From: Telephone No. Social Security Administration Employer’s Name and Address Date: Employee’s Name: Employee’s Social Security Number: Claimant’s Name: Claim Number: U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO.0938-0787 REQUEST FOR EMPLOYMENT INFORMATION FORM CMS-L564 (4-2000) Dear Sir/Madam: We need the following information regarding the above claimant. Please answer the questions below, sign and date this letter and return it in the enclosed envelope. You may call__________________________________________________ at the above telephone number if you have any questions. Sincerely, Office Manager 1. Is (or was) the claimant covered under an Employer Group Health Plan? Yes _______ No _______ 2. If yes, give the original date the coverage began. ________________ (mm/yyyy) 3. Has the coverage ended? Yes _______ No _______ 4. If yes, give the date the coverage ended. _________________ (mm/yyyy) 5. When did the employee work for your company? From ________________ To _________________ Still Employed __________ (mm/dd/yyyy) (mm/dd/yyyy) Signature and Title of Company Official Date Telephone Number According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.The valid OMB control number for this information is 0938-0787. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, N2-14-26, Baltimore, Maryland 21244-1850.
Transcript
From: Telephone No.
Social Security Administration
Employer’s Name and Address Date:
Employee’s Name:
Employee’s Social Security Number:
Claimant’s Name:
Claim Number:
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVEDCENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO.0938-0787
REQUEST FOR EMPLOYMENT INFORMATION
FORM CMS-L564 (4-2000)
Dear Sir/Madam:
We need the following information regarding the above claimant. Please answer the questions below, sign and date thisletter and return it in the enclosed envelope.
You may call__________________________________________________ at the above telephone number if you haveany questions.
Sincerely,
Office Manager
1. Is (or was) the claimant covered under an Employer Group Health Plan?
Yes _______ No _______
2. If yes, give the original date the coverage began. ________________(mm/yyyy)
3. Has the coverage ended? Yes _______ No _______
4. If yes, give the date the coverage ended. _________________(mm/yyyy)
5. When did the employee work for your company?
From ________________ To _________________ Still Employed __________(mm/dd/yyyy) (mm/dd/yyyy)
Signature and Title of Company Official Date Telephone Number
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. Thevalid OMB control number for this information is 0938-0787. The time required to complete this information collection is estimated to average 15 minutes per response,including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have anycomments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, N2-14-26, Baltimore,Maryland 21244-1850.
Medicare’s Claim Number Suffixes
The Medicare claim number identifies whose account the client is drawing from and why they are receiving those benefits.
The first part of the claim number is the Social Security number (SSN) of the wage earner on whose account claims are being paid. If the person receiving benefits is a dependent of the wage earner, the claim number SSN will not be the same as the SSN of the person receiving benefits.
The second part of the claim number is the suffix. It is usually a letter, which may or may not be followed by a digit. The suffix indicates the type of benefits the claimant receives.
Most Common Suffixes and Meanings (not a complete list)
A Primary claimant (wage earner) B Aged wife, age 62 or over B1 Aged husband, age 62 or over B2 Young wife, with a child in her care B3 Aged wife, age 62 or over, second claimant B5 Young wife, with a child in her care, second claimant B6 Divorced wife, age 62 or over BY Young husband, with a child in his care C1- C9 Child - Includes minor, student or disabled child D Aged Widow, age 60 or over D1 Aged widower, age 60 or over D2 Aged widow (2nd claimant) D3 Aged widower (2nd claimant) D6 Surviving Divorced Wife, age 60 or over E Widowed Mother E1 Surviving Divorced Mother E4 Widowed Father E5 Surviving Divorced Father F1 Parent (Father) F2 Parent (Mother) F3 Stepfather F4 Stepmother F5 Adopting Father F6 Adopting Mother HA Disabled claimant (wage earner) HB Aged wife of disabled claimant, age 62 or over M Uninsured – Premium Health Insurance Benefits (Part A) M1 Uninsured - Qualified for but refused Health Insurance Benefits (Part A) T Uninsured - Entitled to HIB (Part A) under deemed or renal provisions; or
fully insured who have elected entitlement only to HIB W Disabled Widow W1 Disabled Widower W6 Disabled Surviving Divorced Wife
Day 1 – 2014 1
Medicare True/False/Multiple Choice Quiz 1. Raymond’s doctor just visited him in the hospital and told him he needs to
stay for a few more days. He is concerned about the costs of his hospital stay. He understands that after he pays his deductible, Medicare Part A will cover the expenses associated with his hospital stay, but that he is responsible for the costs of his television and telephone service.
