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42 U.S.C. § 426 — Entitlement to hospital insurance benefits

submitted 91 years ago by Pub. L. 89-97 to r/title-42-THE-PUBLIC-HEALTH-AND-WELFARE · 2,241 words · no verdicts yet

in plain englishAI-generated · not legal advice

This law says who qualifies for Medicare Part A hospital insurance. People 65 or older who get Social Security or railroad retirement benefits are covered. People under 65 usually need 24 months of disability benefits first, though people with ALS get coverage right away.

(a) Individuals over 65 years. A person who has turned 65 gets hospital insurance under Medicare Part A once they meet one more condition: (A) they get monthly Social Security benefits, would get them except they haven't applied, would get them but for someone else's failure to qualify, or (B) they are a "qualified railroad retirement beneficiary," or (C) they would qualify under (A) if certain government work counted as covered employment, and they apply. Once a person meets these rules, coverage starts with the first month after June 1966 that they qualify. (b) Individuals under 65 years. A person under 65 gets hospital insurance if they have been entitled, for 24 months, to (A) disability insurance benefits, child's insurance benefits based on disability, or widow's or widower's insurance benefits based on disability, or (B) status as a disabled qualified railroad retirement beneficiary, or (C) they would qualify under (A) if certain government work counted as covered employment, and they filed the right application. Coverage begins with the later of July 1973 or the 25th month of that entitlement, and ends the month after the person is notified their entitlement ended, or earlier if they turn 65 first. If a person tried working during a "trial work period" that ended under section 422(c)(4)(A), and their entitlement later ended, they are still treated as entitled — for up to 78 months — as long as the disabling condition continues and they still could not do substantial gainful work. For counting when entitlement ends, a "36-month" rule elsewhere in the law is treated as a "15-month" rule for this purpose. (c) Conditions. For subsection (a), being entitled to hospital insurance for a month means the government will pay, subject to Medicare Part A's limits, for inpatient hospital care, care in a skilled nursing facility after a hospital stay, and home health services received in the United States (or abroad only in narrow, specified cases). Two exceptions apply: no payment for nursing-facility care before January 1967, and no payment for that care unless the hospital stay that qualified the person happened after June 30, 1966, or the month they turned 65 (whichever is later) — unless they qualified instead under subsection (b). Also, a person who dies is treated as if they had been entitled to Social Security or railroad retirement benefits for the month they died, if they would have qualified had they died the next month instead. (d) "Qualified railroad retirement beneficiary" defined. This term means someone the Railroad Retirement Board has certified to the Secretary under section 231f(d) of title 45. A person stops being a qualified railroad retirement beneficiary at the end of the month before the Board certifies that they no longer meet the requirements. (e) Benefits for widows and widowers. Several technical adjustments apply when figuring out disability-based hospital insurance for widows and widowers: certain "age 60" references are treated as "age 65," and certain "before age 60" language is treated as "based on a disability." Months a person received Supplemental Security Income or certain state supplemental payments count toward the 24-month requirement. A person who switches from widow's or widower's disability benefits to old-age benefits is treated as still entitled to the widow's or widower's benefits for counting purposes. A disabled widow or widower age 50 or older who is getting mother's or father's benefits, and who would have qualified for widow's or widower's disability benefits had they applied, is treated as having applied. And for certain individuals, entitlement to widow's or widower's benefits is figured without regard to a remarriage-related rule in section 402(j)(4). (f) Medicare waiting period for recipients of disability benefits. When counting the 24 months required under subsection (b), months from an earlier period of entitlement do not count if that earlier period ended more than 60 months (for disability or disabled-child benefits) or more than 84 months (for disabled widow's or widower's benefits) before the person's current disability began — unless the current disabling condition is the same as, or directly related to, the earlier one. (g) Information regarding eligibility of Federal employees. The Secretary and the Director of the Office of Personnel Management must jointly set up procedures to make sure federal employees whose government work counts toward Medicare fully understand: their eligibility or potential eligibility for hospital insurance based on that work; what is required for that eligibility; and that they must apply on time to become entitled under subsection (b)(2)(C) — with special attention to people applying for a federal retirement annuity based on disability. (h) Waiver of waiting period for individuals with ALS. For a person medically diagnosed with amyotrophic lateral sclerosis (ALS), three special rules apply: subsection (b) is applied as if there were no minimum length of entitlement required beyond one month; entitlement begins the first month of that entitlement rather than the 25th month; and subsection (f)'s waiting-period rule does not apply at all. (i) Certain uninsured individuals. For hospital insurance rules covering certain uninsured individuals, this section points readers to section 426a of this title.
the actual law source: uscode.house.gov ↗public domain
(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,

(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,

shall be entitled to hospital insurance benefits under part A of subchapter XVIII 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 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 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)—

(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 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) 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 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), 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) 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), 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, 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) 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), 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) in the case of an individual described in clause (iii) of subsection (b)(2)(A), 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) (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), 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, (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), 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) 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) shall not be applied.

(i) Certain uninsured individuals

For entitlement to hospital insurance benefits in the case of certain uninsured individuals, see section 426a of this title.

