HI 00815.030 SSA DO/BO Procedures to Develop Buy-In Coverage in Initial Claims Cases — The Public Welfare Accretion Procedure

A. General

The Social Security district/branch office should initiate the Public Welfare (PW accretion procedure) when an individual files an application for Medicare and has or will have Medicaid eligibility which will qualify him as a member of one of the State’s buy-in coverage groups. See the chart in HI 00815.009 for coverage groups. The purpose of the PW procedure is to establish Part B of Medicare for the individual via State buy-in without Part B premiums being deducted from the individual’s check or the individual being placed in direct billing status for a period for which the State should be paying the Part B premium. An application for SMI may be filed at any time in order to establish eligibility for buy-in, not just during an IEP or a GEP. A buy-in coverage period may be retroactive based upon earlier entitlement to SSI or Medical Assistance.

B. The PW Process for SSI Recipients in Auto-Accrete States

For the SSI auto-accrete process to occur, the SSI eligibility data (title XVI) and the Medicare eligibility data (title XVIII) must both be present on the MBR. The Social Security DO/BO can determine whether entitlement to Medicare Part B has been established by querying the MBR.

When an SSI applicant in an auto-accrete State appears to meet the basic Medicare eligibility and Medicare entitlement is not present on the MBR, obtain a title XVIII application. Obtain the application even if the individual refuses Medicare coverage unless the State buys-in for him.

If the DO/BO does not obtain a title XVIII application at the same time the SSI application is taken, SSA’s Office of Systems will release a leads claims package to the servicing DO/BO for development (See HI 00810.010 for developing entitlement to Medicare.)

Additionally, SSA’s Office of Systems (OS) reviews the SSR each month to locate blind or disabled SSI recipients who are age 64 years and 9 months or older, who are not receiving title II or RRB benefits, who reside in an auto-accrete State, and are not enrolled for SMI. OS will prepare an attainment claims package for release to the servicing DO/BO requesting Medicare development (See HI 00810.010). Instructions for processing the attainments and leads claims package are contained in HI 00810.010.

When the State buy-in is based on SSI payments in an auto-accrete State, the DO /BO need not contact the State public assistance agency to verify Medicaid eligibility. Instead, the DO/BO will prepare an RC stating “Medicaid eligibility based on receipt of SSI payments,” and include the RC with the completed title XVIII application when it is forwarded to the PSC.

C. The PW Process in an Alert State and the PW Process for Non-SSI Recipients in All States

When a Medicare applicant states that he is entitled to Medicaid and he resides in an alert State or he is a non-SSI recipient in an auto-accrete State, refer to the chart in Section HI 00815.009 to determine whether the type of Medicaid coverage he alleges is included in the State’s buy-in agreement. If it appears that the individual may be eligible for State buy-in, verify the individual’s title XIX status with the appropriate public assistance agency. IT IS IMPERATIVE THAT THE VERIFICATION BE MADE IN ACCORDANCE WITH THE PROCEDURES AGREED UPON BY SSA, THE STATE, AND THE CMS RO. Failure to correctly verify the individual’s status may result in an erroneous PW accretion and a loss to the Medicare trust fund.

Verification of title XIX status may be based upon a telephone contact with the appropriate public assistance office. It must contain the following information:

  1. Type of assistance the individual is receiving.

  2. The Medicaid effective date (NOTE: If the individual is entitled to title XIX Medical Assistance Only and the State buy-In agreement covers this group, the mandatory 2-month waiting period must be reflected in the buy-in effective date on the award form.)

  3. The Medicaid case number.

  4. The location of the public assistance office furnishing the information and the name of the contact person.