True ___ False ___ 2. Kirby is scheduled to have surgery in two months and will be hospitalized for
a few days. He has Medicare A & B only. Kirby will have the Part A deductible to pay but all other costs will be covered.
True ___ False ___ 3. Mario is 65 years old and receives Social Security benefits. He is covered by the group health insurance policy provided by his wife’s employer. He wants to wait to enroll in Medicare Part B after his wife retires in 2 years. Delaying enrollment will result in an additional 10% penalty added to the monthly premium for each year he could have been enrolled in Part B but was not. True ___ False ___ 4. Gretchen’s doctor has recommended that she receive care under hospice services. How much will Gretchen pay for her prescription medications? a. Nothing b. Up to a $5 co-payment for each prescriptions c. 20% of the Medicare approved amount 5. Marta enrolled in Medicare A and B in 2003. She just had her annual checkup with her doctor. Medicare Part B will not cover which item listed below? a. Flu shot b. Routine Physical c. Diabetes test d. All of the above will be covered
Day 1 – 2014 2
Medicare Part A Quiz 1. What are the requirements for Medicare eligibility for age 65 and over? 2. What is the definition of a benefit period? 3. Name four services covered under Medicare Part A. 1.__________________________ 2.__________________________ 3.__________________________ 4.__________________________ 4. What is the current Part A deductible?___________ 5. Which of the following services is not covered by Medicare Part A? a. Intensive Care b. Operating Room c. Surgeon Charges d. Drugs 6. How many days will Medicare provide full coverage in a skilled nursing facility? 7. What are the four requirements for coverage under Medicare’s Home Health Benefit? 1._______________________________________________________ 2._______________________________________________________ 3._______________________________________________________ 4._______________________________________________________ 8. Doctor and nursing services, homemaker services and short-term respite services are covered by: a. Home Health b. Hospice c. Skilled Nursing Facility
Day 1 – 2014 3
Medicare Part B Quiz
1. What are the major areas of coverage under Part B? 2. What is the current monthly premium for Medicare Part B? 3. Explain the “Mass Ban on Balance Billing” law. 4. A non-participating physician may accept assignment on a case-by-case basis. True____ False ____
5. When physicians accept assignment, they accept Medicare’s payment of 80% of the Medicare approved charges as payment in full for the service. True____ False ____ 6. If you are unhappy with your looks, Medicare will pay for a face lift True____ False ____ 7. Medicare does cover an annual physical. True____ False ____
Day 1 – 2014 4
Medicare A/B Quiz
1. What is the definition of “homebound” for Medicare beneficiaries? 2. Describe Medicare’s Enrollment Categories. 3. Mr. Hoover comes to ask about his mother’s hospitalization. His mother has been hospitalized for 62 days. His mother has no insurance other than Medicare. a. After Medicare pays, what part of the bill is her responsibility? b. If she is discharged, but is readmitted 10 days later and stays for 10 days, what additional amount of money will she owe? c. If she stays an additional 40 days instead of 10 days, what additional amount of money will she owe? 4. List gaps in Medicare Part B coverage. 5. Mr. Smith comes to see you at the Council on Aging (COA) office. He will be retiring soon and living on a limited income. His understanding is that he can get by with just Medicare A+B coverage. What would you tell him about having Medicare A+B coverage only.
Day 1 – 2014 5
Case Study — George Bell
George Bell is a 64 year old man who will soon be reaching his 65th birthday. George is so busy with a full-time career that his plans for retirement are far in the future. George will continue employment with a major corporation beyond his 65th birthday. What should he do about Medicare enrollment and his current group health insurance? Case Study — Frank
Frank is 70 years old. He retired at 65 from the GMYM Savings and Loan. Since he was receiving retiree insurance, he did not sign up for Medicare Part B. He has recently received notification from the bank that the retiree insurance will be changing and some of the benefits will be eliminated. Frank has decided that he now wants to sign up for Medicare Part B. When Frank went to the local Social Security office on April 12, he was told that he would be penalized for not signing up for Part B when he was initially eligible. Is this true? What would Frank’s penalty be?
Ruth Rose comes to see you at the SHINE office. She says that she will be 65 in 5 months. She will continue to work and is covered by her employer group plan. She does not want to sign up for Medicare. However, her friend Rhoda told her that if he does not sign up now, she will not be able to get Medicare later. What information would you give her? Case Study— Agnus
Agnus is 64 years old and has been divorced for 15 years. Agnus married soon after high school and was a full-time homemaker. Until 5 years ago, Agnus had never worked outside the home. For the past 5 years she has worked for the Red Dye Company. She will be retiring in 4 months when she turns 65. The benefits administrator of the Red Dye Company told Agnus that she will not be eligible for Social Security or Medicare since she has not worked for a full 10 years. Is this true? What would you tell Agnus?
