As explained in 24 CFR 406.13, The Social Security Act provides coverage under Medicare's hospital insurance (HI) and supplemental medical insurance (SMI) based on End Stage Renal Disease (ESRD) for a dependent adult child if the claimant:

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  is determined to have ESRD that requires a regular course of dialysis or a kidney transplant, and

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  is a dependent adult child of an individual who is either entitled to monthly title II benefits or is fully or currently insured (including fully or currently insured by employment under the Railroad Retirement Act), and

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  files an application for ESRD benefits as a dependent adult child.

A dependent adult child, who files for ESRD Medicare benefits based on the insured status of a parent, must provide proof of dependency by meeting dependency requirements for entitlement to child's social security benefits on the basis of a parent's earnings (see GN 00306.002C), and meet one of the three additional conditions:

1. 1. 

   is under age 22;

2. 2. 

   is under a disability that began before age 22; or

3. 3. 

   is under age 26, is receiving at least one-half support from that parent, and has continuously received at least one-half support from that parent since the day before attaining age 22.

If the field office (FO) cannot establish one of the conditions under (1) or (3) and there is no determination of a disability that began before age 22, the FO must send the case to the Disability Determination Services (DDS) to decide whether the dependent adult child met the requirements for disability prior to age 22.

When a DDS determination is needed to prove dependency, the FO takes the following actions:

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  Send the case to the DDS for a prior to age 22 disability determination.

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  Include in the folder, a completed SSA-3367, SSA-3368, SSA-827, and any available medical evidence provided by the claimant.

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  Add the remark to the SSA-3367, "ESRD Medicare only, disability determination prior to age 22 needed."

NOTE: These cases are EDCS exclusions

For further information about FO dependency documentation and decisions, see DI 11052.005E.

When the DDS receives an ESRD Medicare only case requesting a prior to age 22 determination, the DDS takes the following actions:

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  Receipt the paper case in as a CDB - this applies to cases at the initial and reconsideration levels.

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  Develop for onset of a mental or physical disability prior to age 22. The disability does not have to be based on ESRD specifically. The FO will prepare and release the notice.

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  For unfavorable disability determinations, the DDS will prepare a personalized disability explanation (PDE) for inclusion with the FO notice. For additional information on preparing a PDE, see DI 26530.001.

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  Transfer the case to the FO to finalize and issue the determination.

Appeals follow the same path as other disability cases, see GN 03101.040.

The appeal determination or decision will be based on the requirements in DI 23050.005C in this section.