TN 26 (11-93)

A. Background

1. 1972 Amendments

The 1972 Amendments extended HI and SMI protection,
effective 7/1/73, to SSA and RRB beneficiaries, fully or currently insured individuals, and their spouses and dependent children, whose kidney failure has progressed to the point that they have end stage renal disease (ESRD).

Entitlement to HI and SMI based on ESRD extends only to the individual who has ESRD, not to other members of the family.

Entitlement to Medicare on the basis of ESRD provides protection for all services covered by Medicare, not only those related to kidney disease.

2. 1978 Amendments

The 1978 Amendments made some changes in the entitlement rules to encourage self-dialysis and transplantation surgery, and to eliminate some inequities and problems that existed under previous law.

B. Policy

1. SMI Entitlement

A person entitled to HI on the basis of ESRD is also entitled to SMI effective with the same month (except as provided in HI 00801.251 B.). Such “automatic enrollment” is important because most of the expenses incurred for treatment of ESRD are covered by SMI rather than HI.

NOTE: In ESRD cases, SMI entitlement is directly dependent on the date of entitlement to HI which, in turn, can be altered by the date of filing for HI. This differs from other SMI entitlement situations which are generally dependent on the date of first eligibility for HI.

2. Terminology

To distinguish between HI on the basis of ESRD and HI based on other eligibility requirements, HI and SMI based on renal failure are referred to as R-HI and R-SMI respectively.