DI 45001: ODO Processing of Initial End-Stage Renal Disease (ESRD) Medicare Cases
The 1972 Amendments to the Social Security Act extended health insurance coverage to people who have Chronic Renal Disease (CRD) and require dialysis (including peritoneal dialysis) or kidney transplantation.
Effective October 1, 1978, amendments to title II and title XVIII of the Social Security Act made significant modifications in the CRD provisions of the Medicare program. By law, it is designated the End-Stage Renal Disease (ESRD) program although SSA will in its communications to claimants continue to refer to it by the less ominous term, “chronic renal disease.”
B. Requirement for entitlement
The law provides that an individual may be deemed disabled for purposes of coverage under Parts A (R-HI) and B (R-SMI) of Medicare based on ESRD if that individual:
meets one of the following conditions:
is entitled to monthly social security benefits, or to an annuity under Railroad Retirement Act (RRA), or
is medically determined to:
have ESRD, and
is undergoing regular dialysis or has received a kidney transplantation, and
is under age 65:
is any age for entitlement in 10/78 or later, or is under age 65 for entitlement prior to 10/78; (be alert to indications of age 65 HI/SMI and the need to associate the ESRD file with such prior Medicare files; etc.), and
has filed an application;
the CMS-43 (Application for Hospital Insurance Benefits for Individuals with End Stage Renal Disease) is the prescribed application form. However; any signed request for, or inquiry about, Medicare on behalf of a specified ESRD patient is considered an application filed as of the date of receipt by SSA, CMS, or RRB, (or the date of the postmark if more advantageous), provided it is perfected by filing of the prescribed application within 6 months after the month its completion is requested in writing. If an individual dies the application may be filed by a proper applicant on his behalf after the patient’s death (see HI 00801.196). The application is retroactivity limited to 12 months from the application date of inquiry (as described above). Finalization of the regulatory authority for the policy providing that an application may be effectively filed after the claimant’s death was published March 25, 1983.
C. Dates of entitlement to R-HI
(See HI 00801.216).
If the above requirements for entitlement are met, entitlement to R-HI begins the earliest of the first day of:
the 3rd month after the month in which dialysis begins; or
the month dialysis begins, if before the qualifying period would have ended, the individual begins a self-dialysis training program in a renal Medicare approved center, has completed or is expected to complete the program, and can reasonably be expected to self-dialyze after the training (i.e., effective 10/1/78, the qualifying period may be waived in cases of appropriate self-dialysis training), or
the month dialysis is resumed following a previously terminated period of R-HI (i.e., no new qualifying period, 10/78 on, if prior R-HI entitlement existed); or
the month of kidney transplant surgery; or
the month 10/78 or later, a decision of transplant surgery is made, provided:
the individual is an inpatient in a renal Medicare approved hospital when the decision is made, and
surgery is performed no later than 2 months after the month of that decision; or
two months prior to the month of transplant surgery, 10/78 or later, provided:
The requirements in 5. (above) are met except that the surgery is performed more than 2 months after the month of decision.
This provision would be applicable should surgery be postponed.
NOTE: If an issue of early transplant entitlement prior to 10 /78 arises, see HI 00801.221B. The first possible month of entitlement under the 1978 Amendments is 10/78.
D. Dates of entitlement to R-SMI
(See HI 00801.251).
The first month of R-HI entitlement is the first month of R-SMI eligibility, and R-SMI claimants are deemed to have enrolled in R-SMI in the first 3 months of their IEP (initial enrollment period). Unless R-SMI is refused, R-SMI entitlement begins:
the first month of R-HI entitlement, or
the month of enrollment is processed or the month of the filing, should there be a premium arrearage of 6 months or more and the claimant prefers either date over the first month of R-HI entitlement, or
July 1st following the end of a GEP (general enrollment period—the first calendar quarter of the year), if SMI was refused after entitlement to R-HI but subsequently elected during a GEP.
NOTE: The Omnibus Budget Reconciliation Act of 1981 reinstates the General Enrollment Period effective October 1, 1981. For the period April 1, 1981 through September 30. 1981, (see HI 00805.700) claimants could file for SMI and be entitled 3 months after the month of the filing. This is no longer possible (beginning October 1, 1981) as claimants must now wait until the next GEP (see item 3. above).
E. Termination events for R-HI
(See HI 00820.030).
Hospital insurance based on ESRD ends with the earliest of the following events:
the date of death of the individual, or
the last day of the 36th month after the month in which the individual receives a kidney transplant, unless on or before such last day he/she begins a course of dialysis or receives another transplant. For transplants occurring prior to 9/77, see HI 00820.030. (Although coverage prior to 10/ 78 is limited to 12 months after the month of the transplant, the 12 months limitation affects only transplants occurring prior to 9/77 in light of the overlap of the 12 months and 36 months coverage provisions); or
the last day of the 12th month after the month in which the individual terminates dialysis, unless on or before such last day, he/she receives a transplant or begins a new course of dialysis.