DI 11036: Amyotrophic Lateral Sclerosis (ALS) - Medicare Waiting Period Waived - FO
BASIC (05-04)
A. Background
Public Law 106-554 amends section 226 of the Social Security Act to waive the 24-month waiting period for Medicare coverage for disabled individuals medically determined to have Amyotrophic Lateral Sclerosis (ALS), better known as Lou Gehrig's disease. The date of Medicare entitlement is the date of entitlement to DIB, DWB, or CDB based on a diagnosis of ALS, or July 1, 2001, whichever is later. This provision affects both new and current beneficiaries.
B. Policy
Effective July 1, 2001, a disability beneficiary diagnosed with ALS will not have to serve the 24-month Medicare waiting period. The date of entitlement to Medicare is the date of entitlement to disability (DOED) benefits or July 1, 2001, whichever is later. If ALS onset is established later than the month of initial disability onset (i.e., initial onset is based on another disability), but the ALS onset is still within the 24-month Medicare waiting period, Medicare entitlement begins with the ALS onset month or July 1, 2001, whichever is later.
The Diagnosis code 3350 is used to identify an ALS diagnosis. This can be the Primary (DIG) or Secondary (SDIG) diagnosis.
A new hospital insurance (HI) Period code of “W” will be annotated on the MBR that will indicate these cases as “NO WAITING PERIOD.”
The supplemental medical insurance (SMI) period code will be “I” (Initial Enrollment Period).
NOTE: This legislation only affects Title II and Title XVIII and has no impact on Title XVI entitlement. In addition, this legislation does not include non-ALS anterior horn cell diseases (e.g., Werdnig-Hoffmann disease, spinal muscular atrophy, etc.).
C. Definitions - Initial Claims
1. Fully Favorable
ALS onset is the same or earlier than the claimant's alleged onset date for ALS.
2. Partially Favorable
ALS onset is later than the claimant's alleged onset date for ALS.
3. Unfavorable
The claimant is not found to have ALS.
D. Definitions - Postentitlement
1. Fully Favorable
ALS onset is the same or earlier than the claimant's alleged onset date for ALS and within the 24-month Medicare waiting period.
2. Partially Favorable
ALS onset is later than the claimant's alleged onset date for ALS but still within the 24-month Medicare waiting period.
3. Unfavorable
The claimant is currently entitled based on another disability and is not found to have ALS anytime within the 24-month Medicare waiting period.
NOTE: If the claimant is found disabled due to ALS after expiration of the 24-month Medicare waiting period, the DIG and/or and the medical re-exam diary are changed to reflect a diagnosis of ALS.
E. Procedure - FO Responsibilities
1. General
Follow normal interviewing guidelines, which include taking the claim in the Electronic Disability Collect System (EDCS). Complete all information as thoroughly as possible to avoid unnecessary re-contact with the claimant. Forward the claim to the DDS with a coversheet identifying the case as “ALS Case - Expedited Action Needed - (P.L. 106-554 waives the 24-month Medicare waiting period for Amyotrophic Lateral Sclerosis.” (See DI 11036.002 Exhibit 1 for paper coversheet and DI 81010.080B for electronic ALS flag. ) Use guidelines and procedures in DI 11005.601D.3.d. to check status of DDS case processing, and carefully control and monitor all cases through completion.
2. Initial Claims Processing – Modernized Claims Systems/Earnings Computations (MCS/EC)
MCS/EC will automatically recognize “NO WAITING PERIOD” claims when either the primary or secondary diagnosis code on the Disability Allowance/Denial (DICL) screen equals 3350.
NOTE: EC will not reflect a “NO WAITING PERIOD” for Medicare until a Disability Determination Services (DDS) allowance is established and code 3350 is entered on the DICL screen.
Enter “1” (YES) to the question “Will Medicare Apply?” on the Additional Benefits (ADDB) screen. EC will establish the hospital insurance (HI) START date equal to the later of the DOED or 07/2001.
Enter the appropriate supplemental medical insurance (SMI) election information on the Health Insurance (HIHI) screen in the application path.
EC will automatically generate a SMI refusal paragraph (HIB152, see NL 00725.005) advising ALS beneficiaries still in their initial enrollment period (IEP) who refuse SMI on their application that they still have a chance to elect SMI if they respond timely. However, if they do not respond timely and wish to enroll, they will have to wait for a general enrollment period or file under the special enrollment period provision if applicable.
EC recognizes equitable relief situations and generates paragraph HIB068 (see NL 00725.005) as it would in a regular waiting period case. No additional equitable relief paragraph input is necessary.
3. Initial Claims Processing – A101
If an A101 is necessary due to other limitations, take the following steps for ALS cases in addition to your normal A101 processing procedures:
a. Additional Benefits (ADDB) Screen
Answer “1” for Yes to the question “WILL MEDICARE APPLY?”
b. Beneficiary Data (BENE) Screen
Answer “Y” to the question “HI AND/OR SMI INVOLVED?”
