TN 60 (12-22)

GN 00203.025 Interviewing Medicare Claimants

A. Interviewing guidelines for Medicare claimants

When interviewing claimants in regards to Medicare, 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. 1. 

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

  2. 2. 

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

  3. 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. 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).

    • The Centers for Medicare & Medicaid Services (CMS) will mail a Medicare card and a “Medicare & You” handbook within 2-4 weeks of processing the claim.

      • Tell the beneficiary to present the card to the medical service providers and the providers will bill Medicare.

  5. 5. 

    The income-related monthly adjustment amount (IRMAA) may apply if income is over the IRMAA threshold (HI 01101.010B).

  6. 6. 

    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.

    • Provide the beneficiary with the Medicare publication 05-10508 “Understanding the Extra Help with Your Medicare Prescription Drug Plan".

    • Explain the different responsibilities of the Prescription Drug Provider (PDP), Centers for Medicare & 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. 1. 

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

  2. 2. 

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

    1. a. 

      Working Aged (HI 00805.751).

    2. b. 

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

    3. c. 

      Disability SEP (HI 00805.300).

    4. d. 

      Exceptional Conditions (HI 00805.382 - HI 00805.387).

  3. 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. 4. 

    Civil service annuitants and spouses (HI 01001.165).

  5. 5. 

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

  6. 6. 

    State Buy-in and Medicaid including QMB, SLMB, and QI (HI 00801.139, HI 00815.024, and SI 01715.005).

  7. 7. 

    Requirements for Low-Income Subsidy (LIS) and how to apply for Extra Help (HI 03001.005).

  8. 8. 

    Receiving medical services through a Medicare health plan (HI 00208.066).

  9. 9. 

    TRICARE (formerly CHAMPUS) (HI 00805.720).

  10. 10. 

    HI for the uninsured (HI 00801.126).

  11. 11. 

    Premium-HI premium reduction for Aged Individuals With At Least 30 Quarters of Coverage (HI 00801.134).

  12. 12. 

    HI Premium Reduction to Zero for Certain Public Retirees (HI 00801.135).

  13. 13. 

    Overview of New Initial Determinations on the Income-Related Monthly Adjustment Amount (IRMAA) Using Beneficiary Provided Information (HI 01120.001).

    NOTE: If claimant alleges modified adjusted gross income (MAGI) over the threshold and reports there is a life-changing event (LCE), the CR must take actions to process the LCE (HI 01120.005).

  14. 14. 

    End-Stage Renal Disease (HI 00801.186).

  15. 15. 

    Immunosuppressive Drug Coverage under Part B (HI 00805.400).

To Link to this section - Use this URL:
GN 00203.025 - Interviewing Medicare Claimants - 12/09/2022
Batch run: 12/09/2022