SSA - POMS: DI 11052.005 - Developing Initial End-Stage Renal Disease Medicare Cases

A. Obtain form CMS-2728 (End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration)

When the field office (FO) receives a completed form CMS-2728, the FO must determine the claimant's current Medicare status prior to taking the claim and before the FO forwards form CMS-2728 and other documentation to the Processing Center 7(PC7).

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If the FO receives form CMS-2728 directly from the dialysis facility before the ESRD claimant files an application, attempt to contact the claimant or the appropriate applicant to complete an application. If contact is unsuccessful, prepare a 6-month closeout notice using the receipt date of form CMS-2728 as the protective filing date.
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If the FO receives form CMS-43 (Application for Health Insurance Benefits Under Medicare for Individual with Chronic Renal Disease), with no form CMS-2728, contact the ESRD facility to obtain form CMS-2728. You may need to obtain information about the facility from the claimant. Refer to HI 00801.233H for rules on when a photocopy of form CMS-2728 may be acceptable.

References:

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HI 00801.258 Relationship Between R-HI, D-HI, and Age 65 HI
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HI 00801.233 Medical Evidence of ESRD – Form CMS-2728-U3
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HI 00801.302 Medical Review of ESRD Claims
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HI 00801.902 CMS-2728-U3, End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration-Exhibit

B. Obtain a completed ESRD claim

Obtain a completed claim for ESRD Medicare either electronically via the Modernized Claims System (MCS) using the claimant's own Social Security number (SSN) or on paper form CMS-43. If you obtain a completed paper form CMS-43, enter the ESRD claim into MCS immediately.

NOTE: Always establish the ESRD claim using the claimant's own SSN even if they are not insured on their own record.

The following are ESRD-specific inputs for the MCS application screens:

MCS Application Screens

Screen	Instruction
APPL (MSOM MS 03505.009)	CLAIM TYPE: 8 (ESRD) - Applies to all claimants filing for ESRD whether based on their own insured status or based on the insured status of a parent or spouse.
IDEN (MSOM MS 03505.059)	DISABLED IN LAST 14 MONTHS - If the claim is for ESRD only, answer N. If the claimant is also filing a disability claim, answer Y.
IDN2 (MSOM MS 03505.060)	Cross-reference SSN: If the claimant is currently entitled on another SSN, enter that SSN.
ADDB (MSOM MS 03505.012)	WILL MEDICARE APPLY: For all ESRD claims, answer this question with either 1-YES or 3-ALREADY ENROLLED ON ANOTHER SSN. If you answer 2-NO, MCS generates the following inter-screen edit: "INVALID ENTRY - WILL MEDICARE APPLY (ADDB) MUST BE 1 OR 3 FOR THIS CLAIM TYPE, CLAIM TYPE = ESRD."
NMAR (MSOM MS 03505.037)	If the claimant is filing for ESRD based on their spouse's insured status, enter the spouse's date of birth on this screen. MCS generates the following inter-screen edit when the date of birth is missing: "BIRTHDATE (NMAR) MUST CONTAIN DATA IF FILING ON SSN OF SPOUSE (ESRD)."
HIKD (MSOM MS 02003.005)	This screen collects information about kidney dialysis and kidney transplant. Complete this screen to process an allowance. Resolve any discrepancies in dates provided by the claimant's allegation and the information found on form CMS-2728. Only complete the section(s) that apply. You can establish a dialysis record, a transplant record, or both, as applicable. NOTE: Form CMS-2728 provides important start and stop dates for dialysis, transplant, and self-dialysis that you will need in order to complete this screen.
ESRD (MSOM MS 03505.029)	This screen captures ESRD filing information. FILING ON SSN OF: Complete this section if the claimant is not insured and filing under the insured status of a spouse or parent.
HIHI (MSOM MS 02003.002)	This screen captures Medicare enrollment data. CAUTION: See DI 11052.001G if the claimant has group health plan (GHP) coverage. IMPORTANT: ESRD - Medicare Part B supplemental medical insurance (R-SMI) covers most of the dialysis expenses ESRD patients incur. If the claimant decides it is advantageous to refuse Part B, as discussed in HI 00801.091D.3, they may choose to postpone filing for R-SMI. If an R-HI claimant elects to decline R-SMI, then, before awarding R-HI, you must explain the effects of such a decision and document the case file to show that the claimant understands the consequences of their action. Pages 13 and 14 of the CMS pamphlet, Medicare Coverage of Kidney Dialysis and Kidney Transplant Services (CMS-10128), explains (in easy-to-understand terms) GHP coverage and the requirement to have R-HI at the time of transplant in order for Medicare to pay for immunosuppressive drugs. TYPE OF ACTION: Enter to enroll in or refuse ESRD Medicare Part B (R-SMI). Other options also available are to withdraw, cancel withdrawal, or waive equitable relief. Options 1 and 2 are the most common at the initial claim level. EQUITABLE RELIEF REQUESTED (Y/N): Enter "Y" if you make an entry in the SMI OPTION field at the bottom of the screen. ESRD OPTIONS: If there are more than six months of retroactive entitlement to R-HI, the claimant can elect R-SMI effective: the first month of R-HI, the month of filing, or the month of processing. BENEFICIARY RESTRICTED HI ENTITLEMENT MONTH (MMYY): This field is optional. Enter the calendar month and year HI entitlement is to begin for premium-free HI. SELECT SMI OPTION ONLY IF PROCESSING DATE IS MORE THAN 5 MONTHS AFTER THE FIRST POSSIBLE MONTH OF ENTITLEMENT - SMI OPTION: Complete this section only if the claimant does not want to (or is unable to) pay premiums back to original date of entitlement. Your choices are, application month or processing month. Because a claimant awarded R-HI retroactively may have difficulty paying the R-SMI premium arrearage, SSA will allow the claimant to choose their R-SMI entitlement month. Equitable relief provisions apply to an R-SMI premium arrearage of six months or more. If you enter an SMI entitlement month, refer to DI 11052.020B to determine whether you also enter "Y" in the EQUITABLE RELIEF REQUESTED field.
DECI (MSOM MS 03509.013)	PC 7 has jurisdiction of all ESRD claims. If the PC JURIS field displays a different PC or office, update this field to PC 7. An MCS earnings computation processing limitation requires the FO to prepare an A101. NOTE: Process ESRD applications by attestation per GN 00201.015, Alternative Signature Methods.

