SSA - POMS: HI 00820.030 - Termination of R-HI

A. Policy - termination

R-HI ends when the individual dies, or is no longer “end stage.” A beneficiary is no longer “end stage” when dialysis stops for 12 months, or a kidney transplant is “successful” for 36 months.

NOTE:Factors which are requirements for eligibility are not required for continuation of entitlement.

1. Termination events

R-HI entitlement (see HI 00801.191) ends with whichever occurs first:

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date of death.
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last day of the 36th month after the month in which the individual receives a kidney transplant.

IMPORTANT: Entitlement terminates even if there is doubt that a transplant has been successful (e.g., the patient is suffering from rejection symptoms involving expensive treatment, but the transplanted kidney is still functioning, even if marginally).
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last day of the 12th month after the month in which the individual terminates dialysis.
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See SM 03020.380 for Age 115 Termination

2. More than one transplant

Where the individual receives a new kidney transplant during the 36-month period following the initial transplant, entitlement ends 36 months after the month in which the new kidney was implanted. This is true unless the beneficiary submits proof that before this new termination date he or she again has end stage renal disease (ESRD) (i.e., has begun another course of dialysis, or received another transplant) because the new kidney has failed.

3. Examples

Mr. Poindexter, a fully insured individual, born 8/2/40, began a course of dialysis in 4/87. R-HI was awarded effective 7/87. In 9/90, he receives a kidney transplant. R- HI ends 9/30/93, unless he has another transplant or returns to dialysis before that day.

Mrs. Rawlings, born 6/27/50, began a course of dialysis in 10/88. She had no QC's, but her husband was fully insured. Her R-HI entitlement was effective 1/89. In 4/89, she and her husband were divorced. The divorce does not affect her R-HI entitlement even though she no longer has R-HI insured status.

4. Reports

The individual will receive an award notice that advises the individual to report to SSA or CMS if and when he or she receives a kidney transplant or the course of dialysis is discontinued.

Evidence that an individual entitled to R-HI has received a kidney transplant should be sent to SSA, OCO/ODO, 1500 Woodlawn Drive, Baltimore, Maryland 21241-1500.

B. Procedure

1. General

ODO takes the following actions in termination cases:

To avoid retroactive termination of HI, take action to terminate R-HI as of the end of the 36th month after the month of transplant as soon as a transplant is reported. Wherever possible before termination, notify the claimant of his or her rights.

2. Transplant occurs before award

Prepare a closed award terminating R-HI 36 months after the month of transplantation (unless diaysis has to be resumed before that time).

3. Transplant occurs after award

If the transplant is performed after R-HI has been awarded, provide timely notice and termination under the following procedures:

a. Diary for 33rd month

Diary the case for the beginning of the 33rd month after the month of transplantation. Send the notice in HI 00820.904 to the current address, to advise the individual about termination and the need to notify SSA promptly if regular dialysis is resumed or there is a subsequent transplant. Include a CMS-2728–U3 and return envelope.

Rediary for 45-60 days due date.

b. Termination

Terminate R-HI entitlement on the last day of the 36th month after the month of transplant, unless evidence is received which shows that the beneficiary has begun a new course of dialysis or received another transplant.

Take action to end Medicare entitlement before the effective date of termination to prevent incorrect program payment for services furnished after that date.

Include in the notice of termination, information on the individual's right to reconsideration, along with advice to contact the local FO promptly upon return to dialysis or if another kidney transplant is received.

c. New transplant

If evidence of a new transplant is received, rediary the case for follow-up at the beginning of the 33rd month after the most recent transplant for termination as of the end of the 36th month after the month of the new transplant. Notify the claimant of the new termination date.

Develop for SMI entitlement, if SMI has been terminated for any reason. (See HI 00801.233G concerning resumption of entitlement.)

d. Course of dialysis

If a course of dialysis is begun (or resumed) after transplant, cancel the R-HI termination and inform the beneficiary that Medicare entitlement will continue.

Develop for SMI entitlement, if SMI has been terminated for any reason. (See HI 00801.233G.)

C. Policy - evidence of transplant

Acceptable sources of kidney transplant information for establishing the date of R-HI termination under HI 00820.030B.3.c. are:

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CMS-2728–U3 (End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration);
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statement or letter from the treating physician or transplant surgeon;
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statement or letter from the transplant hospital;
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CRD Kidney Transplant Beneficiaries Listing.

In each case, the report must show the name and claim number of the beneficiary, and the month and year of transplant and must not be questionable on its face or conflict with other information available.

In addition, a statement from the ESRD patient or from a person acting on his or her behalf may also be used to establish the date of R-HI termination. However, after diarying for termination, additional verifying evidence as shown above must be obtained.

D. Policy - reapplying after termination

The patient may apply for another period of R-HI if regular dialysis is resumed, or another transplant is received, and the requirements for entitlement are met.

Social Security

Program Operations Manual System (POMS)

HI 00820.030 Termination of R-HI