COB Playbook

Determining the Initial Medicare Entitlement Reason

Does patient have Medicare at ESRD entitlement? If NO , not dually entitled at ESRD entitlement date.

If YES , what is the Medicare Part A entitlement date compared to patient’s age and ESRD entitlement date?

Dually entitled at ESRD entitlement date. Age is the initial reason.

AGE, then ESRD

Dually entitled at ESRD entitlement date. Disability is the initial reason.

DISABILITY, then ESRD

NOT DUALLY ENTITLED! Disability record will drop, initial reason changes to Age.

DISABILITY, then AGE

DISABILITY, then ESRD, then AGE

Dually entitled at ESRD entitlement date. Disability is the initial reason.

If initial entitlement is Disability, upon turning 65, the initial reason changes to Age, per CMS. However, if due to Disability and that person next becomes dually entitled due to ESRD, then later turns age 65, Disability is retained as the initial entitlement reason. ESRD entitlement must happen between Disability and Age entitlement for Disability to be retained as the initial reason.