§1395q — Title 42 The Public Health and Welfare | U.S. Code

Summary

Sets the rules for when a person’s coverage period for this medical insurance starts and stops. Coverage always begins on the latest of these: July 1, 1966 (or July 1, 1973 for a disabled person under age 65), or a date tied to when the person enrolls or is treated as if enrolled. Exactly when it starts depends on when you enroll and whether enrollment happens before or after January 1, 2023. That date can be the first day of the month you enroll, the first day of the next month, or in some cases the first day of the second or third month after you enroll. For some earlier enrollments the start could be the July 1 after you enroll. If you are treated as having enrolled, special timing rules apply that can also look back to July 1, 1973. Coverage stays in effect until you cancel it or stop paying premiums. If your hospital insurance is based on disability (not age 65), your coverage ends at the end of the last month you are entitled to hospital insurance. Only expenses you incur while you are in a coverage period can be paid. Special enrollment periods have their own start rules: some let coverage begin the month you enroll (with an option to pick one of the next three months), others begin the month after enrollment, one type starts January 1, 2025, and one lets the Secretary set a start date to protect continuous coverage. For coverage of immunosuppressive drugs, deemed enrollment starts the first day of the month you first meet the rule; if you later enroll, it starts January 1, 2023 or the month after you enroll, whichever is later. That drug coverage ends for the usual reasons and also if you gain other specified benefits or lose eligibility. The Secretary may run public education about more complete health coverage options.

Title 42, §1395q

The Public Health and Welfare — Source: USLM XML via OLRC

(a)The period during which an individual is entitled to benefits under the insurance program established by this part (hereinafter referred to as his “coverage period”) shall begin on whichever of the following is the latest:

(1)July 1, 1966, or (in the case of a disabled individual who has not attained age 65) July 1, 1973; or

(2)(A)in the case of an individual who enrolls pursuant to subsection (d) of section 1395p of this title before the month in which he first satisfies paragraph (1) or (2) of section 1395o(a) of this title, the first day of such month,

(B)in the case of an individual who first satisfies such paragraph in a month beginning before January 2023 and who enrolls pursuant to such subsection (d)—

(i)in such month in which he first satisfies such paragraph, the first day of the month following the month in which he so enrolls,

(ii)in the month following such month in which he first satisfies such paragraph, the first day of the second month following the month in which he so enrolls, or

(iii)more than one month following such month in which he satisfies such paragraph, the first day of the third month following the month in which he so enrolls,

(C)in the case of an individual who first satisfies such paragraph in a month beginning on or after January 1, 2023, and who enrolls pursuant to such subsection (d) in such month in which he first satisfies such paragraph or in any subsequent month of his initial enrollment period, the first day of the month following the month in which he so enrolls, or

(D)in the case of an individual who enrolls pursuant to subsection (e) of section 1395p of this title in a month beginning—

(i)before January 1, 2023, the July 1 following the month in which he so enrolls; or

(ii)on or after January 1, 2023, the first day of the month following the month in which he so enrolls; or

(3)in the case of an individual who is deemed to have enrolled—

(A)on or before the last day of the third month of his initial enrollment period, the first day of the month in which he first meets the applicable requirements of section 1395o(a) of this title or July 1, 1973, whichever is later, or

(B)on or after the first day of the fourth month of his initial enrollment period, and where such month begins—

(i)before January 1, 2023, as prescribed under subparagraphs (B)(i), (B)(ii), (B)(iii), and (D)(i) of paragraph (2), or

(ii)on or after January 1, 2023, as prescribed under subparagraphs (C) and (D)(ii) of paragraph (2).

(b)An individual’s coverage period shall continue until his enrollment has been terminated—

(1)by the filing of notice that the individual no longer wishes to participate in the insurance program established by this part, or

(2)for nonpayment of premiums.

(c)In the case of an individual satisfying paragraph (1) of section 1395o(a) of this title whose entitlement to hospital insurance benefits under part A is based on a disability rather than on his having attained the age of 65, his coverage period (and his enrollment under this part) shall be terminated as of the close of the last month for which he is entitled to hospital insurance benefits.

(d)No payments may be made under this part with respect to the expenses of an individual unless such expenses were incurred by such individual during a period which, with respect to him, is a coverage period.

