TN 28 (07-95)

A. Policy — General

R-HI cannot begin before the first month in which the individual meets the insured status requirements discussed in HI 00801.191C.2.

Actual and deemed quarters from Medicare Qualified Government Employment, described in HI 00801.400., can be used for insured status, if necessary.

A person is considered “insured” for ESRD purposes even if he or she does not personally meet the work requirements but qualifies as the spouse or dependent child, as described in HI 00801.201C.

If there is entitlement to a monthly title II benefit or Railroad Retirement (RR) annuity as a number holder, auxiliary, or survivor, the claimant has R-HI insured status. It does not matter that the monthly RSDI benefit or RR annuity to which a claimant (or spouse, or parent on whom he or she is dependent) is entitled may not be payable for some reason, e.g., deduction or suspension.

B. Policy — Fully or currently insured

An individual who is fully or currently insured, as defined for monthly benefit purposes, is also fully or currently insured for R-HI, but the reverse is not necessarily true.

While the insured status requirements are based on the regular insured status rules, various exceptions exist for the R-HI provision.

1. RR compensation as an entitlement factor

In determining whether a person is fully or currently insured for R-HI, RR compensation (earnings for service covered under the RR Act) earned after 1936 is counted as wages for covered employment even though such compensation might not be creditable for monthly RSDI benefit purposes.

2. Military Service Credits (MSC) as an entitlement factor

MSC may be used to determine insured status (see RS 01701.001.). This is true regardless of any benefits actually or potentially payable by another Federal agency, as long as the individual filing for R-HI is a veteran of World War II or the Post WW II period, or is filing for R-HI on the earnings record of such a veteran.

3. Fully insured for R-HI defined

People with ESRD are fully insured for R-HI if they (or a spouse, or a parent on whom they are dependent) have one QC for each year:

• elapsing after 1950 (or, if later, elapsing after the year the worker attained age 21); and

• up to, but not including, the year of ESRD onset (or the year the worker attained age 62 or died, if earlier).

A minimum of 6 QCs is required when the elapsed years are less than 7.

A year that is totally or partially within a period of disability is not counted as an elapsed year although QCs within that period may be counted toward insured status. Proof of age is not required to establish R-HI insured status whenever the claimant (or spouse or parent) is either currently insured or has at least 40 QCs. However, proof of age is necessary whenever attainment of age 22 or 62 affects the fully insured status determination of a claimant (or spouse or parent) who does not have 40 QCs.

An individual who is not fully insured at ESRD onset may become fully insured after onset. In that case, Medicare entitlement is delayed until fully insured status occurs.

As explained in HI 00801.261, a “freeze,” for HI purposes only, may reduce the number of quarters necessary for fully insured status where the worker was previously entitled to R-HI.

4. Currently insured for R-HI defined

A person with ESRD is currently insured for R-HI if he or she (or the spouse, or parent on whom he or she is dependent) has at least 6 QCs in a period of 13 calendar quarters ending with the quarter of ESRD onset, the quarter of death (if the individual on whose account entitlement is being established is deceased), or some later quarter. A calendar quarter, any part of which falls within a disability freeze, is not counted as one of the 13 quarters, unless the quarter is a QC.

C. Policy — Spouse or dependent child of insured person

1. General

A claimant with ESRD who is not entitled to monthly title II or RR benefits, and is not fully or currently insured, can qualify for R-HI only if he or she is the spouse or dependent child of a person who is an RSDI beneficiary, an RRB annuitant, or fully or currently insured.

The requirements for relationship are the same for R-HI as for monthly title II benefits (except as noted below). Thus, for example, a claimant has R-HI insured status as the dependent child of his or her fully insured grandfather if:

• he or she could be considered the child of his or her grandfather for purposes of child's insurance benefits; and

• he or she is unmarried, and is either under age 22 or otherwise meets the dependency requirement in HI 00801.201C.3.

2. Spouse

a. Spouse defined

A spouse for R-HI purposes is an ESRD patient of any age who could be considered the husband or wife of a living NH (or the surviving widow or widower of a deceased NH) for purposes of monthly benefit entitlement on the NH's SSN. Divorced spouses or divorced widow(er)s can qualify if married to the NH for at least 10 years.

NOTE: For R-HI purposes, there are no dependency requirements, nor a requirement that they be living together (except for deemed marriages), nor married for any specified length of time (except for divorced spouses).

b. Marriage to insured NH

If an ESRD patient, ineligible for Medicare because he or she is uninsured, marries an RSDI beneficiary or a person who is fully or currently insured, the insured status requirement is met as of the first day of the month of marriage.

c. NH no longer insured/divorced

Subsequent loss of the spouse's insured status or subsequent divorce from the spouse does not end the claimant's R-HI entitlement.

3. Dependent child

a. Defined

A dependent child for purposes of R-HI is an ESRD patient who is unmarried, and meets the relationship requirements for child's insurance benefits on the SSN of a NH:

• at or after the onset of ESRD, or

• at the time the NH died (if the NH is deceased).

b. Dependency requirement

In addition, at the time of ESRD onset the ESRD patient must meet either of the following dependency requirements:

• is under age 22 or is under a disability which began before attainment of age 22; or

• has attained age 22, but has not attained age 26, and

  • is receiving at least one-half support from the NH; and

    has received such support continuously since the day before attainment of age 22. (Temporary interruptions such as a stay in a hospital or a visit with a relative do not prevent the claimant from meeting this requirement.)

c. Effect of disability

An individual who attained age 22 prior to onset of ESRD can qualify as a dependent child of an insured parent under a. above, if he or she is under a disability which began before attainment of age 22. Entitlement to, or eligibility for, disability benefits, or any other benefits, is not required.

d. Disability development

If dependency prior to age 26 cannot be established under the guidelines in RS 01301.190, development of disability should be considered. The SSA-3368 (see DI 11005.016) and medical evidence should be obtained for forwarding to the Disability Determination Services (DDS) who will make the determination of disability.

NOTE: When adjudicating or forwarding any case in which an unmarried and uninsured individual attained age 22 before ESRD onset, the file must either:

• show there is no reasonable likelihood that the claimant was under a disability which began before age 22, or

• contain the disability development.

D. References

• Proof of marriage documentation requirements, RS 00202.070.

• Developing Initial Evidence from Medical Sources, DI 22505.007.

• “HI freeze” for insured status in reentitlement cases, HI 00801.261.