Reference:

HI 00801.248, Effect of Immunosuppressive Drug Coverage on Filing for R-HI and R-SMI

C. Obtain proof of age (POA)

POA is required whenever attainment of age 22 or 62 affects fully insured status of an insured number holder who does not have 40 quarters of coverage. The FO should obtain POA following the usual POA guidelines in GN 00302.030. In addition, if the claimant is a child of the insured, POA is required to determine dependency requirements as explained in DI 11052.005D, in this section.

References

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HI 00801.191 Requirements for Entitlement to R-HI
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DI 11052.001 Initial End-Stage Renal Disease Medicare Cases

D. Evidence of relationship and dependency

Apply the same relationship requirements (except as noted in D.1 below) and require the same proofs as if the claimant is filing for monthly benefits on the NH’s earnings record. HI 00801.201C explains the relationship and dependency requirements in detail.

1. Other R-HI relationship requirements

a.

If an ESRD patient who is ineligible for Medicare because they are uninsured, marries a Retirement Survivors Disability Insurance (RSDI) beneficiary or a person who is fully or currently insured, the insured status requirement is met as of the first day of the month of marriage.
b.
A dependent child for purposes of R-HI is an ESRD patient who is unmarried, and meets the relationship requirements for child's insurance benefits on the SSN of a NH:
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  At or after the onset of ESRD, or
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  At the time the NH died (if the NH is deceased).

2. Other R-HI dependency requirements

In addition to the relationship requirement, at the time of ESRD onset the ESRD patient must meet the following dependency requirements:

a.

Is under age 22 or is under a disability which began before attainment of age 22; or
b.

Has attained age 22, but has not attained age 26 and
c.

Is receiving at least one-half support from the NH; and
d.

Has received such support continuously since the day before attainment of age 22. Temporary interruptions such as a stay in a hospital or a visit with a relative do not prevent the claimant from meeting this requirement.

E. Dependent adult child over the age of 22

An adult child who has not attained the age 26 and files for ESRD Medicare benefits based on the insured status of a parent must provide proof of dependency on the parent. It is not necessary for a claimant to be entitled or eligible for disability benefits in order to qualify as a dependent disabled child for ESRD Medicare benefits. If dependency cannot be established, the Disability Determination Services (DDS) must make a determination as to disability prior to age 22. While the DDS will make a disability prior to age 22 determination, the disability determination does not need to be based on ESRD specifically. The disability finding may be based on another medical or physical condition(s).

The FO will take the following steps when the claim requires a DDS determination:

1.
Transfer case to DDS for a prior to age 22 disability determination
1. a.
  
  Obtain form SSA-3368 (Disability Report - Adult), one SSA-827 Authorization to Disclose Information to the Social Security Administration and available medical evidence. The DDS will determine if disability onset can be established prior to age 22, therefore attempt to also obtain the claimant's medical sources prior to age 22.
2. b.
  
  Complete form SSA-3367 (Disability Report - Field Office) and add the following remark: "ESRD Medicare only, prior to age 22 disability determination needed."
3. c.
  
  Prepare a brown folder with all materials and transfer the case to DDS for a disability determination. NOTE: These cases are exclusions to the Electronic Disability Collect System (EDCS).
2.
DDS determination completed
1. a.
  
  Favorable determination
  
  The FO will process the allowance determination via A101 according to instructions in DI 11052.030.
2. b.
  
  Unfavorable determination
  
  The DDS will provide the FO with a personalized disability explanation (PDE) to include in the claimant's denial notice. The FO will process the denial determination and issue a manual denial notice with the PDE.

References:

DI 23050.005 ESRD Medicare Only for CDB Cases

F. Consider retroactivity of Medicare enrollment

ESRD cases are eligible for up to 12 months retroactivity. This may result in possible premium arrearage. Consider this retroactive amount when determining entitlement dates for R-HI and R-SMI. DI 11052.020B.1. discusses how to handle premium arrearage.

G. Prepare Form SSA-892 (End-Stage Renal Disease (ESRD) Medicare Determination)

In all cases, complete form SSA-892 prior to adjudicating the claim and releasing the notice of determination. HI 00801.308 explains how to complete this form.