Effective Dates: 02/02/2023 - Present Previous | Next

TN 11 (03-25)

HI 00803.030 EHH Medicare Application

A. Requirement to file application to be entitled to EHH Medicare

An individual or a proper applicant on the individual's behalf must file an application on the individual’s own Social Security number (SSN) to be entitled to EHH Medicare.

B. Responsibility for taking application for EHH Medicare

Field office (FO) 872 in Kalispell, Montana, in the Denver Region, takes all EHH Medicare applications. If you are not in FO 872, do not take an application for EHH Medicare. Refer the individual to FO 872 using the procedure in HI 00803.020B.1.

C. Consideration of potential for other benefits when taking application for EHH Medicare

When the CR in FO 872 is interviewing to take an application for EHH Medicare, the CR must also consider the claimant’s potential for entitlement to the benefits listed below and follow the instructions provided for each benefit.

1. Social Security and Supplemental Security Income (SSI) benefits

Discuss potential entitlement to other Social Security or SSI benefits with the claimant and take appropriate claims. If the claimant does not want to file for other SSA benefits, document this using Report of Contact (RPOC) screen in MCS.

2. Medicare Part D

A beneficiary entitled to HI under this provision is eligible to enroll in a Medicare prescription drug plan, Medicare Part D. For more information on Medicare Part D, see HI 03001.001. If a person needs counseling on which plan to choose, refer the person to 1-800-MEDICARE, www.medicare.gov , or the appropriate State Health Insurance Assistance Program number listed in the back of the Medicare & You handbook.

3. Medicare Part C (Medicare Advantage Plans)

If a claimant has questions about Medicare Advantage (MA) Plans (Part C), explain that these are plans offered by private insurance companies approved by Medicare. MA Plans require Part A (Hospital Insurance) and Part B (Medical Insurance) coverage and may offer extra benefits, such as vision, hearing, and dental. Most MA Plans include Part D prescription drug coverage as well. For more information on Medicare Advantage Plans, refer the claimant to 1-800-MEDICARE or to www.medicare.gov . The Medicare & You handbook also lists the Medicare Advantage plans in the service area. The claimant may also contact the State Health Insurance Assistance Program number listed in the back of the Medicare & You handbook to discuss enrollment choices.

NOTE: Entitlement to EHH Medicare does not affect any prior enrollment in Medicare Parts C or D.

4. Medicare Part D Extra Help

The claimant may apply for Medicare Part D Extra Help (also known as the low-income subsidy). Take this application in the Medicare Application Processing System (MAPS) when the claimant files the EHH Medicare application. If an MBR does not yet exist, or an MBR exists but does not show at least Part A coverage, wait to submit the Extra Help application until you establish the EHH Medicare MBR.

5. Medicare Savings Programs (MSP)

A claimant who chooses to apply for Medicare Part D Extra Help will also start the application process for the MSP unless the claimant tells us not to do so. Refer the claimant to the state whether claimant files for Medicare Part D Extra Help or not. The state Medicaid agency must complete the process in either case. Remember to explain that the MSP can help Medicare beneficiaries save money each year. These programs can pay the monthly Medicare Part B premium amount; and in some cases, the MSP may also pay Medicare cost-sharing expenses (e.g. coinsurance and deductibles) if the beneficiary’s income and resources qualify.

D. Abbreviated application for EHH Medicare-only in the Modernized Claims System (MCS)

REMINDER: CRs in FO 872 take all EHH Medicare applications.

Whenever possible, the CR must take an application for EHH Medicare-only in MCS. For instructions on taking EHH Medicare-only claims in MCS, see SM 00381.005.

NOTE: If the claimant already has a Disability Insurance Benefits (DIB) claim pending in MCS, the CR will not be able to take the EHH Medicare-only application in MCS. For instructions on taking a paper application for EHH Medicare only, see HI 00803.030E.

E. Paper application for EHH Medicare - only

REMINDER: CRs in FO 872 take all EHH Medicare applications.

If MCS is not available to take an EHH Medicare-only application or the claimant already has a DIB claim pending in MCS, the CR must:

  1. 1. 

    take the application on paper using an CMS-18-F5 (Application for Hospital Insurance);

  2. 2. 

    complete only items 1, 2, 3(a), 10, and 16; and

    NOTE: In 10(c), enter information about place of residence in the last ten years.

  3. 3. 

    include the following in remarks:

    • •

      “I was present at least a total of six months in Lincoln County, Montana, from MM/CCYY to MM/CCYY.”;

      NOTE: If the claimant cannot make such a statement, enter appropriate remark regarding allegation of presence in Lincoln County, Montana.

    • •

      name of the medical source who will complete the EHH Checklist; (For more information about the CMS-10902 (EHH Checklist) and developing the medical requirement, see HI 00803.050.)

    • •

      preferred language for spoken and written communication if other than English;

    • •

      country/territory of citizenship if other than U.S.;

    • •

      type of citizenship if the claimant is a U.S. Citizen who was not born in the U.S. (e.g. U.S. citizen born outside U.S. or citizen by naturalization) and citizenship start date if other than birth;

    • •

      start date of lawful presence if claimant is not a U.S. citizen but lawfully present in U.S.;

    • •

      residence address if other than mailing address;

    • •

      eligibility for Medicaid and, if eligible, Medicaid case number and state; and

    • •

      type of group health plan if claimant is covered by a group health plan based on employment (GHP or LGHP), coverage start date and employment start date.

NOTE: If possible, load the claim in MCS prior to adjudication.

F. Application for EHH Medicare and DIB in MCS

REMINDER: CRs in FO 872 take all EHH Medicare applications.

Whenever possible, the CR must take an application for EHH Medicare and DIB in MCS. For instructions on processing simultaneous claims for EHH Medicare and DIB in MCS, see SM 00381.006.

G. Paper application for EHH Medicare and DIB

REMINDER: CRs in FO 872 take all EHH Medicare applications.

If MCS is not available to take the application for EHH Medicare and DIB, the CR must take a paper SSA-16-BK (Application for Disability Insurance Benefits). The SSA-16-BK serves as an application for both EHH Medicare and DIB.

The CR must add the following in the “REMARKS” section of the SSA-16:

  • •

    I want to apply for Medicare based on exposure to environmental health hazards”;

  • •

    “I was present at least a total of 6 months in Lincoln County, Montana, from MM/CCYY to MM/CCYY”;

    NOTE: If the claimant cannot make such a statement, enter appropriate remark regarding allegation of presence in Lincoln County, Montana.

  • •

    Name of the medical source who will complete the EHH Checklist. (For more information on developing medical requirement, see HI 00803.050.)

NOTE: If possible, load the claim in MCS prior to adjudication.

H. References

  • •

    HI 00803.020 Protective Filing and Leads for EHH Medicare

  • •

    HI 00803.050 Developing Medical Requirement for Entitlement to EHH Medicare

  • •

    HI 03001.001 Description of the Medicare Part D Prescription Drug Program

  • •

    SM 00381.005 Processing Environmental Health Hazard (EHH) Medicare Claims in MCS

  • •

    SM 00381.006 Processing Simultaneous Claims for EHH Medicare and for Disability Insurance Benefits (DIB) in MCS

  • •

    SM 00382.005 Processing an Environmental Health Hazard (EHH) Medicare Award Using an A101

  • •

    SM 00383.005 Processing an Environmental Health Hazard (EHH) Medicare Award Using EF101

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0600803030
HI 00803.030 - EHH Medicare Application - 02/02/2023
Batch run: 12/04/2025
Rev:02/02/2023