TN 49 (11-22)

HI 01001.205 State Buy-In

The Social Security Act provides that States may enter into an agreement with SSA which permits State welfare agencies to enroll individuals for part B (SMI) coverage and/or “buy-in” for the payment of medical insurance premiums if the individual is a member of a coverage group (eligible for welfare payments under one of the titles I, X, XIV, XVI, XIX, or part A of title IV). Once a State has contracted an agreement with the Administration, the State is required to enroll and/or pay the medical insurance premiums for each individual eligible under the titles included in its contract and must continue payments as long as the individual is a member of that coverage group. (See the end of this section for the list of States having buy-in agreements and their effective dates.) States may buy-in for members of its coverage group(s) regardless of whether the individual is uninsured or insured or receiving monthly benefits or not, as long as the SMI eligibility requirements are met (age 65, 25 months of entitlement to disability insurance, etc.).

States electing to pay SMI premiums for individuals determined to be members of the State's coverage group(s) may enroll such individuals in the SMI program regardless of the individual's own option. That is, individuals who have refused SMI coverage or had their coverage terminated, either voluntarily or involuntarily may be enrolled or reenrolled by the State. Individuals covered under a State buy-in may not voluntarily terminate their SMI coverage.

Whenever a State buy-in is processed retroactively for individuals paying their own premiums, all premiums previously paid during the period of buy-in coverage will be refunded. For example, an individual whose premiums are being deducted from their monthly benefits becomes covered under a State buy-in effective 10/75. If the buy-in were processed in the 12/75 operating month, the individual would receive a premium refund for 10/75 through 12/ 75 (the premium for 12/75 having been deducted from 11/75 benefit) in a separate check.

NOTE: States electing to pay part A (HI) premiums for individuals entitled to HI on a premium paying basis, may do so only as group payers. There is no State buy-in agreement for premium-HI nor may a State enroll or reenroll an individual in the premium-HI program.

Dependent upon the type of agreement the State has negotiated, a State may buy-in for its residents who are:

1. A. 

   receiving aid to families with dependent children (AFDC) under part A of title XV: or

2. B. 

   receiving a supplemental security income (SSI) payment or a State supplemental payment, either Federal or State administered, under title XVI; or

3. C. 

   receiving medical assistance (Medicaid) payments or determined to be “categorically needy” for Medicaid under title XIX.

Normally, the individual States have full accretion/deletion responsibility for members of its coverage group(s) except in certain States whose residents are receiving SSI payments as explained below. For example, if an individual is covered under a buy-in in California due to the receipt of AFDC payments and changes residence to Florida, it is California's responsibility to delete its buy-in and Florida's to accrete, if appropriate.

Under the SSI program, certain States have entered into an agreement with SSA whereby entitlement to SSI payment automatically establishes buy-in coverage. For these States, SSA makes the buy-in determination based on the individual's eligibility to SSI and SSA can delete the buy-in coverage when the individual's SSI eligibility has ended. The remaining States have elected to make their own determination as to the individual's buy-in eligibility and have full accretion/deletion responsibility.

Agency codes for State payers will range from 010 through 650. A list of the States that have negotiated buy-in agreements, the effective date, and type of individuals covered under the agreement, their billing codes, and accretion/ deletion responsibility, etc., is provided at the end of this section.

Once a State has submitted a report of buy-in accretion (or deletion), they cannot later modify the effective date unless it would be advantageous to the beneficiary. That is, the effective accretion date can only be adjusted to reflect an earlier date of coverage; the effective deletion date can only be adjusted to reflect a later date of deletion.

When a State buys in for a claimant, the State will pay the SMI premiums for the individual beginning with the effective date of buy-in. The individual is liable for any premiums still due for months of SMI entitlement prior the effective date of the buy-in. Any such premiums due must be withheld from any benefit payable. If no benefit is payable, a premium billing notice including past due premiums must be manually prepared and sent to the claimant. No control should be established for receipt of payment and SMI termination is never appropriate while the State has assumed the responsibility for paying current premiums.

State buy-in coverage will continue until:

1. A. 

   The individual dies; or

2. B. 

   The individual is no longer covered under the State's buy-in agreement; or

3. C. 

   two months after the individual has been notified that entitlement to a disability benefit has ceased (see HIIM section 310.03.).

The States that have negotiated buy-in agreements, the particular contact district office code, the States' billing code, the type of individuals covered, and the effective dates of the buy-in agreement are shown in the chart below. The last column of the chart indicates whether SSA or the State makes the buy-in determination for individuals receiving SSI payments. Either SSA or the State assumes full accretion/deletion responsibility (e.g., in States where SSA determines buy-in coverage based on the receipt of SSI payments, the States will not be allowed to delete the buy-in; the deletion may only be accomplished by SSA and only because SSI eligibility has ceased).

Buy-in determinations for individuals receiving AFDC payments will always be made by the States except in Wyoming whose buy-in agreement terminated July 31, 1967, and Kentucky whose residents are not covered under AFDC.

NOTE: The “Effective Dates” columns also include the types of individuals covered. That is, the date that appears in the “Insured” or “Uninsured” columns indicates when that types of individual became covered (e.g., the State of Massachusetts covered only uninsured individuals prior to 11/75).

 

¹ Buy-in in agreements related to SSI eligibility are effective January 1974with the exception of Maryland, Michigan, Vermont, and Washington and with the exception of the insured in Massachusetts and Wisconsin.

² This code represents a special identification of Cuban refugees eligible for State buy-in under the Cuban Categorical Assistance Program (CCAP).

³ Maine terminated its MAA agreement 8/31/74.

⁴ Nebraska terminated its MAA agreement 3/31/69.

⁵ Wyoming terminated its buy-in agreement effective 7/31/67.