HI 00815.039 Effect of Buy-In on the Individual

A. Routine Buy-In Accretion

The individual will be sent a State Buy-In Notice HCFA-L1614TR (see HI 00815.200) notifying him of the effective date of the buy-in action.

If the individual is receiving a Social Security check, the SMI premium will no longer be deducted from his benefit resulting in a higher monthly payment. If he was not receiving a Social Security check, but instead was being billed directly for SMI, direct billing will cease. In both cases, the individual will receive a refund of any premiums deducted or paid for any month he was on buy-in. Such a refund of SMI premiums is not considered income when determining eligibility for assistance.

If the individual previously refused SMI or withdrew from it, entitlement will be established or reestablished effective with the first month he was eligible for buy-in. The individual will receive a new Medicare Card indicating the new Part B entitlement date.

B. Routine Buy-In Deletion

The individual will be sent a buy-out notice HCFA-L1636TR (see HI 00815.201) notifying him of the date the State stopped paying his Part B premium. If the individual is receiving a Social Security check, the SMI premium will be deducted from his monthly benefit check beginning with the first month after the month in which the buy-in terminated. He may be liable for up to 3 month"s premiums depending on when the termination was processed. If the individual is not receiving a Social Security check, he will be billed directly for the SMI premiums. When buy-in ends he has the option to then withdraw from Part B if he does not want the coverage to continue. However, if he does not withdraw, the premium will be the base amount even if he had been paying a penalty premium for late enrollment prior to being on buy-in.

C. Closed Period of Buy-In Coverage

The State may report a simultaneous accretion/deletion in which both events occurred prior to the State"s notice to CMS. For example, the State may notify CMS that an individual is to be both accreted as of a given month, and deleted as of a later month (that is the month in which the State determined that he had become ineligible).

1. CURRENT CLOSED PERIOD

If the deletion date in the simultaneous accretion/deletion action is less than 3 months retroactive from the month in which CMS is notified of the simultaneous accretion/deletion, the individual"s SMI coverage will continue even though the buy-in has terminated. If the indivdual already had SMI coverage, prior to the simultaneous accretion/deletion action, and is paying increased premiums his premium rate will be reduced to the standard premium amount for all months after the buy-in period. Any amount he paid in excess of the standard premium will be refunded to him along with all premiums he paid for the closed period of buy-in coverage. The individual will have the right to re-enroll in SMI if he terminates his present coverage. The individual will be sent a State buy-in letter HCFA-L1907TR (see HI 00815.202) notifying him of the inclusive dates of the closed period of buy-in coverage.

2. RETROACTIVE CLOSED PERIOD

In simultaneous accretion/deletion cases when the reported deletion month does not represent a current period, i.e., when the effective deletion month is 3 or more months before the month in which CMS received the prescribed notice of accretion and deletion, the enrollee is awarded a closed period of buy-in coverage and has buy-in coverage only for the months reported by the State. The State is liable for premium payments only for those months. If the enrollee had individual coverage and paid premiums for any of the months in the closed period, premiums for those months are refunded to him.

The enrollee's current SMI coverage is not affected, i.e., if he has SMI coverage, it will continue. Conversely, if the individual did not have SMI coverage prior to the State's action, he is not awarded individual SMI coverage following the period of buy-in coverage.

However, the records are annotated to reflect the prior buy-in coverage. Also, if he enrolls for SMI at a later date, only months after the buy-in coverage period will be counted in determining the statutory premium increase for late enrollments.

The individual will be sent a special buy-in letter from CMS Central Office notifying him of the inclusive dates of limited buy-in coverage.


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