TN 40 (12-22)

HI 00815.085 SSA DO/BO Procedures for Resolving Individual Buy-In Problem Cases Not Involving SSR-MBR Interface

1. A. 

   There are three types of buy-in related complaints which can occur regardless of whether CMS or the State has accretion/deletion responsibility and are not caused by a breakdown in the SSR-MBR interface. The complaints are:

   1. 1. 

      Erroneously denied Part B claim or erroneous termination of SMI coverage.

   2. 2. 

      Erroneous premium deduction from title II check or erroneous premium billing.

   3. 3. 

      Failure to start or resume premium deduction from title II check or failure to resume direct billing.

2. B. 

   Although the correctness of the Part B premium depends on the correctness of the MBR and reimbursement of Part B medical charges depends upon the correctness of the HIM, every buy-in case should be evaluated from the perspective that both the MBR and the HIM must be correct. If either master is incorrect, action must be initiated to correct the erroneous record(s) regardless of whether or not the individual is aware that there is an error.

3. C. 

   When a State buy-in has been established on the Third Party Master and the MBR and HIM have been updated, the master records should reflect the following:

   1. a. 

      Master Beneficiary Record (MBR) - Third Party Line, State Code (SC), Third Party entitlement date (TEDS).

   2. b. 

      Health Insurance Master Record (HIM) - Part B Entitlement Date (PBE), SMIB Option Code = Y, State Buy-In Indicator (SBI) = 1.

4. D. 

   When a State buy-in has been terminated and the MBR and HI masters have been updated, the master records should reflect the following:

   1. a. 

      Master Beneficiary Record - Third Party Line, State Code (SC), Third Party entitlement date (TEDS), Third Party termination date (TTDS).

   2. b. 

      Health Insurance Master Record - State Buy-In Indicator (SBI) = 0.

5. E. 

   When an individual contacts the DO/BO with a buy-in complaint described in HI 00815.085 A above, take the following action:

   1. 1. 

      Determine if the individual has received a State buy-in letter within the last 45 days. If they have, and the letter is readily available, photocopy it for the file.

   2. 2. 

      Obtain MBR and HI printouts. Examine the printouts to determine if the State buy-in related fields are in agreement with the beneficiary"s allegation. See HI 00815.085 C and D for an explanation of the entries which should appear on the MBR and HIM.

   3. 3. 

      If the entries on the MBR and HIM are correct, advise the individual that the problem has been resolved. NOTE: If the individual complains that premium billing notices are still being sent, request a BCM. If the BCM has the individual in billing status send an SSA 5002 HB to the appropriate PSC. Annotate the remarks field - “MBR Correct, Beneficiary Being Billed for SMI Premiums - State Buy-in Case - Please correct the BCM”. Attach copies of printouts to the 5002 form.

   4. 4. 

      If one or more entries on the MBR or HIM is incorrect (or if there is no Third Party Line on the MBR and there should be) and the individual"s current buy-in status has been verified by means of the State buy-in letter, complete the CMS-1957, Part 1, Report of Problem by DO/BO, and forward the case to CMS Central Office at the address in HI 00815.088 C.3.

   5. 5. 

      If the individual was unable to furnish a State buy-in letter or furnish one that is no more than 45 days old, verify the individual"s current buy-in status to determine if a problem still exists. Complete Part 1 of the CMS-1957 to the local welfare office or State agency in accordance with the instructions in HI 00815.088C. The State agency and parallel DO will process the CMS-1957 in accordance with the instructions in HI 00815.091 A and B.