TN 49 (11-22)

HI 01001.200 Complaints Involving Alleged State Buy-In Coverage

An individual may complain that they are entitled to SMI under a State buy-in agreement after the carrier has denied their claim for benefits on the ground that they are not entitled to SMI. In many such cases the individual is entitled to SMI, but the State did not correctly identify the individual in submitting its list of enrollees. Most carriers and State Welfare agencies have arrangements under which the State will, upon request, check the individual's eligibility before the carrier denies the claim. However, when this process cannot be used (e.g., because there was no indication of welfare involvement in the claims process), individuals may complain to the DO. Complaints may also be made by individuals who are enrolled under a State buy-in agreement but have received premium billing notices, an incorrect notice that their coverage has terminated, or other improper notices. In these cases the DO contacts the welfare department to verify whether or not the individual is covered by a buy-in agreement, and relays the correct information to in accordance with HI 00815.088.