Identification Number:
DI 11052 TN 3
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:DI 11052.046 Field Office (FO) Processing Instructions for Extended Coverage of Immunosuppressive Dr
Type:POMS Full Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part DI – Disability Insurance
Chapter 110 – Initial Claims Processing
Subchapter 52 – FO Processing of Initial End-Stage Renal Disease (ESRD) Medicare Cases
Transmittal No. 3, 01/12/2023

Audience

PSC: CA, CS, DE, DEC, DTE, ICDS, IES, ISRA, RECONR, SCPS, TSA, TST;
OCO-OEIO: BET, CR, CTE, ERE, FCR, FDE, FDEC, RECONE, RECONR, RECOVR;
OCO-ODO: BET, BTE, CR, CST, CTE, CTE TE, DE, DEC, DS, PAS, PETE, PETL, RCOVTA, RECONE, RECOVR;
ODD-DDS: REF;
FO/TSC: CS, CS TII, CS TXVI, CSR, CTE, DRT, FR, OA, OS, RR, TA, TSC-CSR;

Originating Component

ODP

Effective Date

Upon Receipt

Background

We are establishing this POMS to assist with the processing of Extended Coverage of Immunosuppressive Drugs for Kidney Transplant (Part B-ID) claims. On December 27, 2020, the President signed the Consolidated Appropriations Act, 2021 (CAA 2021) which established Part B-ID which allows a person who has no other health insurance coverage that covers immunosuppressive drugs to enroll in Part B-ID.

Summary of Changes

DI 11052.046 Field Office (FO)Processing Instructions for Extended Coverage of Immunosuppressive Drugs for Kidney Transplant Patients (Part B-ID)

Subsection B details Part B-ID applicant enrollment request instructions when an individual is in person or an individual makes a telephone request.

Subsection C explains how to handle Part B-ID applicant dis-enrollment request and details that development process on how to handle in person and telephone request.

DI 11052.046 Field Office (FO)Processing Instructions for Extended Coverage of Immunosuppressive Drugs for Kidney Transplant Patients (Part B-ID)

A. General

On December 27, 2020, the President signed the Consolidated Appropriations Act, 2021 (CAA 2021), which includes Medicare enrollment changes. Section 402, Extended Months of Coverage of Immunosuppressive Drugs for Kidney Transplant Patients and Other Renal Dialysis Provisions, which allows a person who has no other certain health insurance coverage to enroll in drug coverage under Medicare Part B (Part B-ID) (see HI 00805.400D for list of excluded health coverages). Enrollment in Medicare Parts A and B for people who have End-Stage Renal Disease (ESRD) generally ends 36 months after a successful kidney transplant. This new provision allows Part B-ID coverage, solely for immunosuppressive drugs, to extend beyond the original 36 months. This extended coverage may start as early as January 1, 2023, or the month following the month in which the signed application and attestation is submitted.

Beneficiaries enrolled in Part B-ID will not be covered for any other Medicare benefit(s) or for any items or services other than Part B-ID.

B. Handling a Part B-ID enrollment request

1. Applicant comes into the field office (FO) and request to apply for PART B-ID

  1. a. 

    A Customer Service Representative (CSR),Claims Specialist (CS), or Claims Technical Expert (CTE) verifies the applicant identity .

  2. b. 

    The CS/CTE determines potential eligibility for Part B-ID.

  3. c. 

    Using instructions in HI 00805.400, the CS/CTE reviews the health insurance that would exclude an individual form extended immunosuppressive drug eligibility:

    • Group health plans, individual health plans (including Marketplace), or national health plans ;

    • TRICARE for Life;

    • Medicaid or State Children’s Health Insurance Program (CHIP) coverage that includes immunosuppressive drugs;

    • Medicare entitlement already established based on age, disability or ESRD; and

    • Enrolled in the patient enrollment system of the Department of Veterans Affairs (VA) or otherwise eligible to receive immunosuppressive drugs from the VA.

  4. d. 

    After verifying eligibility or applicant indicates a desire to apply even if they are not eligible, the CS/CTE will instruct the applicant to complete the Part B-ID form CMS-10798 (Application for Enrollment in Part B Immunosuppressive Drug Coverage).

  5. e. 

    After the applicant completes and signs the form CMS-10798, the CS/CST must load the form into PC7's paperless using the Evidence Portal (EP). For instructions on loading to the EP, see DI 11052.046.D. Before uploading CMS-10798 to the EP, the CS/CST will write Part B-ID Enrollment across the top of the form.

  6. f. 

    After the CS/CTE submits the enrollment request, the CS should inform the applicant that:

    • The enrollment request will be reviewed, and a determination regarding eligibility will be rendered, within 30 days;

    • A determination notice will be mailed to the applicant regarding the immunosuppressive drug enrollment request. If the applicant is granted enrollment into the Part B immunosuppressive drug coverage (Part B-ID), the applicant will receive a new Medicare card that will display “ IMMUNO drug only” to indicate the individual’s immunosuppressive drug enrollment.

