TN 31 (06-04)

HI 00801.246 R-HI and R-SMI Benefits - Policy

Medicare payment is made for covered services furnished an R-HI beneficiary whether or not they are required for renal disease. To receive payment from Medicare, institutions and facilities providing kidney transplantation or renal dialysis have to meet special conditions of participation prescribed by the Secretary. Other care that the R-HI beneficiary needs may be obtained (as by all Medicare beneficiaries) from physicians, providers, or suppliers of services which meet the requirements for payment. Because of the youth of many R-HI beneficiaries, benefits are payable for some conditions not normally affecting the aged enrollee; e.g., maternity care, pediatric services, etc.

An individual who is entitled to R-HI is eligible to enroll in SMI (see HI 00801.251). SMI covers:

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  outpatient ESRD treatment, whether provided by a hospital or a free-standing facility which meets prescribed conditions;

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  home dialysis treatment, including the rental or purchase of a dialysis machine and certain accessory equipment;

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  purchase of certain disposable supplies; and

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  immunosuppressive drug therapy.

Therefore, all prospective R-HI enrollees should be informed about their SMI enrollment rights and the advantages of enrolling in the program. See HI 00801.247 when the individual is covered under a group health plan.