Effective Dates: 2/21/2025 - Present

Identification Number:
DI 11036 TN 4
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Amyotrophic Lateral Sclerosis (ALS) - Medicare Waiting Period Waived - FO
Type:POMS Full Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM

Part DI – Disability Insurance

Chapter 110 – Initial Claims Processing

Subchapter 36 – Amyotrophic Lateral Sclerosis (ALS) - Medicare Waiting Period Waived - FO

Transmittal No. 4, 02/21/2025

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

This transmittal incorporates updates to the 5-month waiting period exclusion policy to include all applicable scenarios and clear instructions on how to waive the waiting period. The policy instructions in this section are for cases involving ALS, also known as Lou Gehrig's disease. Effective July 23, 2020, the 5-month DIB entitlement waiting periods are waived for disabled claimants with ALS.

Summary of Changes

DI 11036.001 Amyotrophic Lateral Sclerosis (ALS) – Medicare Waiting Period Waived – Field Office (FO)

Language and formatting changes were made throughout this entire section to provide updates and clarity.

Updated and changed subsection titles to make clearer.

DI 11036.001 Amyotrophic Lateral Sclerosis – 5-Month and 24-Month Waiting Periods Waived – Field Office

A. Overview of waived waiting periods for ALS

The policy instructions in this section are for field office (FO) processing of cases involving ALS, also known as Lou Gehrig's disease. This policy does not apply to claims involving non-ALS anterior horn cell diseases (e.g., Werdnig-Hoffmann disease or spinal muscular atrophy). When responding to inquiries about why the policy does not cover other impairments, explain that currently the law only applies to individuals diagnosed with ALS. Do not attempt to explain why other impairments are not included.

1. No medicare waiting period for ALS

Since July 1, 2001, the 24-month waiting period for Medicare coverage is waived for disabled claimants with ALS. For an individual diagnosed with ALS, the date of Medicare entitlement is the date of entitlement to disability insurance benefits (DIB), disability widow(ers) benefits (DWB), or childhood disability benefits (CDB) based on the diagnosis of ALS.

2. No disability insurance benefits (DIB) waiting period for ALS cases

Since July 23, 2020, the 5-month DIB entitlement waiting periods is waived for disabled claimants with ALS.

For more information on DIB “no waiting period” cases, see DI 10105.075.

B. Initial claims processing

1. Terminal illness (TERI)

An allegation or diagnosis of ALS meets the TERI case criteria. Follow TERI procedures in DI 11005.601D when processing the claim.

NOTE: ALS cases are also priority cases under the Quick Disability Determination (QDD) and Compassionate Allowances (CAL) processes. For QDD policy see DI 11005.603 and for CAL policy see DI 11005.604.

2. Electronic Disability Collect System (EDCS)

Add the “ALS” and “TERI” EDCS flags to the claim prior to sending the case the Disability Determination Services (DDS).

For instructions on EDCS flags, see DI 81010.080B. For EDCS exclusions, use the ALS paper flag available in DI 11036.002.

3. Modernized Claims System (MCS)

a. Additional Benefits (ADDB) screen

Enter “1” (YES) to the question “Will Medicare Apply?” on the ADDB screen.

Processing an allowance through MCS Earnings Computation (EC) in an ALS case will establish the hospital insurance (HI) start date equal to the later of the date of entitlement for disability benefit (DOED) or 07/2001. For general information on MCS EC processing, see GN 01010.205.

b. Health Insurance (HIHI) screen

Enter the appropriate supplemental medical insurance (SMI) election information on the Health HIHI screen.

NOTE: MCS EC will automatically generate a SMI refusal paragraph (HIB152 as described in NL 00725.005) advising beneficiaries still in their initial enrollment period (IEP) who refuse SMI on their application that they still have a chance to elect SMI if they respond timely. However, if they do not respond timely and wish to enroll, they will have to wait for a general enrollment period (GEP) or file under the special enrollment period (SEP) provision if applicable.

c. Adjudication through MCS EC

MCS EC will automatically waive the 5-month and 24-month waiting periods for the claim when primary or secondary diagnosis code on the MCS Disability Allowance/Denial (DICL) screen equals 3350.

