TN 26 (11-93)

HI 00801.140 State Buy-In and Group Payer Provisions for QMBs

A. Background

When the QMB provisions were enacted in 1989, States were given the option of expanding their State buy-in agreements to cover QMBs for SMI, thereby permitting QMBs to be enrolled in SMI without regard to the enrollment period and premium increase provisions applicable to individual enrollees. All States elected to cover QMBs for SMI. Effective January 1, 1990, States were also extended the option of expanding their buy-in agreements to cover QMBs for Premium-HI for the Aged.

B. Policy — Part A Buy-in States

States which elect to cover QMBs for Premium-HI for the Aged are referred to as “Part A Buy-In States.” Following is a list of the Part A Buy-In States and the effective date of the agreement modification, if later than 1/90:

AlaskaMaryland

Pennsylvania

ArkansasMassachusetts

Rhode Island

ConnecticutMichigan

South Dakota

DelawareMinnesota

Tennessee (7/90)

District ofMississippi

Texas (7/93)

.ColumbiaMontana

Vermont (9/90)

FloridaNevada

West Virginia

GeorgiaNew Hampshire

Washington (7/90)

HawaiiNew York (07/04)

Wisconsin (7/90)

IdahoNorth Carolina

Wyoming (11/90)

IndianaNorth Dakota 
IowaOhio 

Louisiana

Oklahoma 
Maine

Oregon (7/2008)

 

C. Policy — Part A Group Payer States

In the remaining States, individuals are subject to the enrollment period and premium increase provisions applicable to individual enrollees. In these States, the HI premium must be paid under a group payer arrangement (Part A Group Payer States). Since individuals in Part A group payer States must enroll for Premium-HI during an enrollment period, there is a special “conditional” enrollment process to permit enrollment to be effective only if the person is determined to be a QMB and only as of the month their QMB status is effective.

D. Procedure

1. Individual entitled to HI — All States

If an individual is entitled to HI (including Premium-HI) and appears to meet QMB income and resource requirements, briefly explain the QMB provisions and refer him/her to the State for further information.

However, if the individual is eligible for Part B buy-in as a cash-assistance recipient or under the medically needy provisions, establish Part B buy-in coverage, as appropriate (see HI 00815.001ff. for a discussion of SMI buy-in procedures).

NOTE: States use BENDEX and SDX to verify Part A entitlement and establish QMB eligibility.

2. Individual not insured for HI— Part A Group Payer State

If an individual is not insured for premium-free HI but may meet QMB income and resource requirements, inform the individual about the QMB provisions and that he/she must file for Premium-HI during a prescribed enrollment period in order to qualify as a QMB.

Advise the person that he/she may file for Premium-HI on a conditional or unconditional basis. Have the individual file conditionally only if he/she wants Premium-HI if determined to be a QMB. Have the individual file unconditionally if he/she wants Premium-HI even if ineligible for QMB status or wants Part A for any months which might elapse between initial Part A eligibility and the State determination of QMB status. If an individual wishes to file unconditionally, follow the procedures in 5. below. If an individual wishes to file conditionally:

  • Take an application for Premium-HI (and SMI if not already entitled).

  • Include the following statement in the “Remarks” section of the application: “I wish to enroll for hospital insurance on a monthly premium basis, and I understand that the hospital insurance premium will be in addition to the monthly premium for supplementary medical insurance. I want this enrollment to be effective only if I am determined to be eligible as a qualified Medicare beneficiary (QMB) and only beginning with the month in which I am eligible as a QMB. I also understand that, if I lose my QMB status, I will have to pay my premiums in order to keep my Medicare hospital insurance.”

  • Refer the individual to the appropriate State office to file for QMB status. Emphasize the importance of promptly contacting the State.

NOTE: The State will query to verify the conditional enrollment and accrete the individual to its Part A Group Payer account. This action will establish the Part A effective date on SSA/CMS records.

3. Individual has SMI — Part A Buy-in State

If the individual appears to meet the QMB income and resource requirements, is already enrolled (or is currently being enrolled) in SMI (either individually or as a member of another buy-in coverage group) and resides in a Part A buy-in State:

  • do not take a Premium-HI enrollment request; and

  • refer the individual to the State to file for QMB status.

NOTE: The State will query to verify SMI entitlement and accrete the individual to its Premium-HI buy-in file.

4. Individual does NOT have SMI — Part A Buy-in State

If an individual does not have SMI and could qualify for buy-in of SMI only as a QMB:

  • Take a SMI enrollment and a conditional Premium-HI enrollment as described in 2. above (unlike Part A group payer States, however, the enrollment may be filed at any time); and

  • Develop for age and residence; and

  • Refer the individual to the appropriate State office to file for QMB status. Emphasize the importance of promptly contacting the State.

5. Unconditional enrollment

If an individual wants Premium-HI even if not eligible for State payment of Part A premiums or wants Premium-HI coverage for any months which may elapse between the first month for which Premium-HI could be awarded based on the month of enrollment and the first month of QMB status, take an unconditional Premium-HI enrollment request if the individual is in a prescribed enrollment period.

Advise an individual who does not already have SMI that he/she must also enroll in SMI at the time the Premium-HI enrollment request is filed.

If an individual filing unconditionally also appears to meet QMB income and resource requirements, refer the individual to the State for further information.

E. Reference

See SM 03040.000 for system processing instructions.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0600801140
HI 00801.140 - State Buy-In and Group Payer Provisions for QMBs - 04/21/2015
Batch run: 04/21/2015
Rev:04/21/2015