TN 67 (02-24)

HI 00801.216 ESRD Medicare Date of Entitlement - Dialysis

A. Policy - Qualifying period

1. Definition

Entitlement to R-HI cannot begin earlier than the first day of the third month after the month in which a regular course of dialysis begins. This 3 month delay is called the qualifying period.

NOTE: Even if dialysis begins on the last day of a month, the entire month is counted for purposes of the qualifying period. That is, whether a person begins dialysis on, e.g., August 1 or August 31, entitlement begins with November 1.

2. Waiver of qualifying period

The qualifying period is waived if, at any time during that period, the individual begins training in self-care dialysis in the expectation of self-dialyzing thereafter (see HI 00801.226). For this waiver to apply, however, the facility providing the training must have its training program approved by CMS’s Office of Clinical Standards and Quality.

The qualifying period is also waived when an individual who has had a previous period of R-HI is subsequently reentitled to R-HI.

3. Other requirements met later

Entitlement cannot begin before the month in which the requirements in HI 00801.191C. are met.

B. Policy — Dialysis ends during qualifying period

The R-HI claim must be disallowed if a patient discontinues dialysis before the qualifying period ends and does not resume dialysis or receive a transplant by the time the claim for R-HI is adjudicated.

If it is not learned until after the R-HI award is made that dialysis was discontinued, the R-HI award is annulled. R-SMI (if awarded) is not annulled under the equitable relief rules, but is terminated with the same month in which the action is taken to annul R-HI.

C. Policy - Dialysis ends after the qualifying period

If an ESRD patient is on dialysis throughout the qualifying period but discontinues treatments shortly thereafter and does not resume dialysis for a period of months or at all, R-HI is nevertheless awarded. R-HI ends with the last day of the twelfth month following the month dialysis ends unless the patient has a transplant or resumes dialysis before the end of that 12 month period.

D. References

  • Effect of a kidney transplant on entitlement, HI 00801.221

  • More information on waiver of the qualifying period based on self-care dialysis training, HI 00801.226

  • Termination of R-HI, HI 00820.030

  • Explanation of equitable relief for erroneous SMI awards, HI 00805.210

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HI 00801.216 - ESRD Medicare Date of Entitlement - Dialysis - 02/27/2024
Batch run: 02/27/2024