 

2. Applicant calls the FO and request to apply for Part B-ID

  1. a. 

    The CSR/CS/CTE will advise the caller to contact the telephonic enrollment unit at 1-877-465-0355, which will allow the caller to telephonically to enroll in Part B-ID: or

    NOTE:The telephonic enrollment unit is open 5 days a week (M-F) from 8:30AM to 6:00PM eastern time. This number is only for Part B-ID enrollment or dis-enrollment requests and should not be given out for other requests.

  2. b. 

    If the applicant does not want to enroll over the phone, the CSR/CS/CTE will advise the caller to download a fillable Part B-ID form from www.cms.gov, CMS-10798 (Application Enrollment in Part B Immunosuppressive Drug Coverage). If the applicant does not have online accessibility, mail the form CMS-10798 to the applicant to fill out and return to the address below.

    SOCIAL SECURITY ADMINISTRATION
    OFFICE OF CENTRAL OPERATIONS
    PO BOX 32914
    BALTIMORE, MARYLAND 21298

C. Handling a PART B-ID dis-enrollment request

1. Beneficiary comes into the FO and request to dis-enroll from PART B-ID

  1. a. 

    The CSR/CS/CTE will verify the beneficiary's identity.

  2. b. 

    The CSR/CS/CTE will provide the beneficiary with form CMS-1763 (Request for Termination of Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage) and ask the beneficiary to complete the form.

    • The CSR/CS/CTE will reverify the beneficiary's identity before accepting a dis-enrollment request.

    • The CS will inform the beneficiary that if a beneficiary does not indicate when they wish coverage to end, dis-enrollment/termination will automatically occur the month after the request.

    • The CSR/CTE will annotate the CMS-1763 “Beneficiary did not provide a termination date.”

      Note: 

      A dis-enrollment request cannot be processed more than 6 months in the future. If the beneficiary does provides a date exceeding 6 months, advise the beneficiary to recontact the agency at a later time.

  3. c. 

    After the beneficiary completes and signs the form, the CSR/CS/CTE must load the form into PC7's paperless using the Evidence Portal (EP). For instruction on loading into the EP, see DI 11052.046.D. The CS/CST will inform the beneficiary that SSA will take action on the beneficiary’s request.

 

2. Applicant calls the FO and request to dis-enroll from PART B-ID

  1. a. 

    CS will advise the caller to contact 1-877-465-0335 to submit a telephonic dis-enrollment; or

    Note: 

    The telephone unit is open 5 days a week (M-F) from 8:30AM to 6:00PM eastern time .This number is only for immunosuppressive drug benefit or "Part B-ID or dis-enrollment" request and should not be given out for other request Do not give out the unit number if it’s not a Part B-ID enrollment or dis-enrollment request.

  2. b. 

    If the applicant does not want to dis-enroll over the phone the CSR/CS/CTE will advise the caller that they can download the fillable CMS 1763 (Request for Termination of Part A, Part B, or Part B Immunosuppressive Drug Coverage)from www.cms.gov. If the applicant does not have online accessibility, mail form CMS-1763 to the applicant to fill out and return to the address below.

    SOCIAL SECURITY ADMINISTRATION
    OFFICE OF CENTRAL OPERATIONS
    PO BOX 32914
    BALTIMORE, MARYLAND 21298

 

D. Proper Routing of Forms

1. If your office receives form CMS-10798 Application for Enrollment in Part B Immunosuppressive Drug Coverage .

Upload CMS-10798 to the EP as follows:

  • Under “Document Type,” select “CMS 10798 Part B-ID”.

  • Does this document require Involvement by the Processing Center? Select Yes.

  • Under “Comments,” type the following information: “Part B-ID ENROLLMENT”.

  • Select the claimant from the “Claim File Matching” options listed for existing claim filings.

  • Under “Storage Method,” select “Import”.

  • Click the “Next” button to upload the file.

NOTE: For the form to be routed properly to the centralized unit in PC7 the correct Type of Event Level (TOEL), (document type) must be selected in EP.

 

2. If your office receives form Part B-ID CMS-1763 Request for Termination of Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage

Upload CMS-1763- Part B-ID Only Termination to the EP as follows:

  • Under “Document Type,” select “CMS 1763 -Part B-ID Only Termination”.

  • Does this document require Involvement by the Processing Center? Select Yes.

  • Under “Comments,” type the following information: “Part B-ID disenrollment”.

  • Select the claimant from the “Claim File Matching” options listed for existing claim filings.

  • Under “Storage Method,” select “Import”.

 

E. References

HI 00805.400 Medicare Part B Immunosuppressive Drug Coverage (Part B-ID)

 


DI 11052 TN 3 - DI 11052.046 Field Office (FO) Processing Instructions for Extended Coverage of Immunosuppressive Dr - 1/12/2023