENEFITS |
§ 426. Entitlement to hospital insurance benefits
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(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 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.
References In Text
Section 212 of Public Law 93–66, referred to in subsec. (e)(1)(B), is section 212 of Pub. L. 93–66 which is set out as a note under section 1382 of this title.
Section 425(c) of this title, referred to in subsec. (i), was repealed by Pub. L. 104–121, title I, § 105(a)(4),
Amendments
2004—Subsec. (e)(1)(A)(i). Pub. L. 108–203 substituted “402(f)(4)” for “402(f)(5)”.
2003—Subsec. (c)(1). Pub. L. 108–173 substituted “part E” for “part D”.
2000—Subsecs. (h), (j). Pub. L. 106–554 added subsec. (h) and redesignated former subsec. (h) as (j) and transferred such subsec. to appear at end of section.
1999—Subsec. (b). Pub. L. 106–170 substituted “78” for “24” in penultimate sentence.
1997—Subsec. (c)(1). Pub. L. 105–33 substituted “part D” for “part C”.
1994—Subsec. (i). Pub. L. 103–296 added subsec. (i).
1990—Subsec. (e)(1). Pub. L. 101–508 designated existing provisions as subpar. (A), redesignated former subpars. (A) and (B) as cls. (i) and (ii), respectively, and added subpar. (B).
1988—Subsec. (a). Pub. L. 100–485 substituted “condition specified in paragraph (2)” for “condition specified in paragraph (1)” in concluding provisions.
Subsec. (b). Pub. L. 100–360, § 411(n)(1), amended last sentence generally. Prior to amendment, last sentence read as follows: “In determining when an individual’s entitlement or status terminates for purposes of the preceding sentence, the second sentence of section 423(a) of this title shall be applied as though the term ‘36 months’ (in such second sentence) read ‘15 months’.”
1987—Subsec. (b). Pub. L. 100–203, § 9010(e)(3), inserted sentence at end which related to determining when an individual’s entitlement or status terminates for purposes of preceding sentence.
Subsec. (f). Pub. L. 100–203, § 4033(a), inserted before period at end “, 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”.
1986—Subsec. (a)(2)(C)(i). Pub. L. 99–272, § 13205(b)(2)(A) substituted “medicare qualified government employment” for “medicare qualified Federal employment”.
Subsec. (b)(2)(C)(ii)(I). Pub. L. 99–272, § 13205(b)(2)(A), substituted “medicare qualified government employment” for “medicare qualified Federal employment”.
Subsec. (g). Pub. L. 99–272, § 13205(b)(2)(C)(ii), substituted “medicare qualified government employment by virtue of service described in section 410(a)(5) of this title” for “medicare qualified Federal employment”.
1984—Subsec. (b). Pub. L. 98–369 substituted “part A” for “part (A)” in provisions following par. (2)(C).
1983—Subsec. (e)(1)(A). Pub. L. 98–21, § 131(a)(3)(H), (b)(3)(G), substituted reference to section 402(e)(4), (f)(5) of this title for reference to section 405(e)(5), (f)(6) of this title.
Subsec. (e)(3). Pub. L. 98–21, § 309(q)(1), amended par. (3) generally, inserting provisions relating to any disabled widower and striking out provision that a disabled widow, upon furnishing proof of such disability prior to
1982—Subsec. (a)(2). Pub. L. 97–248, § 278(b)(2)(A), redesignated existing provisions as subpar. (A), struck out “or is a qualified railroad retirement beneficiary,” after “of this chapter,”, and added subpars. (B) and (C).
Subsec. (b). Pub. L. 97–248, § 278(b)(2)(B), in par. (2)(B) inserted a comma after “24 months” and “or” after “title 45,”, added par. (2)(C), and in provisions following par. (2) inserted provision defining “twenty-fifth month of his entitlement” and “notice of termination of such entitlement” with regards to applying first sentence of this subsection to individuals described in par. (2)(C).
Subsecs. (g), (h). Pub. L. 97–248, § 278(b)(4), added subsec. (g) and redesignated former subsec. (g) as (h).
1981—Subsec. (a)(2). Pub. L. 97–35 substituted “would be entitled” for “or would be entitled” and inserted “, 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,”.
1980—Subsec. (a)(2). Pub. L. 96–473 inserted provisions relating to persons who would be entitled to benefits but for enumerated exceptions.
Subsec. (b). Pub. L. 96–265, § 104(a), in provisions following par. (2), inserted “(subject to the last sentence of this subsection)”, and inserted provision that, 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.
Pub. L. 96–265, § 103(a)(1), substituted “24 calendar months” and “24 months” for “24 consecutive calendar months” and “24 consecutive months”, respectively, in par. (2) and, in provisions following par. (2), substituted “the twenty-fifth month” for “the twenty-fifth consecutive month”.
