BASIC (09-09)

A. Background on MQGE

Section 278 of P.L. 97-248 , (Tax Equity and Fiscal Responsibility Act of 1982) enacted September 3, 1982, provides for Medicare coverage for Federal employees who

• are age 65 (and certain of their auxiliaries/survivors),

• are disabled (worker, child (CDB), widow(er) or surviving divorced spouse (DWB)), or

• have end-stage renal disease (ESRD).

The law, effective January 1, 1983, requires that all wages paid to Federal employees after December 31, 1982, be taxed the hospital insurance portion of the FICA tax. Federal employees earn quarters of coverage (QCs) for Medicare purposes through payment of the tax. In addition, the Federal employees need the same number of QCs to qualify for Medicare as they would need to qualify under Social Security.

NOTE: For information about coverage for State and local government employees, see DI 23540.001B.

These government employment quarters of coverage (GEQCs) are required to meet insured status alone, or in combination with Social Security quarters of coverage (SSQCs) for work in covered employment, to meet the insured status requirements for Medicare. Further, the law contains a transitional provision that provides that any Federal employee who was an employee during January 1983 receives deemed GEQCs for his or her Federal Service prior to January 1983 where there are otherwise insufficient SS or GEQCs to be insured. Thus, it is possible for Federal employees to meet insured status in January 1983.

NOTE: The transitionally insured provision is not relevant when the onset of disability is 10/01/92 or later.

For the disability requirement of the law, treat these MQGE disability claims like a Title II disability claim subject to the same disability evaluation criteria and reviews (e.g., medical re-exam, periodic review, etc.). Generally, for a worker or DWB, the 5-month waiting period and 24 months of disability entitlement must pass before Medicare coverage can begin. A CDB must be under a disability for 24 months before Medicare coverage begins. (See also HI 00801.400 - HI 00801.440.)

EXCEPTION: Section 115 of the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000, waives the 24-month waiting period for beneficiaries whose primary or secondary diagnosis is Amyotrophic Lateral Sclerosis (ALS). The diagnosis code (either primary (DIG) or secondary (SDIG)) is 3350. See “Amyotrophic Lateral Sclerosis (ALS) Medicare Waiting Period Waived – Disability Determination Services (DDS)” DI 23580.001.

NOTE: Entitlement to HI due to ESRD begins in accordance with “Date of Entitlement – General Policy” HI 00801.215.

In addition, months of Supplemental Security Income/State Supplementary Payments (SSI/SSP) eligibility can be counted toward the 24-month waiting period for DWBs (see “SSI/SSP Credit for Disabled Widow(er)s” HI 00801.154).

NOTE: Centers for Medicare and Medicaid Services (CMS) is responsible for providing PolicyNet instructions concerning Medicare policy. If there are any discrepancies between other Program Operations Manual System (POMS) instructions and the Medicare policy in the HI POMS, the HI POMS take precedence.

B. Disability determination necessary for MQGE cases

File MQGE disability claims in Modernized Claims System (MCS), the same as Title II disability claims.

The Field Office (FO) forwards initial and reconsideration MQGE disability cases to the disability determination services (DDS) for a worker, CDB, or DWB when a disability determination is necessary.

For electronic MQGE claims, select the MQGE sub-type, Transitional Federal Medicare or Regular Federal Medicare on the Title II/Title XVI Summary Page in the Electronic Disability Collect System (EDCS).

For paper MQGE claims, annotate the MQGE sub-type, Transitional Federal Medicare or Regular Federal Medicare on the SSA-831 (Disability Determination and Transmittal NOTE: For both electronic and paper MQGE claims, annotate the SSA-3367 (Disability Report – Field Office) with the remark “MQGE claim for Medicare entitlement only” prior to case transfer.

For its workload reporting purposes, the DDS must identify cases in which the number holder (NH) is insured under the transitional provision in the law by the additional remark in item 11 of the SSA-831-U5, “Insured status under transitional provisions of P.L. 97-248.”