Identification Number:
DI 45001 TN 8
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:ODO Processing of Initial End-Stage Renal Disease (ESRD) Medicare Cases
Type:POMS Full Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part DI – Disability Insurance
Chapter 450 – Processing End-Stage Renal Disease (ESRD) Medicare Cases
Subchapter 01 – ODO Processing of Initial End-Stage Renal Disease (ESRD) Medicare Cases
Transmittal No. 8, 01/13/2023

Audience

PSC: CA, CS, DE, DEC, DTE, ICDS, IES, ISRA, PETE, RECONR, SCPS, TSA, TST;
OCO-OEIO: CR, ERE, FDE, RECONE, RECONR;
OCO-ODO: CST, CT, DE, DEC, DS, PAS, PETL, RECONE;
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

Office of Disability Policy (ODP) is establishing this POMS for processing center (PC) 7 benefit authorizers to assist with the processing of Extended Months of Coverage of Immunosuppressive Drugs for Kidney Transplant Patients and Other Renal Dialysis Provisions (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 45001.400 Processing Center (PC) 7 Instructions for Medicare Part B Immunosuppressive Drug

Subsection Section A explains the Consolidated Appropriations Act, 2021 (CAA 2021).

Subsection Section B explains how to process Part B-ID enrollments.

Subsection Section C explains how to process Part B-ID disenrollments.

Subsection Section D explains terminating Part B-ID when entitlement to Medicare exists.

Subsection Section E details POMS references mentioned.

DI 45001.400 Processing Center (PC) 7 Instructions for Medicare Part B Immunosuppressive Drugs Coverage (Part B-ID)

A. General

On December 27, 2020, the President signed the Consolidated Appropriations Act, 2021 (CAA 2021) that includes Medicare enrollment changes. Section 402 of the Extended Months of Coverage of Immunosuppressive Drugs for Kidney Transplant Patients and Other Renal Dialysis Provisions (Part B-ID), allows a person who does not have certain other health insurance coverage that includes immunosuppressive drugs to enroll in Part B-ID. 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 provision allows Part B-ID beyond the original 36 months. Coverage begins January 1, 2023.

B. Processing a Part B-ID enrollment

All Part B-ID actions are completed in processing center (PC) 7. If the form CMS-10798 Application for Enrollment in Part B Immunosuppressive Drug Coverage form is misrouted, load the form into PC7’s paperless system using the Evidence Portal (EP). For instructions on loading to the EP, see DI 11052.046D. Before uploading CMS-10798 to the EP, write Part B-ID Enrollment across the top of the form.

All actions for Part B-ID, and any actions on records that have active Part B-ID, must be processed via the Manual Adjustment Credit & Award Data Entry (MACADE). PC 7 handles all Part B-ID enrollment and disenrollment actions. All other post entitlement actions are processed in the PC of jurisdiction.

Enrollment requests can be identified in the paperless system by Type of Event Level (TOEL) HISMI PBID.

Requests for enrollment may be taken over the telephone by the Office of Disability Operations Teleservice Center, or the beneficiary may complete the CMS-10798 Application for Enrollment in Part B Immunosuppressive Drug Coverage. If the form CMS-10798 is completed or received by the field office, staff will upload the form into PC7’s paperless system for processing.

Review to ensure the request is complete by:

 

  • Confirming eligibility for Part B-ID is met using HI 00805.400. Ensure the individual is or was entitled to Medicare Part A based on ESRD that has or will terminate 36 months after a successful kidney transplant;

  • Ensuring the file contains the request to enroll in Part B-ID; and

  • Ensuring the file contains an attestation that the individual does not have and does not expect to enroll in certain other health insurance that includes immunosuppressive drugs coverage. The beneficiary must agree to notify Social Security within 60 days of obtaining other coverage.

    NOTE: If the individual has Medicare or certain other health insurance as explained in DI 11052.046B1, they are not eligible to enroll in Part B-ID.

  • Once the request is reviewed, the benefit authorizer (BA) may input the action via MACADE. See SM 00850.800.

  • The following day, review the action to ensure the MBR updated.

C. Processing a Part B-ID disenrollment

Disenrollment request can be identified by TOELs HISMI PBIDTRM.

Request for disenrollment may be taken over the telephone by the Office of Disability Operations Teleservice Center, or the beneficiary may complete form CMS-1763 Request For Termination Of Premium Hospital And/Or Supplementary Medical Insurance. If the form CMS-1763 is completed or received by the field office, staff will upload the form into PC7’s paperless system for processing.

Review to ensure the request is complete by:

 

  • Reviewing the record to determine if the individual reported other health coverage and chose a future termination date. You may input that termination date, so long as it is within 6 months in the future; and

    NOTE: We cannot process terminations more than 6 months in the future.

  • Reviewing the record to determine if the individual did not report other coverage or did not specify a termination date. The date of termination is the first day of the month following the month after we discover the individual has other health coverage or after the request is filed.

    Example: If an individual files a Part B-ID disenrollment request May 2023 and does not indicate a termination date then the date of termination would be June 2023.

  • Once the request is reviewed, the BA may input the action via MACADE. See SM 00850.800

  • The following day, review the action to ensure the MBR updated.

D. Terminating Part B-ID when entitlement to Medicare exists

If the record has an active Part B-ID enrollment and an action to entitle the person to Medicare occurs, terminate Part B-ID effective the same month the new Supplemental Medical Insurance (SMI) coverage begins. See SM 00850.800.

E. References

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

SM 00850.800 Immunosuppressive Drug Coverage Part B (PBID)


DI 45001 TN 8 - ODO Processing of Initial End-Stage Renal Disease (ESRD) Medicare Cases - 1/13/2023