Source credit: (Aug. 14, 1935, ch. 531, title II, § 226, as added Pub. L. 89–97, title I, § 101, July 30, 1965, 79 Stat. 290; amended Pub. L. 90–248, title I, § 129(c)(1), Jan. 2, 1968, 81 Stat. 847; Pub. L. 92–603, title II, §§ 201(b), 299I, Oct. 30, 1972, 86 Stat. 1371, 1463; Pub. L. 93–58, § 3, July 6, 1973, 87 Stat. 142; Pub. L. 93–233, § 18(f), Dec. 31, 1973, 87 Stat. 969; Pub. L. 93–445, title III, § 305, Oct. 16, 1974, 88 Stat. 1358; Pub. L. 95–216, title III, §§ 332(a)(3), 334(d)(4)(B), Dec. 20, 1977, 91 Stat. 1543, 1546; Pub. L. 95–292, §§ 1(b), 3, June 13, 1978, 92 Stat. 308, 315; Pub. L. 96–265, title I, §§ 103(a)(1), (b), 104(a), June 9, 1980, 94 Stat. 444; Pub. L. 96–473, § 2(a), Oct. 19, 1980, 94 Stat. 2263; Pub. L. 96–499, title IX, § 930(q), Dec. 5, 1980, 94 Stat. 2633; Pub. L. 97–35, title XXII, § 2203(e), Aug. 13, 1981, 95 Stat. 837; Pub. L. 97–248, title II, § 278(b)(2)(A), (B), (4), Sept. 3, 1982, 96 Stat. 560, 561; Pub. L. 98–21, title I, § 131(a)(3)(H), (b)(3)(G), title III, § 309(q)(1), Apr. 20, 1983, 97 Stat. 93, 117; Pub. L. 98–369, div. B, title VI, § 2663(a)(17), July 18, 1984, 98 Stat. 1165; Pub. L. 99–272, title XIII, § 13205(b)(2)(A), (C)(ii), Apr. 7, 1986, 100 Stat. 317; Pub. L. 100–203, title IV, § 4033(a), formerly § 4033(a)(1), title IX, § 9010(e)(3), Dec. 22, 1987, 101 Stat. 1330–77, 1330–294, renumbered Pub. L. 100–360, title IV, § 411(e)(2), July 1, 1988, 102 Stat. 775; Pub. L. 100–360, title IV, § 411(n)(1), July 1, 1988, 102 Stat. 807; Pub. L. 100–485, title VI, § 608(f)(5), Oct. 13, 1988, 102 Stat. 2424; Pub. L. 101–508, title V, § 5103(c)(2)(C), Nov. 5, 1990, 104 Stat. 1388–252; Pub. L. 103–296, title II, § 201(a)(3)(D)(i), Aug. 15, 1994, 108 Stat. 1497; Pub. L. 105–33, title IV, § 4002(f)(1), Aug. 5, 1997, 111 Stat. 329; Pub. L. 106–170, title II, § 202(a), Dec. 17, 1999, 113 Stat. 1894; Pub. L. 106–554, § 1(a)(6) [title I, § 115(a)], Dec. 21, 2000, 114 Stat. 2763, 2763A–474; Pub. L. 108–173, title I, § 101(e)(1), Dec. 8, 2003, 117 Stat. 2150; Pub. L. 108–203, title IV, § 418(b)(4)(B)(vii), Mar. 2, 2004, 118 Stat. 533; Pub. L. 114–74, title VIII, § 844(a), Nov. 2, 2015, 129 Stat. 617.)

history & why it existsrecord from the source credit
  • 1935Enacted · Pub. L. 89-97 · 79 Stat. 290
  • 1968Amended · Pub. L. 90-248 · 81 Stat. 847
  • 1972Amended · Pub. L. 92-603 · 86 Stat. 1371, 1463
  • 1973Amended · Pub. L. 93-58 · 87 Stat. 142
  • 1973Amended · Pub. L. 93-233 · 87 Stat. 969
  • 1974Amended · Pub. L. 93-445 · 88 Stat. 1358
  • 1977Amended · Pub. L. 95-216 · 91 Stat. 1543, 1546
  • 1978Amended · Pub. L. 95-292 · 92 Stat. 308, 315
  • 1980Amended · Pub. L. 96-265 · 94 Stat. 444
  • 1980Amended · Pub. L. 96-473 · 94 Stat. 2263
  • 1980Amended · Pub. L. 96-499 · 94 Stat. 2633
  • 1981Amended · Pub. L. 97-35 · 95 Stat. 837
  • 1982Amended · Pub. L. 97-248 · 96 Stat. 560, 561
  • 1983Amended · Pub. L. 98-21 · 97 Stat. 93, 117
  • 1984Amended · Pub. L. 98-369 · 98 Stat. 1165
  • 1986Amended · Pub. L. 99-272 · 100 Stat. 317
  • 1987Amended · Pub. L. 100-203 · 101 Stat. 1330
  • 1988Amended · Pub. L. 100-360 · 102 Stat. 807
  • 1988Amended · Pub. L. 100-485 · 102 Stat. 2424
  • 1990Amended · Pub. L. 101-508 · 104 Stat. 1388
  • 1994Amended · Pub. L. 103-296 · 108 Stat. 1497
  • 1997Amended · Pub. L. 105-33 · 111 Stat. 329
  • 1999Amended · Pub. L. 106-170 · 113 Stat. 1894
  • 2000Amended · Pub. L. 106-554 · 114 Stat. 2763, 2763
  • 2003Amended · Pub. L. 108-173 · 117 Stat. 2150
  • 2004Amended · Pub. L. 108-203 · 118 Stat. 533
  • 2015Amended · Pub. L. 114-74 · 129 Stat. 617

A history note hasn’t been published yet. The record shows enactment by Pub. L. 89-97 on 1935-08-14.

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