FOM1 805

FOM1 805 General Medicare Program Revised June 14, 2021 Page 1 of 13

805.5 Introduction

A national health insurance program, better known as Medicare, was enacted in 1965 

(Title XVIII of the Social Security Act) for individuals age 65 and over who are insured 

under the Social Security Act or the Railroad Retirement Act. Subsequent legislation 

has included disabled beneficiaries, individuals with chronic renal disease and 

uninsured individuals.

The Medicare program has four parts: 

• Medicare Part A: Medicare hospital insurance (Part A) helps pay for inpatient 

hospital care, inpatient care in a skilled nursing facility, home health care, 

hospice care, and respite care. Part A has deductibles and coinsurance, but 

RRB Medicare beneficiaries do not have to pay premiums for Medicare Part A.

Uninsured individuals may file an application during an enrollment period and pay 

a monthly premium. This program is called Premium HI and is only available 

through the Social Security Administration (SSA).

• Medicare Part B: Medicare medical insurance (Part B) helps pay for doctors’ 

services, outpatient hospital services, durable medical equipment and various 

other medical services and supplies not covered by Medicare Part A. Part B has 

premiums, deductibles, and coinsurance amounts that an enrollee must pay. 

Participation is voluntary. Part B is also referred to as Supplementary Medical 

Insurance benefits or SMI. Part B claims for RRB Medicare beneficiaries are paid 

by the RRB’s Speciality Medicare Administrative Contractor (SMAC). 

• Medicare Part C: Medicare Advantage Plans (Part C) are health plan options 

similar to Health Maintenance Organizations (HMOs) and Preferred Provider 

Organizations (PPOs). Medicare approved private companies offer these plans. 

All Medicare Advantage (MA) plans cover emergency and urgent care, but do not 

cover hospice care. Medicare Advantage plans may offer extra cover coverage 

such as vision, hearing, dental, and/or other health and wellness programs. In 

addition to the Part B premium, there is a monthly premium for the Medicare 

Advantage plan. An enrollee must have both Medicare Part A and Medicare Part 

B in order to enroll in a Medicare Advantage Plan. The RRB can deduct Part C 

premiums if the beneficiary makes the request for deductions through their Part 

C plan. Refer to FOM-I-1540.15.8 for more on Part C. 

• Part D: Medicare prescription drug coverage (Part D) is offered to everyone 

enrolled in Medicare Part A. The RRB can deduct Part D premiums if the 

beneficiary makes the request for deductions through their Part D plan Refer to 

FOM-I-860 for additional information about Part D benefits.
FOM1 805

FOM1 805 General Medicare Program Revised June 14, 2021 Page 2 of 13

805.10 Program Administration

Refer to Article 3 of the RCM for information about the administration of the Medicare 

program and the responsibilities of various organizations. Here are links to the pertinent 

sections: 

3.1.3 General Assignment of Responsibility

3.1.4 Role of CMS

3.1.5 Role of RRB

3.1.6 Role of Operations’ Medicare Section

3.1.7 Role of the Field Offices

3.1.17 Intermediaries and Carriers

3.1.18 State Health Agencies

805.15 Financing

Refer to RCM 3.1.8 for information about Part A financing and RCM 3.1.9 for 

information about Part B financing.

805.20 Hospital Insurance Benefits (HIB)

Refer to RCM 3.1.60 through 3.1.72 for information about the services covered by Part 

A of Medicare and how Part A payments are made. Here are links to those sections:

3.1.60 General

3.1.61 Benefit Periods

3.1.62 How Medicare Pays for Part A Services

3.1.63 Inpatient Hospital Services

3.1.64 Hospital Inpatient Reserve Days

3.1.65 Coverage of Blood Under Part A

3.1.66 Care in a Psychiatric Hospital
FOM1 805

FOM1 805 General Medicare Program Revised June 14, 2021 Page 3 of 13

3.1.67 Care Outside the United States

3.1.68 Care in a Christian Science Sanatorium

3.1.69 Prospective Payment System

3.1.70 Skilled Nursing Facility Care

3.1.71 Home Health Care

3.1.72 Hospice Care

805.25 Supplementary Medical Insurance Benefits

Refer to RCM 3.1.80 through RCM 3.1.89 for information about the services covered by 

Part B of Medicare and how Part B payments are made. Here are links to those 

sections: 

