CMS Pub. 100-16, ch. mc86c17d, § 20.2.2

• Conversion: Individuals who developed ESRD while a member of a health plan

offered by an organization and who are converting to Medicare Parts A and B, or

Part B only, may enroll in a cost plan in the same organization (within the same

state, with exceptions) at the time of conversion. The individuals must meet all

other cost plan eligibility requirements and must fill out an enrollment form to

enroll.

If a Medicare entitlement determination is made retroactively, an individual has

not been provided the opportunity to elect a cost plan at the time of their

conversion. Therefore, these individuals will be allowed to prospectively elect a

cost plan offered by the organization, as long as they were in a health plan offered

by the same organization the month before their entitlement to Parts A and B, or

Part B only, developed ESRD while a member of that health plan, and are still

enrolled in that health plan. This would also be allowed in cases when there is an

administrative delay and the entitlement determination is not made timely. For

example, an individual who performs self-dialysis will have his/her entitlement

date adjusted to begin at the time of dialysis, rather than the customary third

month after the month dialysis begins.

• If the individual was first medically determined to have ESRD after the date on

which the enrollment form was signed but before the effective date of coverage,

he can still enroll in that cost plan

• An individual who develops ESRD while enrolled in a cost plan may continue to

be enrolled that cost plan. This also can apply to an individual who developed

ESRD while enrolled with the organization offering the cost plan, even if the

individual was not enrolled under the cost contract, and it is not a conversion

situation.

• An individual with ESRD who is a member of a cost plan may enroll in other

plans offered by that organization (within the same state, with exceptions)

• An individual who receives a kidney transplant and who no longer requires a

regular course of dialysis to maintain life is not considered to have ESRD for

purposes of cost plan eligibility (see §40.3 for additional instructions).