Termination of Medicare Entitlement for Beneficiaries with

End Stage Renal Disease (ESRD)

Fact Sheet

Background

The Center for Beneficiary Choices (CBC) and the Office of Clinical Standards and Quality (OCSQ) have identified beneficiaries whose Medicare entitlement under the ESRD provisions should have ended prior to December 1999, but has not.  Under the law, Medicare Part A entitlement for beneficiaries with ESRD ends 36 months after the month of transplant or 12 months after the month dialysis treatments stop.  The CBC and OCSQ established a process to ensure that, beginning in January 2000, Medicare coverage is being terminated appropriately for beneficiaries with ESRD.  The CBC is now working with OCSQ and the Social Security Administration (SSA) to process those cases where Medicare coverage should have ended prior to 1999.  

At the time, there were approximately 50,000 beneficiaries who were entitled to Medicare on the basis of ESRD, but whose Medicare coverage should have ended prior to December 1999.  We expect only a subset of these individuals to ultimately lose their Medicare coverage; a significant portion may now be entitled to Medicare based on disability, or based on their attaining age 65. 

To rectify this situation the Centers for Medicare & Medicaid Services (CMS) plans to take the following steps:

I.  The termination actions will be processed in phases based on the Medicare entitlement reason, e.g. renal only, renal and disabled, etc., and number of coverage periods.  Phase I includes beneficiaries who are entitled to Medicare based solely on ESRD, have one coverage period and there has been no reported subsequent dialysis or transplant.  All components and partners will be notified in advance when each Phase is initiated.

II. Beneficiary Notification of Intent to Terminate Medicare Entitlement

The CBC will mail pre-termination notices to beneficiaries in Phase I on or about

August 1, 2003. The notice instructs beneficiaries to contact their treatment facility within 30 days of the receipt of the notice if they received a kidney transplant or started dialysis so that their Medicare entitlement may continue. Beneficiaries are also advised that should Medicare benefits terminate, they are not financially liable for any Medicare Part A services or items obtained prior to the receipt of the formal termination notice from SSA.

III.  Beneficiary Inquiries

      A.   ESRD Networks

The ESRD Networks will respond to beneficiary inquiries concerning their current ESRD status and answer general Medicare questions. The Networks will report any change in the beneficiary’s status directly to CMS CO in addition to updating the ESRD records to reflect that dialysis continues or a transplant has been received.  OCSQ will provide the Networks with the list of beneficiaries who will receive the pre-termination notice and a Question and Answer document to assist in responding to beneficiary inquiries.

2. CMS Call Center

The CMS Call Center will respond to beneficiary inquires concerning the pre-termination notice and answer general Medicare questions.  The CBC will provide the Call Center with a Question and Answer document to assist in responding to beneficiary inquiries.

IV. Waiver of Potential Overpayments

The CMS has determined that beneficiaries are not financially liable for Medicare Part A items and services received prior to the receipt of the formal termination notice from SSA.  The Office of Financial Management will issue a Program Memorandum to the Intermediaries that instructs them to take no action to recover payments for Medicare Part A services from Medicare beneficiaries or providers.

V.  Termination of Medicare Entitlement

When the Networks have updated all ESRD data, CMS will send a tape file to SSA on September 17, 2003, containing only those beneficiaries whose Medicare coverage should end.  The SSA will terminate Medicare entitlement and issue a notice to each beneficiary.  The notice will provide the date(s) that Medicare entitlement ends and give the beneficiary the right to file an appeal.