DI 45001.010 Non-Medical Review of Non-DOFA ESRD Claims

A. Relationship to dependency

To establish that a claimant is, for R-HI purposes, the spouse or child of a person who is fully or currently insured or entitled to benefits, apply the same relationship requirements (except an noted below) and require the same proofs as if he/she were claiming monthly benefits on that person's earnings record. Obtain assistance from or refer the case to a claims authorizer on unresolved or complex issues of relationship (common-law, etc.) and dependency (support). Document the file of such referrals and the specific resolution and be certain these referrals are handled on a top priority basis. Also, see DI 45001.010C.

If insured status is acquired by a marital relationship after ESRD onset, the spouse's date of entitlement is the first day of the month of the marriage establishing the relationship and insured status. This differs from an individual who obtains insured status on his/her own employment, as in that case the entitlement date would be the first day of the quarter in which insured status was met. Also, a child cannot acquire insured status after ESRD onset by a marital relationship of a parent.

A claimant is the dependent child of an insured person for purposes of R-HI if at the onset of ESRD the individual:

  1. 1. 

    is unmarried, and

  2. 2. 

    meets the relationship requirements for child's insurance benefits on that person's earnings record (see HI 00801.201C.) at the onset of ESRD or, if the Wage Earner (WE) is deceased, at the time the WE dies; and

  3. 3. 

    meets one of the following dependency requirements:

    1. a. 

      is below age 22;

    2. b. 

      is under a disability which began before age 22; or

    3. c. 

      is under age 26, and

      • is receiving a least one-half support from the WE, and

      •  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 the continuous support requirement.

It is not necessary for an individual to be entitled or eligible for disability benefits in order to qualify as a dependent disabled child under 3.a. above. However, a determination as to disability prior to age 22 is needed by the Disability Determination Services (DDS). See HI 00801.201C.3.

B. Insured status

Review the file to determine that the earnings requirement is met on or after the time the claimant began a course of dialysis or received a kidney transplant, (e.g., a WE born in 1938, began dialysis in 9/78 requires 19 QC's to be fully insured or 6 QC's in the 13 calendar quarters ending in 9/ 79 to be currently insured, see RS 00301.105, RS 00301.110 and HI 00801.201B. Also see RS 01702.510C. for gratuitous Military Service Wage Credits (MSWCs) and DI 45001.200 and DI 11035.001 for Federal Quarters of Coverage (FQCs).

The claimant may be insured on his/her own earnings record, on a spouse's earnings record, or on the earnings record of a parent or grandparent (see HI 00801.201C.) on whom the claimant is dependent. Care should be taken not to deny a claim for lack of insured status until entitlement on all possible earnings record has been considered, e.g., do not deny a married individual for lack of insured status without investigating possible insured status of the spouse. When determining whether the earnings requirement is met based on the earnings record of a deceased worker always figure the insured status by using the date of birth of the deceased worker and the earlier of 1 ) the date the worker dies, 2) the date the worker attained age 62, or 3) the date the ESRD claimant began a course of dialysis or received a kidney transplant.

If an earnings record is necessary to resolve the insured status requirement, follow procedures in DI 11010.015 and RM 01403.015. MSWCs, FQCs, and railroad compensation are creditable for purposes of R-HI insured status even though they may not be creditable for purposes of monthly RSDI benefit entitlement (see HI 00801.201, HI 00801.400, and RS 01702.510). If there is an unresolved earnings discrepancy in file, refer the case to a claims authorizer for handling per DI 40105.055 and RM 03844.020. Indicate the problem on a Form SSA-559 and request priority handling.

There will be instances when some individuals will seek re-entitlement to R-HI after failure to receive a transplant which functioned effectively in excess of 36 months. HI 00801.261 explains the special “HI Freeze” afforded these individuals.

An adult child who has been disabled since before age 22 shall be insured for “ESRD Medicare Purposes Only” if the parent meets the insured status requirements. ESRD insured status exists for a disabled adult child regardless of the benefit status of either the insured parent or the adult child.

C. Referral of non-medical issues

Cases which contain conflicting evidence or raise a question as to eligibility based on non-medical factors should be referred by SSA-559 (prior to adjudication) to OD, Special Programs Branch, 3-M-25 Operations Bldg. with a brief explanation of the problem in the remarks section. (First, consider DI 45001.010E.)

All referrals (medical and non-medical) should be reviewed in ODO in accordance with instructions issued by ODO's Operations Support Staff in order to insure that the referral is not only necessary, but adequately states the issue for which resolution is being requested.

D. Proof of age for the claimant

Proof of Age (POA) is not required unless one of the following applies:

  1. 1. 

    The claimant is possibly age 65 at ESRD onset and onset was prior to 10/ 78; or

  2. 2. 

    Fully insured status is an issue and the claimant is not insured by all of the dates in file (e.g., age 22 involved).

When development of age is required under these rules, request the field office to obtain POA following the usual POA guidelines in GN 00302.001. If the claimant's insured status is based on another person's earnings record, be aware that POA may be needed for the WE.

E. Technical assistance

Adjudication of non-medical entitlement factors is the responsibility of claims authorizers when issues remain undecided or a decision is questionable. Request priority handling when referral is needed.

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DI 45001.010 - Non-Medical Review of Non-DOFA ESRD Claims - 12/05/2014
Batch run: 09/09/2019