(e)Notwithstanding subsection (a), in the case of an individual who enrolls during a special enrollment period pursuant to section 1395p(i)(3) or 1395p(i)(4)(B) of this title—

(1)in any month of the special enrollment period in which the individual is at any time enrolled in a plan (specified in subparagraph (A) or (B), as applicable, of section 1395p(i)(3) of this title or specified in section 1395p(i)(4)(A)(i) of this title) or in the first month following such a month, the coverage period shall begin on the first day of the month in which the individual so enrolls (or, at the option of the individual, on the first day of any of the following three months), or

(2)in any other month of the special enrollment period, the coverage period shall begin on the first day of the month following the month in which the individual so enrolls.

(f)Notwithstanding subsection (a), in the case of an individual who enrolls during a special enrollment period pursuant to section 1395p(k) of this title, the coverage period shall begin on the first day of the month following the month in which the individual so enrolls.

(g)Notwithstanding subsection (a), in the case of an individual who enrolls during a special enrollment period pursuant to section 1395p(m) of this title, the coverage period shall begin on a date the Secretary provides in a manner consistent (to the extent practicable) with protecting continuity of health benefit coverage.

(h)In the case of an individual described in section 1395o(b)(1) of this title, the following rules shall apply:

(1)In the case of such an individual who is deemed to have enrolled in part B for coverage of immunosuppressive drugs under section 1395p(n)(3) of this title, such individual’s coverage period shall begin on the first day of the month in which the individual first satisfies section 1395o(b) of this title.

(2)In the case of such an individual who enrolls (or reenrolls, if applicable) in part B for coverage of immunosuppressive drugs under paragraph (2) or (4) of section 1395p(n) of this title, such individual’s coverage period shall begin on January 1, 2023, or the month following the month in which the individual so enrolls (or reenrolls), whichever is later.

(3)The provisions of subsections (b) and (d) shall apply with respect to an individual described in paragraph (1) or (2).

(4)In addition to the reasons for termination under subsection (b), the coverage period of an individual described in paragraph (1) or (2) shall end when the individual becomes entitled to benefits under this subchapter under subsection (a) or (b) of section 426 of this title, or under section 426–1 of this title, or is no longer eligible for such coverage as a result of the application of section 1395o(b)(2) of this title.

(5)The Secretary may conduct public education activities to raise awareness of the availability of more comprehensive, individual health insurance coverage (as defined in section 300gg–91 of this title) for individuals eligible under section 1395o(b) of this title to enroll or to be deemed enrolled in the medical insurance program established under this part for purposes of coverage of immunosuppressive drugs.

(i)Notwithstanding subsection (a), in the case of an individual who enrolls during the special enrollment period pursuant to section 1395p(o) of this title, the coverage period shall begin on January 1, 2025.

Notes & Related Subsidiaries

Editorial Notes

Amendments

2022—Subsec. (i). Pub. L. 117–108 added subsec. (i). 2020—Subsec. (a)(2). Pub. L. 116–260, § 120(a)(1)(A), amended par. (2) generally. Prior to amendment, par. (2) related to coverage period for individuals enrolling pursuant to section 1395p(d) of this title. Subsec. (a)(3). Pub. L. 116–260, § 120(a)(1)(B), amended par. (3) generally. Prior to amendment, par. (3) read as follows: “(A) in the case of an individual who is deemed to have enrolled on or before the last day of the third month of his initial enrollment period, the first day of the month in which he first meets the applicable requirements of section 1395o of this title or

