TN 26 (01-11)

GN 00203.025 Interviewing Medicare Claimants

A. Interviewing guidelines for Medicare claimants

When interviewing claimants approaching age 65 or older, provide a general explanation of Medicare. To help explain Medicare provisions, refer to GN 00203.050. For procedures on how to handle special situations that are likely to arise during the interview that may require additional explanations or actions, see GN 00203.025C in this section.

B. Explaining Medicare coverage

Explain the following points to the claimant:

  1. Provisions of Part A (Hospital Insurance) and Part B (Medical Insurance) including the premium, deductibles, and coinsurance.

  2. Premium payment amounts and the premium collection process (HI 01001.020).

  3. The option of having fee-for-service Medicare coverage (original Medicare coverage) or coverage through a Medicare health plan (Part C, Medicare Advantage) such as a health maintenance organization (HI 00208.066).

  4. The claimant's enrollment period, the month coverage begins, and the consequences of refusing Part B when first eligible. Subsequent enrollment may only occur during a general enrollment period or Special Enrollment Periods (HI 00805.025 and HI 00805.265). The claimant may be subject to a premium surcharge (HI 01001.010).

  5. A Medicare Card and a “Medicare & You” handbook will be mailed within 4 weeks of processing the claim. Tell the beneficiary to present the card to the medical service providers and the providers will bill Medicare.

  6. The income-related monthly adjustment amount (IRMAA) may apply if income is over the IRMAA threshold (HI 01101.010B). If the individual is likely to be subject to IRMAA (e.g., had very high earnings), the interviewer must provide the claimant with the fact sheet, publication number 05-10536, “Medicare Premiums: Rules For Higher-Income Beneficiaries.”

  7. Give a general overview of the Medicare Prescription Drug Coverage, Part D, and the Application for Extra Help With Medicare Prescription Drug Plan Costs, the application for low-income subsidy. To close out the issue of subsidy on all cases, be certain to document the application per HI 03010.020C.3. Provide the beneficiary with the Medicare factsheet 05-10126 “What you Should Know About The Medicare Prescription Drug Plans: Qualify for Extra Help and Pay No Penalty. Explain the different responsibilities of the Prescription Drug Provider (PDP), Centers for Medicare and Medicaid Services (CMS), and SSA (HI 03001.001).

C. Handling situations that require additional explanations or actions

For detailed information and processing instructions on specific issues, refer to the appropriate listed sections.

  1. Tailoring the interview to the individual situation (HI 00820.065).

  2. Definition of Special Enrollment Periods (HI 00805.265) and When Enrollment Can Occur (HI 00805.275).

    1. Working aged (HI 00805.751).

    2. Working Disabled (HI 00805.752.) and (HI 00801.170).

    3. Disability SEP (HI 00805.752).

  3. Medigap Policies (HI 00820.065).

    NOTE: Effective January 1, 1995, DIB and ESRD beneficiaries are entitled to a 6-month Medigap enrollment period upon attainment of age 65. The 6-month period begins the first month the beneficiary is both age 65 and enrolled in Part B. Originally, open enrollment applied only to individuals who first enrolled in SMI at age 65.

  4. Civil service annuitants and spouses (HI 01001.165).

  5. Medicare Qualified Government Employment (MQGE) (HI 00801.400).

  6. State Buy-in and Medicaid including QMB, SLMB, and QI (HI 00801.139, HI 00815.025, and SI 01715.005).

  7. Requirements for Low Income Subsidy (LIS) and how to apply for Ex