Identification Number:
HI 00805 TN 52
Intended Audience:See Transmittal Sheet
Originating Office:Centers for Medicare & Medicaid Services (CMS)
Title:Supplementary Medical Insurance Entitlement
Type:POMS Transmittals
Program:Medicare
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part HI – Health Insurance
Chapter 008 – Requirement for Entitlement and Termination
Subchapter 05 – Supplementary Medical Insurance Entitlement
Transmittal No. 52, 08/08/2022

Audience

PSC: BET, BTE, CR, CST, CTE, DEC, EHI, LCC, PAS, PCS, PETL, RECONR;
OCO-OEIO: BET, BIES, CCRE, CR, CTE, EIE, ERE, FCR, PETL, RECONE, RECONR;
OCO-ODO: BET, BTE, CR, CST, CTE, CTE TE, DEC, PAS, PETE, PETL;
FO/TSC: CS, CS TII, CSR, CTE, DRT, FR, OA, OS, RR, TA, TSC-CSR;

Originating Component

CMS

Effective Date

Upon Receipt

Background

CMS created a new Mediare Part B policy.

Summary of Changes

HI 00805.400 Medicare Part B IMMUNOSUPPRESSIVE DRUG COVERAGE (PART B-ID)

Updated policy with new sections, subsections, and language.

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

Section 1836(b); 42 C.F.R. 407.1, 407.55, 407.57, 407.59, 407.62, 408.20, and 423.30

A. Introduction

An individual who receives a kidney transplant must take immunosuppressive drugs to help prevent the individual from rejecting the transplanted kidney. Entitlement to Medicare, and coverage of immunosuppressive drugs under Part B, ends 36 months after the month in which an individual receives a successful kidney transplant.

The Consolidated Appropriations Act of 2021 amended section 1836(b) of the Social Security Act to provide solely for coverage of immunosuppressive drugs beginning January 1, 2023, for eligible individuals whose entitlement to Medicare based on End-Stage Renal Disease (ESRD) ends the 36th month after the month in which the individuals receive a successful kidney transplant. We refer to this new benefit as the Part B immunosuppressive drug benefit or “Part B-ID.”

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

B. Eligibility for Part B-ID

An individual is eligible for Part B-ID if he or she:

  1. 1. 

    Is or was entitled to Medicare Part A based on End-Stage Renal Disease (R-HI) that ends 36 months after a successful kidney transplant; and

  2. 2. 

    Attests that he or she is not enrolled in other certain health coverage, as discussed in section D., that would make them ineligible for Part B-ID.

C. Attestation

Every individual enrolling in Part B-ID must:

  1. 1. 

    Attest that they are not enrolled in other health coverage and do not expect to enroll in other coverage which would make them ineligible for Part B-ID; and

  2. 2. 

    Agree to notify SSA within 60 days of enrolling in other health coverage.

NOTE: An individual can inform us of other health coverage up to 6 months in advance.

D. Other health coverage that makes an individual ineligible for Part B-ID

An individual who has other certain health coverage is not eligible for Part B-ID. Other health coverage includes:

  • 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; and

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

E. When enrollment may occur

There are no enrollment periods associated with Part B-ID. Therefore, eligible individuals can enroll at any time.

  1. 1. 

    R-HI entitlement ends on or after January 1, 2023:

    • An eligible individual whose R-HI entitlement ends on or after January 1, 2023, may enroll in Part B-ID any time after their R-HI entitlement ends.

  2. 2. 

    R-HI entitlement ends prior to January 1, 2023:

    • An eligible individual whose R-HI entitlement ends prior to January 1, 2023, may enroll in Part B-ID beginning October 1, 2022 and their coverage will start the later of January 2023 or the month after they enroll.

F. Reenrollment

Individuals who had previously enrolled in Part B-ID can reenroll at any time if they meet the eligibility requirements in section B.

NOTE: Late enrollment penalties are not applicable to Part B-ID enrollment. See more under section K (Part B-ID Premiums).

 

G. Effective Date of Entitlement

  1. 1. 

    R-HI ends on or after January 1, 2023:

    • If an individual’s R-HI entitlement ends on or after January 1, 2023, and they submit the attestation before the end of the 36th month after the month of the successful kidney transplant, Part B-ID begins effective with the month their R-HI terminates.

    • If the attestation is submitted after R-HI entitlement ends, Part B-ID begins the month following the month in which the attestation is submitted

  2. 2. 

    R-HI ends prior to January 1, 2023:

    • If an individual’s entitlement to R-HI ended prior to January 1, 2023, and they enroll between October 1, 2022 through December 31, 2022, Part B-ID begins effective January 1, 2023.

    • If an individual enrolls after December 31, 2022, Part B-ID begins the following month.