Subsec. (c)(1). Pub. L. 96–499 substituted “and home health services” for “and post-hospital home health services” and struck out “or post-hospital home health services” before “unless the discharge”.
Subsecs. (f), (g). Pub. L. 96–265, § 103(b), added subsec. (f) and redesignated former subsec. (f) as (g).
1978—Subsec. (a). Pub. L. 95–292, § 3(a), substituted “condition specified in paragraph (1), beginning with the first month after June 1966 for which he meets the conditions specified in paragraphs (1) and (2)” for “conditions specified in subparagraph (B), beginning with the first month after June 1966 for which he meets the conditions specified in subparagraphs (A) and (B)”.
Subsec. (e). Pub. L. 95–292, §§ 1(b)(1), (2), 3(b), redesignated subsec. (h) as (e) and, in subsec. (e) as so redesignated, corrected a technical error resulting from the 1973 amendment of pars. (2) and (3) by Pub. L. 93–233 under which a reference to subsec. (b) of this section had been inserted without the required parentheses. Former subsec. (e), relating to Medicare eligibility of persons medically determined to have chronic renal disease requiring hemodialysis or renal transplantation, was struck out. See section 426–1 of this title.
Subsec. (f). Pub. L. 95–292, § 1(b)(1), (2), redesignated subsec. (i) as (f). Former subsec. (f), relating to the duration of Medicare coverage of persons medically determined to have chronic renal disease requiring hemodialysis or renal transplantation, was struck out. See section 426–1 of this title.
Subsec. (g). Pub. L. 95–292, § 1(b)(1), struck out subsec. (g) which related to reimbursement for kidney transplant and kidney treatment. See section 1395rr of this title.
Subsecs. (h), (i). Pub. L. 95–292, § 1(b)(2), redesignated subsecs. (h) and (i) as (e) and (f), respectively.
1977—Subsec. (h)(1)(B). Pub. L. 95–216, § 334(d)(4)(B), substituted “subparagraph (F) of section 402(f)(1)” for “subparagraph (G) of section 402(f)(1)”.
Subsec. (h)(4). Pub. L. 95–216, § 332(a)(3), added par. (4).
1974—Subsec. (b)(2). Pub. L. 93–445, § 305(a), substituted “section 7(d) of the Railroad Retirement Act of 1974” for “section 22 of the Railroad Retirement Act of 1937”.
Subsec. (d). Pub. L. 93–445, § 305(b), substituted “section 7(d) of the Railroad Retirement Act of 1974” for “section 21 or 22 of the Railroad Retirement Act of 1937”, in two places.
Subsec. (e). Pub. L. 93–445, § 305(c), substituted “Railroad Retirement Act of 1974” for “Railroad Retirement Act of 1937”, wherever appearing.
1973—Subsec. (a). Pub. L. 93–233, § 18(f)(1)(A), redesignated subsec. (a)(1) as subsec. (a).
Subsec. (a)(1), (2). Pub. L. 93–233, § 18(f)(1)(B), redesignated cls. (A) and (B) as (1) and (2), respectively.
Subsec. (e)(2). Pub. L. 93–58, inserted in: item (2)(A) “or would be fully or currently insured if his service as an employee (as defined in the Railroad Retirement Act of 1937) after
Subsec. (h). Pub. L. 93–233, § 18(f)(1)(C), (2)–(4), redesignated as subsec. (h) provisions originally enacted as subsec. (e) by section 201(b)(5) of Pub. L. 92–603 and redesignated as subsec. (f) by section 299I of Pub. L. 92–603, and in par. (1)(A) substituted “, 402(e)(5),” for “and 402(e)(5) of this title, and the term ‘age 62’ in sections”, in par. (1)(B) substituted “and the phrase ‘before he attained age 60’ in the matter following subparagraph (G) of section 402(f)(1) of this title shall each” for “shall”, and in pars. (2) and (3) substituted “(b)” for “(a)(2)”, respectively.
Subsec. (i). Pub. L. 93–233, § 18(f)(1)(C), redesignated as subsec. (i) provisions originally enacted as subsec. (d) by section 101 of Pub. L. 89–97 and redesignated as subsec. (f) by section 201(b)(5) of Pub. L. 92–603.
1972—Subsec. (a). Pub. L. 92–603, § 201(b)(1), incorporated provisions of former subsec. (a) and subsec. (a)(1), and redesignated pars. (1) and (2) as subpars. (A) and (B).
Subsec. (b). Pub. L. 92–603, § 201(b)(1), added subsec. (b). Former subsec. (b) redesignated subsec. (c).
