This screen captures Medicare enrollment data. CAUTION: See DI 11052.001G if the claimant has group health plan (GHP) coverage.
IMPORTANT: ESRD - Medicare Part B supplemental medical insurance (R-SMI) covers most
of the dialysis expenses ESRD patients incur. If the claimant decides it is advantageous
to refuse Part B, as discussed in HI 00801.091D.3, they may choose to postpone filing for R-SMI. If an R-HI claimant elects to decline
R-SMI, then, before awarding R-HI, you must explain the effects of such a decision
and document the case file to show that the claimant understands the consequences
of their action. Pages 13 and 14 of the CMS pamphlet, Medicare Coverage of Kidney
Dialysis and Kidney Transplant Services (CMS-10128), explains (in easy-to-understand
terms) GHP coverage and the requirement to have R-HI at the time of transplant in
order for Medicare to pay for immunosuppressive drugs.
TYPE OF ACTION: Enter to enroll in or refuse ESRD Medicare Part B (R-SMI). Other options also available
are to withdraw, cancel withdrawal, or waive equitable relief. Options 1 and 2 are
the most common at the initial claim level.
EQUITABLE RELIEF REQUESTED (Y/N): Enter "Y" if you make an entry in the SMI OPTION field at the bottom of the screen.
ESRD OPTIONS: If there are more than six months of retroactive entitlement to R-HI, the claimant
can elect R-SMI effective: the first month of R-HI, the month of filing, or the month
of processing.
BENEFICIARY RESTRICTED HI ENTITLEMENT MONTH (MMYY): This field is optional. Enter the calendar month and year HI entitlement is to begin
for premium-free HI.
SELECT SMI OPTION ONLY IF PROCESSING DATE IS MORE THAN 5 MONTHS AFTER THE FIRST POSSIBLE
MONTH OF ENTITLEMENT - SMI OPTION: Complete this section only if the claimant does not want to (or is unable to) pay
premiums back to original date of entitlement. Your choices are, application month
or processing month. Because a claimant awarded R-HI retroactively may have difficulty
paying the R-SMI premium arrearage, SSA will allow the claimant to choose their R-SMI
entitlement month. Equitable relief provisions apply to an R-SMI premium arrearage
of six months or more. If you enter an SMI entitlement month, refer to DI 11052.020B to determine whether you also enter "Y" in the EQUITABLE RELIEF REQUESTED field.
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