3.1.80 What Medicare Part B Includes

3.1.81 Deductible and Coinsurance Amounts Under Part B

3.1.82 Doctors’ Services Covered by Medicare Part B

3.1.83 Second Opinion Before Surgery

3.1.84 Services of Special Practitioners

3.1.85 Outpatient Hospital Services

3.1.86 Other Services and Supplies Covered by Medicare

3.1.87 Drugs and Biologicals

3.1.88 Medicare Payments for Non-Hospital Treatment of Mental 

Illness

3.1.89 Services Rendered Outside the United States

805.30 Medicare Advantage Plans (Part C)

Medicare Advantage Plans, also referred to as Part C of Medicare, are health plan 

options, like Health Maintenance Organizations (HMOs) and Preferred Provider 

Organizations (PPOs), that are approved by the Centers for Medicare & Medicaid 

Services (CMS), but are run by private companies. Medicare Advantage Plans (or MA 
FOM1 805

FOM1 805 General Medicare Program Revised June 14, 2021 Page 4 of 13

plans) combine Part A and Part B benefits. They must cover at least all of the 

medically-necessary services that the Original Medicare plan, i.e. the traditional fee-forservice plan, provides. Some Medicare Advantage plans also include Part D 

prescription drug coverage. Medicare Advantage plans first became available as an 

option for receiving Medicare benefits on February 1, 1985 (Public Law 97-248). The 

plans were originally referred to as Health Maintenance Organizations or HMOs, then 

as Medicare + Choice plans, and beginning in 2004 as Medicare Advantage plans.

805.30.1 Election of Medicare Advantage Plan

A beneficiary enrolls in a Medicare Advantage Plan directly with the plan or provider; 

district offices are not involved. A beneficiary must meet these requirements: 

• Have Part A and Part B.

• Live in the service area of the plan.

• Not have end-stage renal disease (except when special circumstances exist.)

Beneficiaries usually compare plans that provide services near their residence, then 

choose the one which best satisfies their needs. It is not necessary that a beneficiary 

notify the RRB regarding such enrollments, since there is NO change in the RRB's 

Medicare record or in the collection of Medicare premiums. 

805.30.2 Medicare Advantage Election Periods

The Balanced Budget Act of 1997 provides for Coverage Election Periods. During 

Coverage Election Periods, eligible beneficiaries may enroll in Medicare Advantage 

health plans. 

Do not confuse Medicare Advantage Coverage Election Periods with the Initial 

Enrollment Period (IEP), General Enrollment Period (GEP), and Special Enrollment 

Period (SEP) of Medicare Part B. IEPs, GEPs, and SEPs are still in effect for 

beneficiaries who enroll only in Medicare Part B.

There are four types of Medicare Advantage Coverage Election Periods.

1. Initial Coverage Election Period (ICEP)

The ICEP is the period during which an individual newly eligible for MA may make 

an initial enrollment request to enroll in a MA plan. This period begins three months 

before a beneficiary becomes entitled to coverage under Medicare Parts A and B. 

An ICEP ends the last day of the month preceding the month of the beneficiary’s 

entitlement.

Once an ICEP enrollment request is made and enrollment takes effect, the ICEP 

election has been used.
FOM1 805

FOM1 805 General Medicare Program Revised June 14, 2021 Page 5 of 13

Coverage under the health plan starts the first day of the month in which the 

beneficiary is entitled to Medicare Parts A and B.

Note: If a beneficiary enrolls in a MA during their IEP, they can change to another 

MA (with or without drug coverage) or go back to Original Medicare (with or without 

a drug plan) within the first 3 months they have Medicare. 

2. Annual Election Period (AEP)

The Annual Enrollment Period runs from October 15 through December 7 each year. 

During this time beneficiaries can choose to enroll in a stand-alone Medicare 

Prescription Drug Plan (PDP), a Medicare Advantage Plan (MA), a Medicare 

Advantage Plan with Prescription Drug Coverage (MA-PD), or other Medicare Health 

Plan, or switch to another plan. Coverage under the health plan starts January 1 of 

the following calendar year.

No action is required by beneficiaries during the AEP who are currently enrolled in a 

plan and do not want to change plans. 

3. Open Enrollment Period (OEP)

Beginning in 2007, the OEP is from January 1 through March 31. The following 

limitations apply to the OEP:

• Only one election is allowed during the OEP.

• An individual who is enrolled in an MA-PD plan may elect another MA-PD plan, 

or disenroll from the MA-PD plan by enrolling in a PDP. (A Special Election 

Period allows the individual to enroll in a PDP under these circumstances.) 

Either action will generate an automatic disenrollment from the current MA-PD 

plan. 

• An individual enrolled in a PDP may elect an MA-PD during the OEP. Such an 

individual may not elect an MA plan that does not provide qualified prescription 

drug coverage.

