DI 45001.030 Completion of the Automated 101 (A101)

Follow MS MCS 014.000 for the preparation and routing instructions of the A101. NOTE: MS MCS 014.012, especially if there is an indication by the FO that premiums will be covered under a State buy-in agreement (FAC code “PW”). If the claimant is already entitled to monthly benefits (or Medicare based on age or disability) when the ESRD disability determination is made, an A101 need not be prepared; however, prepare and dispatch a Form HCFA-8063 in the usual manner (see DI 45001.045). Then forward the case via SSA-559 to the benefit authorizer for annotation of Medicare coverage on the MBR. Show the following information on the SSA-559:

1. A. 

   The remark “ESRD CLAIMANT”,

2. B. 

   R-HI - (date),

3. C. 

   R-SMI - (date), if the claimant elects SMI,

4. D. 

   SMI option code (see SM 00850.000),

5. E. 

   The date dialysis began or transplant date (including date of hospitalization in preparation for transplant), whichever results in the earliest entitlement.

If not entitled to any repetitive monthly benefit, the claimant will be entitled to R-HI/R-SMI on his/her own SSN - even if insured status is met only on another SSN.

An award notice will also be required when an A101 is prepared. This will ordinarily be prepared manually on award Form SSA-L31-C1 (Social Security Health Insurance Certificate). Several of the necessary general information paragraphs (MG10, MG20, etc.) are preprinted on the reverse side of the SSA-L31-C1 and need not be assigned. The earnings reviewer is responsible for assigning the paragraphs listed below. These paragraphs should be displayed under the claims symbol in item 12 of the A101, if space permits, or on an SSA-573. Additionally, they should be sequenced in the order shown below.

1. 1. 

   MA01: This paragraph with appropriate fill-ins should be assigned if the proof of birth code in item 6 of the A101 is a “B”, “C”, “F” or “Q”.

2. 2. 

   MH16: This paragraph with appropriate fill-ins should be shown if the date of entitlement is based on transplant.

3. 3. 

   MH17: This paragraph should be shown if the date of entitlement is based on dialysis. (If the claimant participated in a self-care dialysis training program and development is currently being taken to determine if the facility is approved, this paragraph should be modified along the lines of the first paragraph in DI 45001.080.)

4. 4. 

   Equitable Relief: If equitable relief applies, one of the paragraphs listed in DI 45001.060 should be included in the award notice.

See DI 45001.081 through DI 45001.086 for appropriate notices in conversion cases. It is not necessary that an award notice be sent if the conversion notice was sent.