SSA - POMS: HI 00801.191 - Requirements for Entitlement to R-HI

A. Introduction

An individual can be entitled to Medicare on the basis of ESRD no earlier than the month in which the requirements in C. are met. In addition, the date of entitlement is dependent on the type of treatment received for the disease.

B. Definition

1. End-stage renal disease

For purposes of R-HI entitlement, ESRD means irreversible damage to a person's kidneys so severely affecting the ability to remove or adjust blood wastes that, to maintain life, must have either a regular course of dialysis, see HI 00801.206, or a kidney transplant, see HI 00801.211.

2. Date of onset

The term date of onset in ESRD instructions means the first day (or month) in which the claimant meets the transplant or regular dialysis requirement.

C. Policy - Requirements

1. Application

The individual must file an application, as described in HI 00801.196. The application may be retroactive for up to 12 months.

2. R-HI insured status

The individual must have R-HI insured status on or after the date of onset, see HI 00801.191C.3. To have R-HI insured status, the individual must be:

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entitled to a monthly benefit under title II or an annuity under the Railroad Retirement Act; or
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fully or currently insured; or
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the spouse or dependent child of a person who is entitled to a monthly benefit or fully or currently insured, as described above.

NOTE: Ffor additional insured status requirements for alien workers, see RS 00301.102.

For further discussion of the R-HI insured status requirement, see HI 00801.201.

3. Date of onset

A medical determination is required to show that the claimant has ESRD and meets the transplant or regular dialysis requirements.

D. Policy - Additional considerations

1. Eligible for HI based on DIB or age 65

Concerning when to develop an R-HI claim for an individual who is already entitled to HI/SMI or HI only, see HI 00801.258

2. No alien residence requirements

The law does not prohibit entitlement to R-HI or R-SMI for illegal aliens or anyone else based on length of U.S. residence or any other “alien residence” requirement, as long as the requirements in HI 00801.191C. are met.

NOTE: Medicare will not pay for services rendered to an alien who is not lawfully present in the U.S. as outlined in RS 00204.010.

3. Postponing enrollment

a. Premium arrearage is for 6 or more months

If there will be 6 or more months' premium arrearage, as explained in HI 00801.251B., R-SMI can be elected as of:

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the first month of R-HI; or

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the month of filing; or
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the month of processing.

b. Medicare expenses will not be paid by Medicare

Individuals whose medical care is not payable by Medicare for any reason can delay enrolling in Medicare until they are receiving covered services. This would apply, for example, to those who:

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have Medicare as the secondary payer of benefits as described in HI 00801.247,
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are in prison when they begin their dialysis treatments or receive a transplant (often, such services are excluded from Medicare coverage when furnished by a governmental entity, see HI 00620.060 and HI 00620.070 C., or
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receive their initial treatment outside the U.S. Medicare generally does not pay for services received outside the U.S. as explained in HI 00630.001.

Filing for R-HI entitlement in the first month that services are covered by Medicare is recommended so that they can begin R-SMI with that month.

c. Examples

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ESRD treatments begin in prison

Mary, a fully insured individual, was imprisoned on 4/5/ 00. Mary began a course of dialysis at the State's expense in 1/01 while still in prison. Mary filed for R-HI and R-SMI in 6/03, upon release from prison. Mary R-HI was awarded as of 6/1/02 (12 months retroactive to the date of filing). Mary elected R-SMI to begin as of the month of filing (6/03), rather than 12 months retroactive. Thus avoided premium liability for the time Mary could not take advantage of the Medicare coverage.

If Mary had filed for Medicare when first eligible in 2001, would have had to pay SMI premiums when there was no possibility of Medicare's paying for care. If Mary had filed for R-HI but refused R-SMI in 2001, or if had lost R-SMI by voluntary disenrollment or for nonpayment of premiums, Mary would not have R-SMI upon release from prison and would be unable to have R-SMI until 7/1/04 based on a 2004 GEP enrollment (unless withdraw R-HI application, as described in HI 00801.197).

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Medicare is secondary payer

Gina is working and covered by employer’s group health plan when begins a regular course of dialysis in 1/01. Gina is eligible for Medicare beginning 4/01, however after learning that the group health plan will be primary payer of medical expenses until 9/30/03, Gina decides to wait to apply for Medicare. In 11/03, Gina files a Medicare application and elects to have R-HI and R-SMI coverage begin effective 10/1/03, the first month Medicare is primary payer for medical expenses.

Social Security

Program Operations Manual System (POMS)

HI 00801.191 Requirements for Entitlement to R-HI