• An individual who is enrolled in an MA plan and who does not have qualified 

prescription drug coverage may elect another MA plan that does not provide drug 

coverage or may elect to disenroll from the MA plan during the OEP.

• An individual enrolled in Original Medicare but not a PDP may elect an MA plan 

that does not provide qualified prescription drug coverage during the OEP. Such 

an individual cannot elect an MA-PD plan during this period. (Note: The Tax 

Relief and Health Care Act of 2006 allows people with Original Medicare to join a 

Medicare Advantage plan that doesn’t include Medicare prescription drug 

coverage at any time in 2007 or 2008. If they want to join a Medicare Advantage 
FOM1 805

FOM1 805 General Medicare Program Revised June 14, 2021 Page 6 of 13

plan that offers prescription drug coverage, they must enroll during the Annual 

Enrollment Period from October 15 through December 7.)

The following chart summarizes the OEP limitations.

If current coverage is Can use OEP to get Cannot use OEP to get

Medicare Advantage with 

prescription drug coverage 

(MA-PD)

MA-PD or 

Original Medicare + 

PDP

MA-only or

Original Medicare only

Medicare Advantage with no 

prescription drug coverage 

(MA-only)

MA-only or

Original Medicare only

MA-PD or 

A different PDP to use 

with Original Medicare

Original Medicare and a 

prescription drug plan (PDP)

MA-PD MA-only or

Original Medicare only

Original Medicare only MA-only MA-PD or

Original Medicare + PDP

Coverage under the health plan starts the first day of the month following the 

election.

4. Medicare Advantage Special Election Period (MA SEP)

• During a Medicare Advantage SEP, a beneficiary may discontinue the 

election of a MA plan and enroll in Original Medicare, switch from Original 

Medicare to a MA plan, or change from one MA plan to another MA plan, 

except for Medicare Medical Savings Account (MSA) plan enrollees. 

• A MA SEP may occur at any time, other than an Initial, Annual or Open 

Election Period, for the following reasons:

• The health plan terminates service in the area in which the beneficiary 

resides.

• The beneficiary moves out of the service area of the health plan.

• The beneficiary shows a provision of the Medicare Advantage contract was 

violated by the plan or the marketing of the plan materially misrepresented the 

provisions of the plan.
FOM1 805

FOM1 805 General Medicare Program Revised June 14, 2021 Page 7 of 13

• The beneficiary or a group of beneficiaries meets exceptional conditions 

specified by CMS, including on a case-by-case basis. A few examples of 

some SEPs that CMS has established include: 

• Beneficiaries making MA enrollment requests into or out of employer 

sponsored MA plans.

• Beneficiaries may disenroll from an MA plan at any time in order to enroll in 

the Program of All-inclusive Care for the Elderly (PACE).

• Beneficiaries that become entitled to Medicare Parts A and B, and also 

receive any type of Medicaid assistance, or who lose their dual-eligibility. 

• Beneficiaries with ESRD whose entitlement determination is made 

retroactively.

• Beneficiary whose Medicare entitlement determination is made retroactively. 

The Centers for Medicare & Medicaid Services will determine the beginning and ending 

dates of the MA SEP on a case-by-case basis.

The Medicare health plan is not required to accept the beneficiary’s enrollment. 

However, if a plan is open to new enrollees, the plan may then accept a beneficiary’s 

enrollment. Coverage under the new health plan starts at such a time as to avoid any

disruption in benefits.

805.30.2.1 Special Rules for Medical Savings Account (MSA) Plans

There are special enrollment rules for a beneficiary who elects a Medicare Medical 

Savings Account (MSA) Plan.

1. A beneficiary may elect a MSA Plan ONLY during:

• an Initial Coverage Election Period (ICEP) or

• the Annual Election Period (AEP).

2. A beneficiary who elects an MSA Plan during an ICEP MUST STAY in the plan 

through the last day of the calendar year in which he or she made the election. 

3. A beneficiary may disenroll from an MSA Plan ONLY between October 15 and

December 7 of each year during the AEP. Disenrollment will be effective 

January 1 of the next year.

EXCEPTION: A beneficiary who never previously elected an MSA Plan and who 

elects one during an AEP may revoke the election no later than December 15 of 

the same year. They still only have until December 7 to join another health or 
FOM1 805

FOM1 805 General Medicare Program Revised June 14, 2021 Page 8 of 13

drug plan. After December 7 and up until December 15, they can only return to 

Original Medicare. 

805.30.3 Disenrollment from a Medicare Advantage Plan

The Centers for Medicare & Medicaid Services’ 1-800-MEDICARE customer service 

representatives (CSRs) process requests for disenrollment from Medicare Advantage

plans. CMS requires that all disenrollments be made by calling a 1-800-MEDICARE 

CSR, or by submitting a request to the Medicare Advantage (MA) plan, either in writing, 

by fax, or if the plan allows, by Internet.

