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the beneficiary wants help paying for Medicare
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see information on:
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Eligibility for extra help (prescription drug low-income subsidy) in HI 03001.020;
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Eligibility under the Supplemental Security Income provisions in SI 00501.001;
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Medicare prescription drug subsidy eligibility and filing in TC 24020.020; and
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Comparing Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary
(SLMB), Qualified Individual (QI), and Qualified Disabled & Working Individuals (QDWI)
in TC 23001.040.
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The request may be an Extra Help or Supplemental Security Income (SSI) inquiry or
a potential referral for a Medicare Savings Program.
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the beneficiary wants to file an application for Retirement or Medicare benefits
NOTE: Disabled beneficiaries with ALS (amyotrophic lateral sclerosis, also known as Lou
Gehrig’s disease) get Medicare when their Disability Insurance (DI) benefits start
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800 number agents establish an initial claims appointment for the servicing office.
To determine the method of filing, see TC 10003.010.
SRs refer to or make an appointment with a Claims Representative (CR).
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The field office (FO) takes an application. The systems processing determines whether
to impose the Income-Related Monthly Adjustment Amount (IRMAA) after the Internal
Revenue Service (IRS) match occurs.
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the beneficiary received a notice about IRMAA and has questions
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try to determine specifically what the beneficiary wants to know:
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If the question is “What is IRMAA?” explain the legal requirement to charge IRMAA
based on certain income levels of income. (For information on modified adjusted gross
income (MAGI), see HI 01101.010 and for information on IRMAA sliding scale tables, see HI 01101.020.)
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If the question is how the Social Security Administration (SSA) determined IRMAA,
explain the determination process. See HI 01101.030. If the question is how to get a new decision or new initial determination, explain
new initial determinations.
For an overview of new initial determinations on IRMAA using beneficiary provided
information, see HI 01120.001.
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It is important to know what the beneficiary is asking, so that there is no misinformation
or misdirection that could disadvantage the beneficiary.
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the beneficiary does not agree with the amount of the IRMAA
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Try to determine what the beneficiary does not agree with, either:
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how we derived at the amount, or
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the information that IRS provided.
NOTE: Once you determine why the beneficiary does not agree, see information on determining
the process for CR in HI 01101.050C.
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If the beneficiary is trying to understand the IRMAA computation, there may be a lack
of understanding about the requirement to pay IRMAA. These calls may not always be
IRMAA related. They may involve surcharges, Medicare Advantage reductions in Part
B premiums, or concerns about the prescription drug plan (PDP) of the Medicare Advantage
Plan with prescription drug coverage (MA-PD) charges.
The caller may question whether the information IRS provided is correct. Since the
information we use does not come directly from the beneficiary, and beneficiaries
can change the information they provide to IRS, it is possible that our information
may be wrong.
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the beneficiary has not filed an amended return or received a correction from IRS
and disagrees with the information IRS provided
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advise the beneficiary to contact IRS at 1-800-829-1040.
Inform the beneficiary that they are responsible for recontacting us once they receive
proof of a correction.
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If IRS verifies that they provided erroneous information, IRS can correct the information
and provide the beneficiary with a correction of the MAGI information upon the beneficiary’s
request. It will be up to the beneficiary to recontact us once they receive proof
of a correction.
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the beneficiary disagrees with the information IRS provided and has an amended return
or a correction from IRS
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For information on determining the appropriate process for SR and 800 number agents,
see HI 01101.050B.
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The beneficiary may be eligible for a new initial determination.
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the beneficiary claims not to have a Medicare prescription drug coverage plan and
is charged for IRMAA-D
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800 number agents and SRs:
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1.
Review the beneficiary’s MBR, MEDQ, and HI/SMI queries.
NOTE: If we do not withhold the Part D premium from the T2 benefit, MEDQ will not display
Part D information.
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2.
If Part D or MA-PD enrollment information is not available in our records, ask the
beneficiary if they:
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have a Medicare Advantage Plan with prescription drug coverage, or
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are enrolled in a prescription drug plan (such as AARP, Humana, Wal-Mart prescription
drug plan, etc.), and
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have a prescription drug coverage ID card.
If the beneficiary answers yes to any of the above bullets:
Ask the beneficiary to verify that the ID card has a Medicare Prescription Drug Benefits
Program Mark. All versions include the term “Medicare Rx.”
If the beneficiary answers no to any of the information above:
Refer the beneficiary to the Centers for Medicare & Medicaid Services (CMS) at 1-800-MEDICARE (1-800-633-4227). Refer TTY callers to 1-877-486-2048. CMS will verify Medicare Part D enrollment details.
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The beneficiary may be enrolled in a prescription drug coverage program and not realize
it is a Medicare plan, since premiums are paid directly to the prescription drug coverage
provider.
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the beneficiary wants to know why CMS bills the IRMAA for prescription drug coverage
or why we take the IRMAA out of the benefit payment when Part D premiums are paid
directly to the prescription drug plan (PDP)
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Explain that regardless of how the beneficiary chooses to pay PDP premiums, we must
deduct IRMAA-D from the Social Security benefit. If the benefit is insufficient or
the beneficiary does not receive Title II benefits, the Office of Personnel Management
(OPM), railroad retirement benefits (RRB), or CMS must bill the beneficiary.
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Requirement in the statute.
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