TN 31 (06-04)

HI 00801.258 Relationship Between R-HI, D-HI, and Age 65 HI

A. Introduction

R-HI entitlement can exist concurrently with HI entitlement based on age or disability.

R-HI does not terminate because of HI entitlement under another provision, and vice versa.

NOTE: Some individuals who can meet the relationship or currently insured status requirements for R-HI cannot meet the requirements for monthly benefits at age 65.

B. Policy — D-HI and R-HI

R-HI may begin earlier than D-HI, which usually involves a 24 month qualifying period. R-HI may also continue after D-HI ends, or vice versa. As explained in HI 00801.258D., an individual may also be able to have a “second IEP” based on ESRD.

If a person filing for DIB, or already entitled to DIB (even if already entitled to D-HI), is also eligible for R-HI, an R-HI claim must be developed. The only exception to this requirement is where Medicare will be secondary payer of benefits and the individual does not wish to become entitled to SMI until the end of the 30-month ESRD coordination period as described in HI 00801.247C.2.

C. Policy — Age 65- and R-HI

Dual entitlement to age 65 HI and R-HI guards against termination of Medicare if monthly benefits terminate. Also, R-HI entitlement for individuals entitled to Medicare based on age provides a “second IEP,” as explained in HI 00801.258D., if they did not enroll in SMI when first eligible.

If an individual with ESRD is filing for or already entitled to HI based on attainment of age 65, it is not necessary to obtain an application unless it is advantageous for the individual. It would be beneficial for the beneficiary to file if he/she:

  • is not currently enrolled in SMI;

  • is paying an increased premium because of late enrollment in SMI;

  • has recently become entitled to HI and SMI for the aged and entitlement to R-HI and R-SMI would result in an earlier entitlement date; or

  • is currently enrolled for Premium-HI and now meets insured status requirements for ESRD Medicare.

D. Policy - SMI rights of those who develop ESRD

An individual has a new IEP when he/she:

  • develops ESRD after he/she is entitled to HI based on age or disability, and

  • is not entitled to SMI.

The individual is automatically enrolled in R-SMI, along with R-HI, unless he/she refuses R-SMI. The new IEP begins 3 months before and ends 3 months after the first month of R-HI entitlement.

If the individual is already enrolled in SMI based on age or disability, but is paying a premium surcharge for late enrollment, the premium is reduced to the standard rate effective with the first month of R-HI entitlement.

EXAMPLE: Mr. Martinez has been a DIB beneficiary since 2/96. He refused SMI when he became entitled to D-HI in 2/98. He filed for SMI in the 2000 GEP and was assessed a 10 percent premium surcharge for late enrollment upon becoming entitled as of 7/1/00.

In 11/02, Mr. Martinez began a course of renal dialysis and filed for R-HI. His R-HI is effective with 2/1/03 and his SMI premium is reduced to the standard amount effective with 2/1/03.

If Mr. Martinez had not enrolled in SMI during the 2000 GEP, he could also have enrolled in R-SMI effective with 2/1/03 with no premium surcharge.

E. Policy - Individual not filing for R-HI

If a dually eligible ESRD patient is not currently filing for R-HI because of the MSP provisions, the CMS-2728-U3 must be returned to the facility.

If the individual is age 65 or over and there is no advantage in filing for R-HI, the CMS-2728-U3 must be destroyed.

NOTE: In both situations the ESRD Networks will transmit the information on the CMS-2728-U3 to CMS for statistical purposes.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0600801258
HI 00801.258 - Relationship Between R-HI, D-HI, and Age 65 HI - 04/22/2015
Batch run: 04/22/2015