Field Office Procedures

Field office claims representatives should direct all beneficiaries requesting 

disenrollment, including requests received by telephone, mail and walk-in, to call 

Medicare directly at 1-800-MEDICARE (1-800-633-4227). TTY users should be 

instructed to call 1-877-486-2048 to request disenrollment.

RRB claims representative may assist walk-in requests by calling 1-800-MEDICARE for 

the beneficiary while he or she is in the office. It is important that the claims 

representative advise the beneficiary that he or she does not have to place the call from 

the RRB office; the beneficiary may call 1-800-MEDICARE on their own. 

Refer all disenrollment inquiries (e.g., individual requesting to disenroll from a MA plan, 

individuals following up on a disenrollment request, etc.) to 1-800-MEDICARE.

Beneficiary Disenrollment Process 

Beneficiaries will need the following information when they call 1-800-MEDICARE to 

disenroll:

• Name

• Medicare Claim Number

• Date of Birth

In addition, for the protection of their identity, beneficiaries will need to provide at least 3 

of the following pieces of information:

• Telephone number

• SSN

• Street Address

• City, State, Zip
FOM1 805

FOM1 805 General Medicare Program Revised June 14, 2021 Page 9 of 13

• Part A/Part B coverage

• Part A/Part B effective

Here is a description of the process beneficiaries follow when calling 1-800-MEDICARE 

to disenroll from a Medicare Advantage plan. (Beneficiaries will hear an automated 

introduction before being connected to a CSR after saying the word “Agent.”)

• The beneficiary will select English or Spanish

• The beneficiary should wait for the introduction to finish and then say “Agent.”

• When an agent answers, the beneficiary should state that he or she wants to 

disenroll from a Medicare Health Plan.

• The agent will transfer the beneficiary to a disenrollment customer service 

representative.

• The customer service representative will ask questions (e.g. name, Medicare 

number, date of birth, etc) as described above to verify the beneficiary’s identity.

Note: If the individual does not have this information at the time of the call, the 

individual will be asked to call back when he or she has the information available.

• After identifying information is provided, the CSR will verify the plan that the 

beneficiary is currently enrolled in (and would like to disenroll from).

• The CSR will input the disenrollment.

• Once the Medicare systems confirm the disenrollment, which takes 

approximately 1 week, a confirmation letter will be mailed to the beneficiary.

Status Inquiries/Congressional Inquiries

Instruct beneficiaries who inquire to follow up on a disenrollment request to call 1-800-

MEDICARE.

Congressional inquiries on behalf of constituents with disenrollment questions should be 

referred to the appropriate CMS regional office. Here is a list of the CMS regional 

offices with email addresses and telephone numbers:

Region 1 Boston (617) 565-1232

ROBOSORA@cms.hhs.gov

Connecticut, Massachusetts, 

Maine, New Hampshire, Rhode 

Island, Vermont
FOM1 805

FOM1 805 General Medicare Program Revised June 14, 2021 Page 10 of 13

Region 2 New 

York

(212) 616-2222

RONYCORA@cms.hhs.gov

New Jersey, New York, Puerto 

Rico, Virginia Islands

Region 3 

Philadelphia

(215) 861-4140

ROPHIORA@cms.hhs.gov

Delaware, District of Columbia, 

Maryland, Pennsylvania, Virginia, 

West Virginia

Region 4 Atlanta (404) 562-7500

ROATLORA@cms.hhs.gov

Alabama, Florida, Georgia, 

Kentucky, Mississippi, North 

Carolina, South Carolina, 

Tennessee

Region 5 Chicago (312) 353-7180

ROCHIORA@cms.hhs.gov

Illinois, Indiana, Michigan, 

Minnesota, Ohio, Wisconsin

Region 6 Dallas (214) 767-6423

RODALORA@cms.hhs.gov

Arkansas, Louisiana, New Mexico, 

Oklahoma, Texas

Region 7 Kansas 

City

(816) 426-5233

ROKCMORA@cms.hhs.gov

Iowa, Kansas, Missouri, Nebraska

Region 8 Denver (303) 844-1568

ROREAORA@cms.hhs.gov

Colorado, Montana, North Dakota, 

South Dakota, Utah, Wyoming

Region 9 San 

Francisco

(415) 744-3501

ROSFOORA@cms.hhs.gov

Arizona, California, Hawaii, 

Nevada, Pacific Territories

Region 10 Seattle (206) 615-2354

ROSEA_ORA2@cms.hhs.gov

Alaska, Idaho, Oregon, 

Washington

805.30.4 Disenrollment Effective Date

The effective date of disenrollment is the first day of the month after the month in which 

the beneficiary requests disenrollment. 

