HI DAL00815.030 Establishing State Buy-In For SMI In Initial Claims through the Public Welfare (PW) Accretion Process (RTN 05, 10/2015)

See HI 00815.030

A. General

The field office (FO) initiates the public welfare (PW) accretion process when an applicant files for Supplementary Medical Insurance (SMI), also referred to as Medicare Part B, and has or will have Medicaid eligibility. The PW process allows the FO to establish the individual’s SMI through State Buy-in Program preventing deductions from the beneficiary’s monthly benefit check or direct billing for SMI premiums.

The requirements for verification and documentation of Medicaid eligibility prior to a PW accretion depends on the applicant’s Supplement Security Income (SSI) eligibility and residence:

  • An auto-accrete (or 1634) State has entered into a 1634 agreement with SSA, authorizing the Secretary of Health and Human Services to determine Medicaid (Title XIX) eligibility for the aged, blind or disabled based on the individual’s entitlement to SSI payments or federally- administered State supplement payments (HI 00815.006A). In the Dallas region, Arkansas, Louisiana, New Mexico, and Texas are auto-accrete States.

  • An alert (or 209.b) State did not enter into a 1634 agreement with SSA but reserved the right to make its own Medicaid eligibility determinations using SSI standards or a more restrictive standard (HI 00815.006B). Alert States receive monthly data exchange transmission from Centers for Medicare and Medicaid Service (CMS) alerting them of SSI recipients. In the Dallas region, Oklahoma is the only alert State.

B. Buy-in process for SSI recipients or recent applicants in auto-accrete states

If the individual has a pending SSI application, the FO will wait for the SSI determination before adjudicating the current Title II/Title XVIII application. If the SSI determination is a denial, process the current Title II/Title XVIII application using the procedures in HI DAL00815.030C.

The effective date under the Buy-in Program for a resident of an auto-accrete State based on entitlement to SSI or a federally-administered State supplement is the first month the applicant is eligible for both Medicare and SSI. (HI 00815.018A and HI DAL00815.030E.)

NOTE: Use caution in coding PW accretions prior to the SSI determination. Erroneous PW accretions result in a loss to the Medicare trust fund due to erroneous enrollments for individuals who cannot or do not wish to pay premiums.

C. PW Buy-in process in alert states and for non-SSI recipients in all States

The effective date of the PW accretion for beneficiaries living in an alert State or non-SSI recipient living in any state is based on the type of state assistance they receive and the procedures in HI 00815.018.

NOTE: If Medicaid eligibility ends, the state must initiate the accretion. We cannot establish a PW accretion for a closed period. If the beneficiary is in a prescribed enrollment period, they may complete the application for Medicare, agreeing to pay the premiums.

Develop to the State for Medicaid verification. Include the following information with your request for verification:

  • Complete name, address, and date of birth of the applicant,

  • Social Security number,

  • Welfare case number, if available and,

  • Your contact information.

Request the State to provide the following information for processing the PW accretion:

  • Type of assistance the individual is receiving (AFDC, TANF, MAO, etc.),

  • Medicaid eligibility date and,

  • Contact person’s name and telephone number.

D. Special procedures for Dallas region

Contacts for the Dallas region are as follows:

Arkansas:
Ruthie Broughton 501-682–8269

Louisiana:
Send an email to the secured email CENLA@la.gov with the information provided in HI DAL00815.030C.

New Mexico:
Jill Bowles-505-476-6824
Vanessa Matthews-505-476-6865
Sonya Pierce-505–827-7777

Oklahoma:
Brooke Calhoun 405-521-4405

Texas:
Helen Lammert 512-706-7177

E. Coding PW accretions

Once the CR receives verification of Medicaid eligibility from the State of residence or the favorable SSI determination, complete the HI19 (MS ICD 003.003) screen with the type of assistance, eligibility date and the Welfare number. Review any propagated date or code the SMID ( MS MCS 014.014) screen to ascertain the SMI START is correct based on the State Bu