Typically, the code of 3350 will propagate onto the DICL screen when the DDS makes a favorable disability determination based on a diagnosis of ALS. If the diagnosis code does not propagate, the FO identifies the code in item of 18 of the SSA-831 (Disability Determination and Transmittal) form or electronic equivalent and will manually enter the diagnosis code 3350 on the DICL screen.

NOTE: The FO technician should carefully review the DDS provided diagnosis code in claims with ALS involved prior to adjudication and resolve any discrepancies to ensure waiver of the waiting period is properly applied.

d. Exclusions from District Office Final Authorization (DOFA) or MCS EC adjudication

For non-DOFA cases and other MCS EC exclusions, process the award via automated 101 (A101) or electronic form 101 (EF101). For more information on FO adjudication procedures and processing of determinations, see DI 10005.020B.4.

C. Claimant currently serving waiting period and alleges ALS post-entitlement

Cases where beneficiaries allege ALS and are currently serving the 5-month or 24-month waiting period are EDCS exclusions and require processing via the following steps:

1.      Obtain information from the claimant on a curtailed SSA-3368 (Disability Report - Adult), including:

  • •

    the ALS alleged onset date,

  • •

    the name, address, telephone number, and fax number of each medical source diagnosing ALS, and

  • •

    the date the claimant first saw each medical source for ALS.

    2.      Obtain an SSA-827 for each source,

    3.      Place materials in a brown paper folder.

    4.      Attach the ALS case flag to the front on the paper folder.

    5.      Send the paper folder to the DDS.

    6.      Establish a Modernized Development Worksheet (MDW) control pending for the DDS determination. The standard issue should be “ALS.”

NOTE: When curtailing completion of the SSA-3368, do not complete sections five (Education, Training, and Literacy) and six (Work History) of the form. For curtailed SSA-3368 procedures, see DI 11005.020C.

D. Post-entitlement determinations handled by the DDS

1. Favorable determination

All favorable determinations will be sent from the DDS to the servicing processing center (PC) for MACADE input. The DDS will also send a copy of the SSA-833 (Cessation or Continuance of Disability or Blindness Determination and Transmittal) to the FO as notification that the DDS determination is complete and the outstanding MDW ALS control can be closed after the FO enters the copy of the SSA-833 into the claimant’s electronic folder (EF) via Evidence Portal (EP).

2. Unfavorable determination

a.      Claimant found to have ALS after expiration of the 5-month and 24-month waiting periods

DDS will send to the PC for MACADE input to change the DIG or SDIG to 3350 and to update the medical re-exam diary to 7 years if necessary to reflect a disability of ALS. The DDS will also send a copy of the SSA-833 to the FO as notification that the DDS determination is complete and the outstanding MDW ALS control can be closed after the FO enters the copy of the SSA-833 into the claimant’s EF via EP.

b.      Claimant not found to have ALS

DDS will send to the FO to hold for the appeals period. The FO will:

o    Tickle the case for 65 days via MDW.

o    If no appeal filed after 65 days, input an MBR special message “ALS AOD MM/DD/YY denied – claimant must serve 24-month Medicare waiting period. See Evidence screen.” In Shared Processes, include in the “comments” portion of the Evidence screen the alleged ALS onset date and date of the DDS unfavorable determination notice.

o    Query for location of original folder and send all material to be associated with original folder. If the prior folder is a certified electronic folder (CEF), enter copies of the material into the CEF.

NOTE: Although the DDS receipts post-entitlement ALS cases as continuing disability reviews (CDR), the claimant is not entitled to Disability Hearings Office (DHO) appeal rights (i.e., no face-to-face hearing is required) because no cessation or adverse reopening is involved. If the claimant appeals the determination, annotate the level of the current appeal request (e.g., “ Reconsideration Request”) on the ALS coversheet and process the appeal in the usual manner for EDCS exclusions. For examples of appeals, see sections in GN 03101.000.


DI 11036 TN 4 - Amyotrophic Lateral Sclerosis (ALS) - Medicare Waiting Period Waived - FO - 2/21/2025