805.30.5 Resolving Beneficiary Problems with Medicare Advantage Plans

If a beneficiary in a Medicare Advantage plan is unhappy with the quality of the care he 

or she is receiving or needs to resolve differences with his or her plan, the beneficiary 

can:

• follow the Medicare Advantage plan’s grievance procedure, or

• contact the local Quality Improvement Organization (QIO). The beneficiary 

can call 1-800-MEDCARE to get the telephone number of the local QIO. 
FOM1 805

FOM1 805 General Medicare Program Revised June 14, 2021 Page 11 of 13

If a person believes that the MA plan made an incorrect decision on the coverage of 

benefits or payment of a claim, the person can exercise their appeal rights. Those 

rights are similar to those provided under traditional Medicare. See CMS Publication No. 

10112 and RCM 3.1.115 for more information about appeals.

A. Possible MA Plan Problems - Some of the problems that could develop because 

of MA plan involvement are:

• beneficiary should be enrolled in an MA plan, but the Entitlement Database 

(EDB) and Medicare Beneficiary Database (MBD) do not indicate MA plan 

involvement;

• beneficiary should be disenrolled from an MA plan but the EDB and MBD still 

indicate MA plan involvement;

• beneficiary was never enrolled in an MA plan but EDB and MBD indicate MA 

plan involvement;

• beneficiary should not be disenrolled from an MA plan but the EDB and MBD 

indicate the beneficiary is disenrolled; 

• beneficiary complains about an incorrect MA plan effective date on the EDB

and MBD; 

• beneficiary complains about an incorrect disenrollment date on the EDB and 

MBD. 

B. Resolving MA Plan Problems - Problems with MA plans are generally resolved in 

CMS's Regional Offices. However, the following steps should be taken first to try 

to resolve the problem:

• MU or the field office should determine if the inquiry or letter contains enough 

information to determine what the problem is. If not, secure a statement and 

whatever other proof the beneficiary may have.

• When enough information is obtained, it should be determined what is on the 

EDB. Check ELMO to see what is on EDB. Based on what is on the EDB, 

take one of the following actions:

• If the EDB has recently been updated to show correct information, advise the 

beneficiary accordingly. No further action is necessary.

• If the EDB has not been updated, MU will call CMS's Regional Office about 

the problem. The field office should forward the inquiry to MU. MU will 

discuss the problem with CMS. If it cannot be resolved over the phone, MU 

will refer the inquiry and other related material to CMS's Regional Office to 

resolve. The beneficiary will be advised with a short letter, with a copy to 
FOM1 805

FOM1 805 General Medicare Program Revised June 14, 2021 Page 12 of 13

CMS's Regional Office, of the referral. In the letter, explain that CMS's 

Regional Office will contact them about the problem. A copy of the letter 

should be included with the package being referred to CMS's Regional Office. 

See FOM-I-805.30.3 and Exhibit 17 of RCM 3.1 for a listing of CMS's 

Regional Offices and the States they service. See Exhibit 16 of RCM 3.1 for 

a sample letter.

If MU receives a manual payment/account correction from the Part B carrier 

when there is MA involvement, a manual payment should not be authorized. The 

package should be returned to the Part B carrier to verify their records. The Part 

B carrier should process the claim in accordance with the instruction in their 

carriers’ manual. The Part B carrier should either pay, deny, or transfer the claim 

to the MA plan. 

If the beneficiary still protests or complains and the necessary information and 

proofs are submitted, MU will call CMS's Regional Office to see if the problem 

can be resolved.

805.35 Medicare Prescription Drug Plans (Medicare Part D)

Medicare Part D prescription drug plans are private plans that contract with the Centers 

for Medicare & Medicaid Services (CMS) to provide drug coverage to people with 

Medicare who live within a certain geographic area.

Refer to FOM I 860.05 through FOM I 860.15.4 for additional information regarding the 

Medicare prescription drug plan (Part D). Here are the links:

860.05 Background

860.10.1 Part D Eligibility Requirements

860.10.2 Part D Enrollment Periods

860.10.3 Part D Enrollment Penalty

860.12 Payment of Part D Premiums

860.10.4.2 No Part D Subsidy

860.10.4.3 Entitled to Part D Subsidy

860.15.4 Subsidy Enrollment Periods

 
FOM1 805

FOM1 805 General Medicare Program Revised June 14, 2021 Page 13 of 13