July 1, 1973, whichever is later, or “(B) in the case of an individual who is deemed to have enrolled on or after the first day of the fourth month of his initial enrollment period, as prescribed under subparagraphs (B), (C), (D), and (E) of paragraph (2) of this subsection.” Subsec. (b). Pub. L. 116–260, § 402(c)(2), inserted in concluding provisions “or section 1395p(n)(3) of this title” after “section 1395p(f) of this title” in two places. Subsec. (c). Pub. L. 116–260, § 402(a)(2)(B)(i), substituted “section 1395o(a) of this title” for “section 1395o of this title”. Subsec. (g). Pub. L. 116–260, § 120(a)(2)(B), added subsec. (g). Subsec. (h). Pub. L. 116–260, § 402(c)(1), added subsec. (h). 2006—Subsec. (f). Pub. L. 109–171 added subsec. (f). 2003—Subsec. (a)(1). Pub. L. 108–173 inserted comma after “1966”. 1997—Subsec. (e). Pub. L. 105–33 inserted “or 1395p(i)(4)(B)” after “1395p(i)(3)” in introductory provisions and “or specified in section 1395p(i)(4)(A)(i) of this title” after “1395p(i)(3) of this title” in par. (1). 1994—Subsec. (e). Pub. L. 103–432 amended pars. (1) and (2) generally. Prior to amendment, pars. (1) and (2) read as follows: “(1) in the first month of the special enrollment period, the coverage period shall begin on the first day of that month, or “(2) in a month after the first month of the special enrollment period, the coverage period shall begin on the first day of the month following the month in which the individual so enrolls.” 1986—Subsec. (b). Pub. L. 99–509 substituted “month following the month” for “calendar quarter following the calendar quarter” in second and sixth sentences. Subsec. (e). Pub. L. 99–272 amended subsec. (e) generally. Prior to amendment, subsec. (e) read as follows: “Notwithstanding subsection (a) of this section, in the case of an individual who enrolls during a special enrollment period pursuant to— “(1) subparagraph (A) of section 1395p(i)(3) of this title— “(A) before the month in which he attains the age of 70, the coverage period shall begin on the first day of the month in which he has attained the age of 70, or “(B) in or after the month in which he attains the age of 70, the coverage period shall begin on the first day of the month following the month in which he so enrolls; or “(2) subparagraph (B) of section 1395p(i)(3) of this title— “(A) in the first month of the special enrollment period, the coverage period shall begin on the first day of such month, or “(B) in a month after the first month of the special enrollment period, the coverage period shall begin on the first day of the month following the month in which he so enrolls.” 1984—Subsec. (e). Pub. L. 98–369, § 2338(c), added subsec. (e). 1981—Subsec. (a)(2)(E). Pub. L. 97–35, § 2151(a)(3), substituted “the July 1 following” for “the first day of the third month following”. Subsec. (b). Pub. L. 97–35, § 2106(b)(2), struck out provision that notice filed by an individual enrolled pursuant to section 1395p(f) of this title shall not be considered a disenrollment for purposes of section 1395p(b) of this title. 1980—Subsec. (a)(2)(E). Pub. L. 96–499, § 945(c)(1), substituted “the first day of the third month” for “the July 1”. Subsec. (b). Pub. L. 96–499, § 947(b), inserted “(except as otherwise provided in section 1395v(e) of this title)”. 1972—Subsec. (a)(1). Pub. L. 92–603, § 201(c)(3)(A), inserted “or (in the case of a disabled individual who has not attained age 65)

July 1, 1973” after “

July 1, 1966”. Subsec. (a)(2). Pub. L. 92–603, § 201(c)(3)(B), substituted in subpar. (A) “paragraph (1) or (2)” for “paragraphs (1) and (2)” and in subpars. (B) to (D) “paragraph” for “paragraphs”. Subsec. (a)(3). Pub. L. 92–603, § 206(b), added par. (3). Subsec. (b). Pub. L. 92–603, §§ 206(c), 257(a), inserted provisions relating to an individual who is deemed to have enrolled for medical insurance pursuant to section 1395p(f) of this title and an individual who is deemed enrolled for medical insurance benefits pursuant to section 1395p(f) of this title and struck out provisions limiting the allowable grace period to 90 days and inserted provision for extension of such period of up to 180 days where failure to pay premiums is due to good cause. Subsecs. (c), (d). Pub. L. 92–603, § 202(c)(3)(C), added subsec. (c) and redesignated former subsec. (c) as (d). 1968—Subsec. (b). Pub. L. 90–248 struck out “, during a general enrollment period described in section 1395p(e) of this title,” after “notice” in par. (1), and substituted in first sentence following par. (2) “the calendar quarter following the calendar quarter” for “December 31 of the year”.

Statutory Notes and Related Subsidiaries

Effective Date

of 2006 AmendmentAmendment by Pub. L. 109–171 effective Jan. 1, 2007, see section 5115(b) of Pub. L. 109–171, set out as a note under section 1395p of this title.

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of 1997 AmendmentAmendment by Pub. L. 105–33 applicable to involuntary terminations of coverage under a group health plan occurring on or after Aug. 5, 1997, see section 4581(c) of Pub. L. 105–33, set out as a note under section 1395p of this title.

Effective Date

of 1994 AmendmentAmendment by Pub. L. 103–432 effective on first day of first month beginning after expiration of the 120-day period that begins on Oct. 31, 1994, see section 147(f)(1)(C) of Pub. L. 103–432, set out as a note under section 1395p of this title.

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of 1986 Amendment Pub. L. 99–509, title IX, § 9344(b)(2), Oct. 21, 1986, 100 Stat. 2042, provided that: “The

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made by paragraph (1) [amending this section] shall apply to notices filed on or after

July 1, 1987.” Amendment by Pub. L. 99–272 effective

May 1, 1986, see section 9201(d)(2) of Pub. L. 99–272, set out as a note under section 1395p of this title.

