CMS Pub. 100-16, ch. mc86c17d, § 20.2

Generally, an individual is not eligible to enroll in a cost plan if he or she has been

medically determined to have ESRD (see exceptions described under §20.2.2). End

Stage Renal Disease (ESRD) is defined as that stage of kidney impairment that appears

irreversible and permanent, and requires a regular course of dialysis or a kidney

transplant to maintain life.

An individual who receives a transplant that restores kidney function and no longer

requires a regular course of dialysis to maintain life is no longer considered to have

ESRD for purposes of cost plan eligibility. The individual may elect to enroll in a cost

plan if he or she meets the other applicable eligibility requirements indicated in §20. If a

beneficiary is only eligible for Medicare on the basis of ESRD (i.e., not based on

disability or age), he or she would only be permitted to remain enrolled in a cost plan

during his or her remaining months of Medicare eligibility. See §40.3 for additional

information.

The cost plan is permitted to ask whether the beneficiary has ESRD at the time of

application. This question is permissible since the law does not permit a person with

ESRD to join a cost plan. If the applicant answers “yes” to the question of whether he or

she requires regular maintenance dialysis, the plan can deny enrollment after ensuring the

beneficiary is not eligible for one of the exceptions listed in §20.2.2. The CMS will

reject the enrollment if Medicare records indicate the applicant has ESRD.