TN 6 (04-13)

HI 01101.040 Screening Beneficiary Questions and Inquiries Regarding Medicare, Medicare Part D, and Income-Related Monthly Adjusted Amount (IRMAA)-D

A. Procedure for Service Representative (SR), 800 number agent or receptionist in responding to inquiries on Medicare, Medicare Part D, and IRMAA-D

When a beneficiary calls with questions regarding Medicare, it is important to determine the reason for contact. The following chart provides guidance on how to screen the beneficiary in order to provide accurate information to resolve the beneficiary’s concerns:

Determining the Reason for the Contact

If…

Then…

Why…

the beneficiary wants help paying for Medicare

see information on:

  • Eligibility for extra help (prescription drug low-income subsidy) in HI 03001.020;

  • Eligibility under the Supplemental Security Income provisions in SI 00501.001;

  • Medicare savings programs income limits in HI 00815.023;

  • Medicare prescription drug subsidy eligibility and filing in TC 24020.020; and

  • Comparing Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), Qualified Individual (QI), and Qualified Disabled & Working Individuals (QDWI) in TC 23001.040.

The request may be an Extra Help or Supplemental Security Income (SSI) inquiry or a potential referral for a Medicare Savings Program.

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

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).

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.

the beneficiary received a notice about IRMAA and has questions

try to determine specifically what the beneficiary wants to know:

  • 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.)

  • 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.

It is important to know what the beneficiary is asking, so that there is no misinformation or misdirection that could disadvantage the beneficiary.

the beneficiary does not agree with the amount of the IRMAA

Try to determine what the beneficiary does not agree with, either:

  • how we derived at the amount, or

  • 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.

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.

the beneficiary has not filed an amended return or received a correction from IRS and disagrees with the information IRS provided

advise the beneficiary to contact IRS at 1-800-829-1040.

Inform the beneficiary that he or she is responsible for recontacting us once he or she receives proof of a correction.

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 he or she receives proof of a correction.

the beneficiary disagrees with the information IRS provided and has an amended return or a correction from IRS

For information on determining the appropriate process for SR and 800 number agents, see HI 01101.050B.

The beneficiary may be eligible for a new initial determination.

the beneficiary claims not to have a Medicare prescription drug coverage plan and is charged for IRMAA-D

800 number agents and SRs:

  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.

  1. If Part D or MA-PD enrollment information is not available in our records, ask the beneficiary if he or she:

    • has a Medicare Advantage Plan with prescription drug coverage, or

    • is enrolled in a prescription drug plan (such as AARP, Humana, Wal-Mart prescription drug plan, etc.), and

    • has 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.

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.

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)

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.

Requirement in the statute.

B. Process for Claims Representative (CR)

If you have an IRMAA interview with a beneficiary who does not agree with the decision, determine whether the beneficiary should file an appeal or a request for a new initial determination. For information on determining the appropriate process for service representatives and 800 number agents, see HI 01101.050B.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0601101040
HI 01101.040 - Screening Beneficiary Questions and Inquiries Regarding Medicare, Medicare Part D, and Income-Related Monthly Adjusted Amount (IRMAA)-D - 08/05/2014
Batch run: 08/05/2014
Rev:08/05/2014