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 – Initial Claims Processing

For initial claims processing via MCS/EC and A101, see DI 11036.001E. See DI 23580.001 for Disability Determination Services (DDS) initial claims processing instructions.

F. Procedure - Postentitlement Processing – Claimant Currently Serving 24-Month Medicare Waiting Period Now Alleging ALS

1. General

All fully favorable and partially favorable determinations will be sent from the Disability Determination Services (DDS) to the PC in a brown folder with a coversheet identifying the case as “ALS Case - Expedited Action Needed - (P.L. 106-554 waives 24-month Medicare waiting period for Amyotrophic Lateral Sclerosis).” The brown folder will include the completed form SSA-833-U3 establishing ALS onset during the 24-month Medicare waiting period.

An unfavorable determination when the claimant is found disabled due to ALS after expiration of the 24-month Medicare waiting period will be sent from the DDS to the PC for MACADE input to update the DIG and/or SDIG to 3350 and the medical re-exam diary to 7 years to reflect a disability of ALS.

An unfavorable determination when the claimant is not found to have ALS will be sent from the DDS to the field office (FO) for the appeals period.

2. Receipt Coding

ALS cases in which the diagnosis changed during the Medicare waiting period will be receipted as continuing disability review

(CDR) cases in the PC using TOEL 1 HISMI and TOEL 2 MISC and forwarded to the claims authorizer.

3. Claims Authorizer (CA)

a. Fully Favorable and Partially Favorable ALS Determinations

If the ALS onset date is later than the original disability onset date on the MBR, input special message “ALS onset date MM/DD/YY - Medicare entitlement begins MM/YY.” Query the disability control file (DCF) to determine the DIG and SDIG codes.

• If the DIG or SDIG code on the DCF is 3350 (ALS), prepare an SSA-559 routing form to reflect the changed Medicare entitlement based on the ALS determination (i.e., Medicare entitlement month equal to ALS onset month) to the benefit authorizer (BA) for MACADE processing.

• If the DIG or SDIG code on the DCF is other than 3350 (ALS), prepare an SSA-559 routing form to reflect the changed Medicare entitlement (i.e., Medicare entitlement month equal to ALS onset month). Forward the case to the Disability Processing Branch Specialist (DPS) or the disability examiner (DE). Instruct the DPS/DE to:

  Correct the DIG and/or SDIG to 3350 on the DCF, and

  Send the case to the benefit authorizer (BA) for the necessary Medicare entitlement MADCAP action.

b. Unfavorable ALS determinations

Claimants found to have ALS after the 24-month Medicare waiting period has expired are considered unfavorable ALS determinations. The DDS will send these unfavorable determinations to the PC to update diagnosis and medical diary coding only, (waiver of the Medicare waiting period does not apply). No PC notice is required.

• If the DIG and/or SDIG code on the DCF is 3350 (ALS), forward to the benefit authorizer (BA) via SSA-559 routing form and instruct the BA to update the DIG and/or SDIG to 3350 (ALS) and the medical re-exam diary to 7 years.

• If the DIG and/or SDIG code on the DCF is other than 3350 (ALS), forward the case to the Disability Processing Branch Specialist (DPS) or the disability examiner (DE). Instruct the DPS/DE to correct the DIG and/or SDIG to 3350 on the DCF and send the case to the benefit authorizer (BA) to update the DIG and/or SDIG to 3350 and the medical re-exam diary to 7 years.

Do not remove the ALS coversheet.

4. Benefit Authorizer (BA) Responsibility

Input the change in Medicare entitlement per MADCAP processing instructions. Update the DIG and/or SDIG to 3350 (ALS) and update the medical re-exam diary to 7 years. Send a Medicare notice via MACADE for fully favorable and partially favorable ALS determinations. Do not send a notice for unfavorable ALS determinations (i.e., no ALS onset established within the 24-month Medicare waiting period.) Remove the ALS coversheet if all actions are complete.

5. Notices

a. Fully Favorable Determination

In fully favorable determinations, the processing center (PC) will issue a Medicare entitlement notice via MACADE. No DDS notice is sent.

b. Partially Favorable Determination

In partially favorable determinations, i.e., onset of ALS is established later than alleged but still within the 24-month Medicare waiting period, the DDS will send a notice with appeal rights to the claimant including personalized disability language. The PC will issue a separate Medicare notice via MACADE.

c. Unfavorable Determination

In unfavorable determinations, the DDS will send a denial notice with appeal rights stating the claimant must serve the 24-month waiting period for Medicare entitlement. No PC notice is sent.