TN 59 (02-23)

HI 00801.435 Taking the Claim

A. Background

Many Federal, State, and local government employees (and/or their auxiliaries) will be insured for HI based on SSQCs and will not need to rely on GEQCs to qualify for HI entitlement.

B. Policy

To qualify for HI based on MQGE, it must be established that the individual meets all the eligibility requirements for entitlement to monthly SS benefits and/or HI as if the NH's GEQCs were SSQCs. This means the same applications and proofs are necessary for an individual who needs GEQCs to be insured for HI.

C. Procedure — When to develop GEQCS

Develop GEQCs only if the claimant:

  • Is not insured using SSQCs; or

  • Refuses to cooperate in establishing insured status using SSQCs alone; or

  • Is insured for title II benefits only through use of military service wage credits (MSWCs) and, upon eligibility for an OPM annuity using the same MSWCs, will lose their title II eligibility (in this case, develop insured status based on both SSQCs and GEQCs).

D. Procedure — Taking the claim

Have any individual who is filing for HI based on GEQCs file an unrestricted monthly title II benefit application with the following exceptions:

  • The applicant is an aged person who does not want monthly title II benefits even if potentially eligible (e.g., the person is still working or does not want to file for title II benefits because they will be in total government pension offset (GPO) and wants SMI premiums withheld from their OPM annuity as discussed in HI 01001.190); or

  • It is clear the individual is not insured for monthly title II benefits (if in doubt, take an unrestricted monthly benefit application); or

  • The applicant is a Federal employee insured for title II benefits only through use of military service wage credits which, if used to compute an OPM annuity, would result in loss of title II insured status and the individual does not wish to file for title II benefits.

In these situations, restrict the application to HI only. However, develop HI eligibility based on SSQCs alone before developing GEQCs.

Also, if an individual is requesting HI entitlement solely on the basis of Federal employment or is not insured for title II benefits based on SSQCs, but there is an indication of Federal employment and the individual would need deemed GEQCs to be insured for HI, have the individual complete a HCFA-565. (See HI 00801.905 for an exhibit of this locally reproducible form.) Only the NH need complete the form if a NH and auxiliary are concurrently filing.

E. Procedure — Processing the claim

See SM 00850.725 for systems instructions on processing MQGE claims.

If the claim must be forwarded to the PC for processing, annotate the transmittal cover sheet in red: “Medicare Qualified Government Employment Claim.”

See workflow from the KC RO: KC Net Title2 Systems

F. Procedure — Establishing entitlement

When an individual is not eligible for HI based on SSQCs alone but is eligible using GEQCs, establish entitlement on the NH's SSN using the BICs in SM 00550.010.


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HI 00801.435 - Taking the Claim - 02/08/2023
Batch run: 02/08/2023