      For example: Mr. John Doe applies for Part B-ID. on January 1, 2023. His benefits for Part B-ID will begin February 1, 2023.

H. Procedure for enrolling in PB-ID

Eligible individuals may enroll by:

  1. 1. 

    Calling SSA at 1-877-465-0355 and providing an oral attestation, or

  2. 2. 

    Completing and filing the Application for Enrollment in Part B Immunosuppressive Drug Coverage Form CMS-10798 and mailing it to the following address:

SOCIAL SECURITY ADMINISTRATION OFFICE OF CENTRAL OPERATIONS
PO Box 32914
BALTIMORE, MARYLAND 21298-2703

Route all CMS-10798 forms to the PC 7 by submitting into Evidence Portal (EP).

NOTE: The Office of Disability Operations’ Teleservice Center (ODO TSC) only will handle the telephonic enrollments and PC 7 will process the Part B-ID applications. If a CMS-10798 is received in a PC that is not PC 7 route the enrollment via EP to PC 7.

If enrolled, the individual will receive a new Medicare card that will display the Part B-ID enrollment.

I. Termination of Part B-ID

  1. 1. 

    Individuals who enroll in certain other health coverage are required to report to SSA and Part B-ID will terminate.

    1. a. 

      When a Part B-ID covered individual notifies SSA that they have enrolled in certain other health coverage, as described in section D, and if not otherwise specified, Part B-ID terminates effective with the first day of the month following the month we receive the notification.

    2. b. 

      If the individual states that their certain other health insurance begins in the future, the individual may request a termination date up to 6 months in the future.

      • Example: If an individual enrolls in employer health coverage during an employer’s open enrollment period in October, for a January 1st effective date, the individual can submit their request for termination of the Part B-ID benefit in October or November, and not lose their Part B-ID benefit prior to the January 1st effective date.

If a Part B-ID covered individual fails to notify us of their enrollment in certain other health coverage, Part B-ID will terminate effective the first day of the month after the month in which we discover the individual has other health coverage as described in section D.

  1. 2. 

    Voluntary termination request

    1. a. 

      Part B-ID terminates effective with the first day of the month following the month we receive the request.

    2. b. 

      If the individual files a request within 30 days after the date of the notice that buy-in coverage has ended, the individual's entitlement ends on the last day of the last month for which the State paid the premium.

  1. 3. 

    Death - Entitlement to Part B-ID continues into the month of death, up to and including the date of death.

  2. 4. 

    Non-payment of premiums – Part B-ID coverage will terminate for non-payment of premiums following the same rules, including grace periods, used for Medicare Part B for monthly billing in HI 01001.095.

  3. 5. 

    Individual becomes entitled to Medicare on another basis – In cases where a Part B-ID enrollee becomes eligible for Medicare based on age, disability, or ESRD, Part B-ID will terminate effective with the last day of the month prior to the month in which they become entitled on the other basis.  Equitable relief for retroactivity may apply.

J. Procedure for Termination of Part B-ID

Individuals enrolled in the Part B-ID benefit can report attainment of certain other health coverage and request to terminate their enrollment by either:

  1. 1. 

    Calling SSA at 1-877-465-0355 to disenroll verbally over the phone, or

  2. 2. 

    Completing and submitting Form CMS-1763, Request for Termination of Premium Hospital and/or Supplementary Medical Insurance, and mailing it to:

SOCIAL SECURITY ADMINISTRATION OFFICE OF CENTRAL OPERATIONS
PO Box 32914
BALTIMORE, MARYLAND 21298-2703
  1. 3. 

    Or submitting any other request to SSA that shows the unequivocal desire to end Part B-ID coverage.

    Load into Evidence Portal (EP) the CMS-1763 that indicates disenrollment from Part B-ID.

    If a CMS-1763 that indicates disenrollment for Part B-ID is received in a PC that is not PC 7. Route the disenrollment via EP to PC 7.

NOTE: The Office of Central Operations Office of Disability Operations’ Teleservice Center (ODO TSC) only will handle the telephonic disenrollment and PC 7 will process the disenrollment and other actions for Part B-ID.

When the individual is reporting attainment of certain other health coverage and choosing a future termination date, a termination effective date that is more than 6 months in the future cannot be processed.

K. Part B-ID Premiums

Part B-ID premiums may be adjusted based on:

  • Rounding

  • The income-related monthly adjusted amounts (IRMAA), and

  • The hold harmless provision.

    NOTE: The premiums will not be increased based on late enrollment.

    If the individual is directly billed for premiums, billing will be on a monthly basis.

L. Medicare Savings Programs for Part B-ID Premiums

Beneficiaries with limited income and resources may be eligible for assistance through the Medicare Savings Programs. See HI 00815.023.


HI 00805 TN 52 - Supplementary Medical Insurance Entitlement - 8/09/2022