Justin Time will turn 65 and be retiring in 4 months. After talking with the benefits manager at his employer, he is very confused about Medicare and what it does and does not pay for. Since he will be getting retiree insurance from his employer, he is not sure if he really needs Medicare at all. What information would you give him?
*Complete a Client Contact form on Justin
Case Study - Mrs. Carroll
Mrs. Carroll called the SHINE office for help on June 1st for help with a problem. Mr. Carroll, much to his wife’s dismay, refused to sign up for Medicare Part B when he was initially eligible. He is very proud of the fact that he has only spent $1,000 for medical care in the last 3 years. As he repeatedly told his wife, that is cheaper than paying the Part B premium for the last 3 years. Mr. Carroll now needs to have surgery. His wife is beginning to realize some of the problems involved as a result of an uninformed decision he made three years ago. List the problems he will now face.
Ms. Washington lives in Massachusetts. She goes to see Dr. Franklin in her town who does not accept assignment. Ms. Washington is required to pay the entire bill of $150. When she receives the Medicare Summary Notice (MSN), she notices that the Medicare approved amount is $100. She wants to know what the exact amount is that Medicare will pay and the amount that is her responsibility? She explains that she has already met her Part B annual deductible. What would Ms. Washington owe if she lived in Florida? Case Study — Hal
Hal will celebrate his 65th birthday in a couple of months. He just received his Medicare Initial Enrollment Package from the Social Security Administration. While he has a general understanding of Medicare Part A, Hal doesn’t feel well informed about Medicare Part B. What information would you provide Hal?
Bill Fold comes to meet with you at the SHINE office. He will be turning 65 and retiring in 3 months and wants to know about Medicare. He tells you that he will be receiving retiree health insurance from his employer and would like to know if he really needs Medicare. He says that he is healthy and takes no medication. What questions would you ask and what information would you give?
1. What are the major areas of coverage under Part B? 2. What is the current monthly premium for Medicare Part B? 3. Explain the “Mass Ban on Balance Billing” law. 4. A non-participating physician may accept assignment on a case-by-case basis.
True____ False ____
5. When physicians accept assignment, they accept Medicare’s payment of 80% of the Medicare approved charges as payment in full for the service.
True____ False ____
6. If you are unhappy with your looks, Medicare will pay for a face lift
True____ False ____
7. Medicare does cover an annual physical.
True____ False ____
Medicare A/B Quiz
1. What is the definition of “homebound” for Medicare beneficiaries?
2. Describe Medicare’s Enrollment Categories.
3. Mr. Hoover comes to ask about his mother’s hospitalization. His
mother has been hospitalized for 62 days. His mother has no
insurance other than Medicare.
a. After Medicare pays, what part of the bill is her responsibility?
b. If she is discharged, but is readmitted 10 days later and stays for
10 days, what additional amount of money will she owe?
c. If she stays an additional 40 days instead of 10 days, what
additional amount of money will she owe?
4. List gaps in Medicare Part B coverage.
5. Mr. Smith comes to see you at the Council on Aging (COA) office.
He will be retiring soon and living on a limited income. His
understanding is that he can get by with just Medicare A+B coverage.
What would you tell him about having Medicare A+B coverage only.
Medicare True/False/Multiple Choice Quiz
1. Raymond’s doctor just visited him in the hospital and told him he needs to
stay for a few more days. He is concerned about the costs of his hospital stay.
He understands that after he pays his deductible, Medicare Part A will cover
the expenses associated with his hospital stay, but that he is responsible for the
costs of his television and telephone service.
True ___ False ___
2. Kirby is scheduled to have surgery in two months and will be hospitalized for
a few days. He has Medicare A & B only. Kirby will have the Part A
deductible to pay but all other costs will be covered.
True ___ False ___
3. Mario is 65 years old and receives Social Security benefits. He is covered by
the group health insurance policy provided by his wife’s employer. He wants
to wait to enroll in Medicare Part B after his wife retires in 2 years. Delaying
enrollment will result in an additional 10% penalty added to the monthly
premium for each year he could have been enrolled in Part B but was not.
True ___ False ___
4. Gretchen’s doctor has recommended that she receive care under hospice
services. How much will Gretchen pay for her prescription medications?
a. Nothing
b. Up to a $5 co-payment for each prescriptions
c. 20% of the Medicare approved amount
5. Marta enrolled in Medicare A and B in 2003. She just had her annual checkup
with her doctor. Medicare Part B will not cover which item listed below?