If the ALS diagnosis code of 3350 is indicated as the primary diagnosis on the DICL screen, it should propagate onto the BENE screen in the A101 path. If it does not, input the primary diagnosis code.
c. BCF/Remarks/Notice (BCRN) Screen
The BENE screen does not contain a field to capture the secondary diagnosis code. If the ALS diagnosis is present in the secondary diagnosis field on the DICL screen, it should propagate onto the BCF/REMARKS/NOTICE (BCRN) screen. The BCF code of “SD” will be propagated with the diagnosis code 3350 displayed in the “CODE” field in the last four positions (preceded by two zeroes). If propagation of the secondary diagnosis code does not occur on the BCRN screen, enter the BCF of “SD” with 003350 in the “CODE” field.
d. HI Data (HIDA) Screen
Input the following:
A “START DATE” equal to the later of the DOED or 07/2001;
The “BASIS” code of “D” for disability; and
The “PERIOD” code of “W” to indicate “NO WAITING PERIOD.”
e. SMI Data (SMID) Screen
Input the following:
The applicable “START DATE” based on the enrollment period;
The “BASIS” code of “D” for disability;
The “PERIOD” code of “I” for initial enrollment period.
F. Procedure - Postentitlement Processing – Claimant Currently Serving 24-Month Medicare Waiting Period Now Alleging ALS
Cases where beneficiaries allege ALS and are currently serving the 24-month waiting period should be processed as follows (it is not necessary to retrieve the original folder):
NOTE: Check the MBR for possible special message indicating the claimant previously alleged ALS and was denied. If claimant previously alleged ALS, notify the DDS when forwarding the current ALS allegation.
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Take an SSA-795 statement from the beneficiary alleging ALS. (See DI 11036.003 Example 1 for SSA-795.) The SSA-795 must include:
the ALS alleged onset date,
the name, address, telephone number, and fax number of each medical source alleging a diagnosis of ALS, and
the date the claimant first saw each medical source for ALS.
Obtain an SSA-827 for each source, plus 2 extras.
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Place materials in a brown paper folder.
NOTE: Although these cases are treated as CDR cases in the DDS, DO NOT enter the case into EDCS as an eCDR. There are systems limitations that prevent complete electronic case processing and may delay the processing of the case.
Flag the case “ALS Case – Expedited Action Needed” and forward to the DDS.
Establish a Modernized Development Worksheet (MDW) control pending the DDS determination. The standard issue should be “ALS.”
Send the brown folder to the DDS.
G. Process - Postentitlement – Claimant Currently Serving 24-Month Medicare Waiting Period Now Alleging ALS
1. Fully Favorable Determinations
All fully favorable determinations will be sent from the DDS to the servicing processing center (PC) for MACADE input. The DDS will also send a copy of the 833 to the field office (FO) as notification that the DDS determination is complete and the outstanding MDW ALS control can be closed.
2. Partially Favorable Determinations
All partially favorable determinations will be sent from the DDS to the PC for MACADE input. The DDS will also send a copy of the 833 to the FO as notification that the DDS determination is complete and the outstanding MDW ALS control can be closed.
3. Unfavorable Determinations
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Claimant found to have ALS after expiration of the 24-month Medicare waiting period – DDS will send to the PC for MACADE input to change the DIG and/or SDIG to 3350 and to update the medical re-exam diary to 7 years to reflect a disability of ALS.
The DDS will also send a copy of the 833 to the FO as notification that the DDS determination is complete and the outstanding MDW ALS control can be closed.
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Claimant not found to have ALS - DDS will send to the field office (FO) to hold for the appeals period.
Tickle the case for 65 days via MDW
If no appeal filed after 65 days, input an MBR special message “ALS AOD MM/DD/YY denied – claimant must serve 24-month Medicare waiting period. See Evidence screen.” In Shared Processes, include in the “comments” portion of the Evidence screen the alleged ALS onset date and date of the DDS unfavorable determination notice.
Query for location of original folder and send all material to be associated with original folder.
H. Process – Notices
The FO is not responsible for any ALS notice.
1. Fully Favorable Determinations
Medicare entitlement notice is sent by the processing center (PC) upon completion of their action. No DDS notice is sent.
2. Partially Favorable Determinations
The DDS sends a notice with personalized disability language and appeal rights and the PC issues a separate Medicare notice.
3. Unfavorable Determinations
The DDS sends a notice with personalized disability language and appeal rights explaining the claimant must serve a 24-month waiting period for Medicare entitlement. No PC notice is sent.
I. Procedure – Reconsiderations
If the claimant files a reconsideration on a partially favorable or unfavorable determination, follow normal reconsideration procedures in DI 12095.000. Annotate the ALS coversheet “Request for Reconsideration” and forward the file to the DDS. Postentitlement reconsideration requests are processed as paper. DO NOT enter postentitlement reconsideration requests into EDCS. (See DI 11036.002 Exhibit 1 for ALS paper coversheet and DI 81010.080B for electronic ALS flag.)
J. Procedure - Handling Inquiries
If you receive questions about why the 24-month waiver does not cover other impairments, explain that currently the law only applies to individuals diagnosed with ALS. Do not attempt to explain why other impairments are not included.