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of 1984 AmendmentFor

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of amendment by Pub. L. 98–369, see section 2338(d)(2) of Pub. L. 98–369, set out as a note under section 1395p of this title.

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of 1981 AmendmentAmendment by section 2106(b)(2) of Pub. L. 97–35 effective Apr. 1, 1981, see section 2106(c) of Pub. L. 97–35, set out as a note under section 1395l of this title. Amendment by section 2151(a)(3) of Pub. L. 97–35 not applicable to enrollments pursuant to written requests for enrollment filed before Oct. 1, 1981, see section 2151(b) of Pub. L. 97–35, set out as a note under section 1395p of this title.

Effective Date

of 1980 AmendmentAmendment by section 945(c)(1) of Pub. L. 96–499 applicable to enrollments occurring on or after Apr. 1, 1981, see section 945(d) of Pub. L. 96–499, set out as a note under section 1395p of this title. Amendment by section 947(b) of Pub. L. 96–499 applicable to notices filed after third calendar month beginning after Dec. 5, 1980, see section 947(d) of Pub. L. 96–499, set out as a note under section 1395v of this title.

Effective Date

of 1972 Amendment Pub. L. 92–603, title II, § 257(b), Oct. 30, 1972, 86 Stat. 1447, provided that: “The

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made by subsection (a) [amending this section] shall apply with respect to nonpayment of premiums which become due and payable on or after the date of the enactment of this Act [Oct. 30, 1972] or which became payable within the 90-day period immediately preceding such date; and for purposes of such

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any premium which became due and payable within such 90-day period shall be considered a premium becoming due and payable on the date of the enactment of this Act.”

Effective Date

of 1968 AmendmentAmendment by Pub. L. 90–248 effective Apr. 1, 1968, see section 145(e) of Pub. L. 90–248, set out as a note under section 1395p of this title. Coverage Period; Termination Dates Pub. L. 90–97, § 3(a), Sept. 30, 1967, 81 Stat. 249, provided that: “In the case of any individual who, pursuant to section 1838(b)(1) of the Social Security Act [42 U.S.C. 1395q(b)(1)], terminates his enrollment in the insurance program established under part B of title XVIII of such Act [42 U.S.C. 1395j et seq.], his coverage period (as defined in section 1838(a) of such Act) [42 U.S.C. 1395q(a)]—“(1) shall terminate at the close of

December 31, 1967, if he filed his notice of termination before

January 1, 1968, or “(2) shall terminate at the close of

March 31, 1968, if he filed his notice of termination after

December 31, 1967, and before

April 1, 1968. An individual whose coverage period terminated pursuant to paragraph (1) at the close of

December 31, 1967, may, notwithstanding section 1837(b)(2) of such Act [42 U.S.C. 1395p(b)(2)], enroll in such program before

April 1, 1968, and for purposes of section 1838(a)(2)(E) [42 U.S.C. 1395q(a)(2)(E)] and 1837(b)(2) of such Act [42 U.S.C. 1395p(b)(2)] such enrollment shall be deemed an enrollment under section 1837(e) of such Act [42 U.S.C. 1395p(e)] and a second enrollment under such part.” Extension of 1967 General Enrollment Period Through

March 31, 1968Extension of the general enrollment period under section 1395p(e) of this title through

March 31, 1968, see section 1 of Pub. L. 90–97, Sept. 30, 1967, 81 Stat. 249, set out as a note under section 1395p of this title. Coverage Period for Individuals Becoming Eligible in March 1966 Who Enroll in May 1966 Pub. L. 89–384, § 3(d), Apr. 8, 1966, 80 Stat. 105, provided that: “In the case of an individual who first satisfies paragraphs (1) and (2) of section 1836 of the Social Security Act [42 U.S.C. 1395o] in March, 1966, and who enrolls pursuant to subsection (d) of section 1837 of such Act [42 U.S.C. 1395p] in May 1966, his coverage period shall, notwithstanding section 1838(a)(2)(D) of such Act [42 U.S.C. 1395q(a)(2)(D)], begin on

July 1, 1966.” Commencement of Coverage Period of Certain EnrolleesCommencement of coverage period upon enrollment before Oct. 1, 1966 of eligible individuals failing for good cause to enroll before

June 1, 1966, see section 102(b) of Pub. L. 89–97, set out as a note under section 1395p of this title.

§1395q Coverage period

Summary

Title 42, §1395q

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