Subsec. (c)(1). Pub. L. 92–603, § 201(b)(2), (5), redesignated subsec. (b)(1) as subsec. (c)(1) and, in subsec. (c)(1) as so redesignated, inserted reference to entitlement to hospital insurance benefits pursuant to subsec. (b) of this section. Former subsec. (c) redesignated subsec. (d).
Subsec. (c)(2). Pub. L. 92–603, § 201(b)(3), (5), redesignated subsec. (b)(2) as subsec. (c)(2) and inserted reference to section 423 of this title. Former subsec. (c) redesignated subsec. (d).
Subsec. (d). Pub. L. 92–603, § 201(b)(4), (5), redesignated former subsec. (c) as subsec. (d) and inserted reference to section 22 of the Railroad Retirement Act of 1937. Former subsec. (d) redesignated subsec. (i).
Subsecs. (e) to (h). Pub. L. 92–603, §§ 201(b)(5), 299I, added subsecs. (e) to (h). See 1973 Amendment note above.
Subsec. (i). Pub. L. 92–603, § 201(b)(5), redesignated former subsec. (d) as subsec. (i). See 1973 Amendment note above.
1968—Subsec. (b)(1). Pub. L. 90–248 struck out outpatient hospital diagnostic services from services for which hospital insurance benefits are payable.
Effective Date Of Amendment
Amendment by Pub. L. 108–203 applicable with respect to applications for benefits under this subchapter filed on or after the first day of the first month that begins after
Pub. L. 106–554, § 1(a)(6) [title I, § 115(c)],
Pub. L. 106–170, title II, § 202(b),
Amendment by Pub. L. 103–296 applicable with respect to benefits based on disability (as defined in section 425(c)(9) of this title) which are otherwise payable in months beginning after 180 days after
Amendment by Pub. L. 101–508 applicable with respect to items and services furnished after December 1990, see section 5103(e) of Pub. L. 101–508, set out as a note under section 402 of this title.
Pub. L. 100–485, title VI, § 608(f)(5),
Except as specifically provided in section 411 of Pub. L. 100–360, amendment by Pub. L. 100–360, as it relates to a provision in the Omnibus Budget Reconciliation Act of 1987, Pub. L. 100–203, effective as if included in the enactment of that provision in Pub. L. 100–203, see section 411(a) of Pub. L. 100–360, set out as a Reference to OBRA; Effective Date note under section 106 of Title 1, General Provisions.
Pub. L. 100–203, title IV, § 4033(b), formerly § 4033(a)(2),
Amendment by section 9010(e)(3) of Pub. L. 100–203 effective
Amendment by Pub. L. 99–272 effective after
Amendment by Pub. L. 98–369 effective
Amendment by section 131(a)(3)(H), (b)(3)(G) of Pub. L. 98–21 effective with respect to monthly benefits payable under this subchapter for months after December 1983, and in the case of an individual who was not entitled to a monthly benefit of the type involved under this subchapter for December 1983, no benefit shall be paid under this subchapter by reason of such amendments unless proper application for such benefit is made, see section 131(d) of Pub. L. 98–21 set out as a note under section 402 of this title.
Amendment by section 309(q)(1) of Pub. L. 98–21 applicable only with respect to monthly payments payable under this subchapter for months after April 1983, see section 310 of Pub. L. 98–21, set out as a note under section 402 of this title.
Pub. L. 97–448, title III, § 309(c)(1),
Pub. L. 97–248, title II, § 278(c)(2), (d),
Pub. L. 97–35, title XXII, § 2203(f)(3),
Amendment by Pub. L. 96–499 effective with respect to services furnished on or after
Pub. L. 96–473, § 2(d),
Pub. L. 96–265, title I, § 103(c),
Pub. L. 96–265, title I, § 104(b),
Pub. L. 95–292, § 6,
Amendment by section 332(a)(3) of Pub. L. 95–216 effective with respect to monthly insurance benefits under this subchapter to which an individual becomes entitled on the basis of an application filed on or after
Amendment by section 334(d)(4)(B) of Pub. L. 95–216 applicable with respect to monthly insurance benefits payable under this subchapter for months beginning with December 1977, on the basis of applications filed in or after December 1977, see section 334(f) of Pub. L. 95–216, set out as a note under section 402 of this title.
Amendment by Pub. L. 93–445 effective
Pub. L. 93–58, § 4(a),
Pub. L. 92–603, title II, § 299I,
Amendment by Pub. L. 90–248 applicable with respect to services furnished after
Miscellaneous
Pub. L. 96–473, § 2(c),
Pub. L. 106–170, title II, § 202(c),
Pub. L. 98–21, title III, § 309(q)(2),
Special payment of $50 as soon as practicable after
Pub. L. 93–58, § 4(b),