TN 34 (10-21)

HI 00815.021 The End of State Payment of Medicare Premiums Under a Buy-in Agreement

 

A. Background

The state or the Centers for Medicare & Medicaid Services (CMS) can end (delete) a state’s payment of Medicare Part A or Part B premiums under the state’s buy-in agreement (also known as “Part A or Part B buy-in”) based on the circumstances indicated below, as outlined in the CMS Manual for the State Payment of Medicare Premiums, chapter 1, sections 1.14.2 and 1.13.2.States must notify CMS through a Medicare Part A and/or Medicare Part B deletion request when an individual loses eligibility for state buy-in coverage. The end of state buy-in has important implications for beneficiaries. For information about beneficiary impact and options for relief when buy-in ends, see HI 00815.042.

 

B. End of a State Payment of Part A Premiums for Qualified Medicare Beneficiaries

The Qualified Medicare Beneficiary (QMB) program is a Medicaid program that helps pay the Part A and Part B premiums and cost-sharing for eligible low-income Medicare beneficiaries, as described in HI 00801.139. All states must pay Part A premiums for individuals who are enrolled in the QMB program and not otherwise entitled to "premium-free" Part A coverage. States can choose one of two methods to pay Part A premiums for QMBs:

  1. 1. 

    Under their buy-in agreement,"Part A buy-in state" or

  2. 2. 

    Through a group payer arrangement, "group payer state"

See HI 00801.140 for more information about the state payment of Part A premiums for QMBs.

The duration of the state's payment of Part A premiums ends with earliest of the events specified below:

 

If the event is...

AND...

THEN...

Termination Initiated by...

Loss of QMB status

If the state determines the beneficiary is no longer eligible for QMB and completes a termination of QMB coverage consistent with Medicaid regulations

The Part A buy-in coverage period ends no earlier than the last day of the month in which the beneficiary is enrolled in QMB.

State

Death

 

Coverage ends on the last day of the month in which the beneficiary dies.

CMS or State

Entitlement to Medicare Premium-free Part A

If a beneficiary becomes entitled to premium-free Part A

Part A buy-in coverage ends on the last day of the last month the beneficiary is entitled to premium Part A, at which point the beneficiary will be entitled to premium-free Part A. See HI 00820.015 for information about the termination of premium Part A.

CMS or State

Termination of Part A buy-in agreement

If the state terminates its Part A buy-in agreement (i.e, removes payment of Part A premiums for QMBs from the buy-in agreement)

Coverage through the buy-in agreement will end. However, payment of the Part A premiums for QMBs must continue without interruption under the group payer arrangement.

CMS

Note: CMS may modify the effective stop date of a Part A buy-in termination (deletion) request submitted by a state based on processing rules described in the CMS Manual for the State Payment of Medicare Premiums, chapter 2, section 2.6.1.4.CMS terminates (deletes) Part A buy-in coverage effective at the end of the month in the month the state's deletion request is received, even if the individual lost eligibility in an earlier month.

C. End of a Part B Buy-in Coverage Period

Under their buy-in agreements, states pay the Part B premiums for certain Medicare-eligible Medicaid beneficiaries (members of their Part B buy-in coverage group). The state’s Part B buy-in coverage group includes multiple Medicaid eligibility categories identified in its buy-in agreement.

The Part B buy-in coverage period ends with the earliest of the events specified below:

IF the event is...

AND...

THEN...

Termination Initiated by...

Loss of membership in the state's buy-in coverage group

 

Coverage ends the last day of the month in which the beneficiary is enrolled in any Medicaid category included in the buy-in coverage group.

State

Death

 

Coverage ends on the last day of the month in which the beneficiary dies.

CMS or State

Loss of entitlement to Medicare Premium free Part A

If a beneficiary is:

  • under age 65 and

  • is no longer entitled to Medicare Premium-free Part A (i.e., has lost Social Security Disability Insurance (SSDI) benefits due to excess earnings)

 

Part B buy-in coverage, if applicable, ends on the last day of the last month for which the beneficiary is entitled to Premium-free Part A

CMS

Termination or modification of the buy-in agreement

If the state's buy-in agreement is terminated or modified to restrict coverage to a narrower buy-in group

Coverage for the beneficiary ends on the last day of the last month for which the agreement is in effect for the beneficiary's buy-in group.

CMS

Note: If the state determines an individual is no longer eligible for a Medicaid coverage group in the state Part B buy-in coverage group, the state's must follow the steps described in section D below.

Note: CMS may modify the effective stop date of a Part B buy-in termination (deletion) request submitted by a state based. on processing rules as described in the CMS Manual for the State Payment of Medicare Premiums, chapter 2, section 2.6.1.3.., Part B deletion requests cannot be earlier than two months before the month in which the state notifies CMS of the deletion, even if the individual lost eligibility in an earlier month.

D. State Requirements for Part B Buy-in When a Beneficiary Experiences a Change in Circumstance That Affects Medicaid Eligibility

If a beneficiary enrolled in a Medicaid eligibility category included in the state’s buy-in group experiences a change in circumstance and the state determines the beneficiary ineligible for that Medicaid category, the state must promptly redetermine eligibility on all other bases in order to determine if the beneficiary qualifies for a different Medicaid category, including those included within the Part B buy-in coverage group. .See 42 CFR §435.916(f). While the state is making this determination, the state must maintain Medicaid coverage and must not terminate the beneficiary from buy-in. See 42 CFR § 435.930(b).Further, if the state determines the beneficiary continues to qualify under another Part B buy-in group category, Part B buy-in coverage must continue without interruption. SeeCMS Manual for the State Payment of Medicare Premiums, chapter 1, section 1.4 for additional information about state requirements under their buy-in agreements.

 

Note on loss of Supplemental Security Income (SSI): Loss of SSI constitutes a change in circumstances that may affect a beneficiary’s Medicaid eligibility and thus triggers a redetermination. See 42 CFR § 435.916(d).

CMS transmits an informational “SSI deletion” notification record to states upon notification from SSA that a beneficiary has lost SSI eligibility.

The alert is not a notification that CMS has deleted the record or that the state must submit a deletion transaction. Rather, the alert is intended to prompt the state to conduct a redetermination pursuant to 42 CFR § 435.916(f)if the individual is no longer eligible for the Medicaid eligibility group based on receipt of SSI (e.g., no longer has a qualifying disability).


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0600815021
HI 00815.021 - The End of State Payment of Medicare Premiums Under a Buy-in Agreement - 11/20/2001
Batch run: 10/12/2021
Rev:11/20/2001