HI 01001.220 “PW” Process
If an individual is eligible for a buy-in, a PW accretion is made immediately. When an initial award is processed, a State buy-in may be initiated through the award processes (HI 00815.030) based on a statement from a local welfare office that the individual is a member of its coverage group. (These cases can be recognized by the presence of a Factor Analysis Code of “PW” in item 7 of the SSA-101-U3).
If the state feels that the accreted enrollee is not a buy-in eligible, it cannot effectuate an annulment of the PW premium billing. Instead, it must furnish the Medicare Bureau Regional Office (MBRO) with the details of the accretion before the close of the 4th month following the one in which it received the premium billing. Otherwise, the State's premium liability stands until terminated by a deletion action.
Where a State objects to the accretion or the effective date of coverage, the MBRO determines whether the buy-in is correct based on the information obtained from the claims folder maintained in the PSC. For cases on file in the MAT-PSC and GLPSC, the parallel RO obtains the PW information but the buy-in review is made by the RO servicing the State. In all other cases, including those in BDI, the RO can contact the PSC directly.
The RO contacts the PSC via a standard memorandum (see HI 01010.803). The subject line of the memorandum reflects “Health Insurance-PW State Buy-In Case.” The RO needs to know the servicing DO, Welfare office contacted, type of assistance (Medicaid, Aid to Families with Dependent Children, Welfare, etc.), effective date of buy-in eligibility, welfare case number (Medicaid, public assistance, social services, welfare I.D. number, etc.) and other information that relates to the PW buy-in. In gathering this information from the claims folder to support a PW premium billing, look for the following acceptable evidence:
Evidence from State records showing an attempted buy-in accretion action that was rejected by SSA because there was no record of Medicare entitlement.
Evidence from SSA records (e.g., MBR) showing SSI payment in an accrete State.
Statement or report signed by a State public assistance representative showing the type of assistance, effective date, and identification of the individual.
Statement or report signed by a SSA representative showing the type of assistance, effective date, and identification of the public assistance office that furnished the original PW information.
The above evidence will be on various forms. Form SSA-5002 (Report of Contract) and Form SSA-1610 U2 (SS-Public Assistance Agency Information Request and Report) are two of the forms most frequently used to record the evidence.
The requested information should be recorded along each preprinted item on the RO memorandum. If the information for an item cannot be found, indicate “Unavailable” along side the item. If none of the facts can be found, check the box preceding “Information not available.” Return the completed RO memorandum within 30 days.
If no buy-in coverage is justified or the SSA office followed incorrect procedure, the PW determination will be considered erroneous. At the request of the RO, BSS will process an annulment to the State's premium account. SSA's MBR records will receive a buy-in deletion which cannot be any earlier than COM-3 months. Regardless of the claimant's prior SMI election (even if it's a refusal), a regular deletion will be processed. If the enrollee does not want coverage, he must request a withdrawal.
NOTE: The PSC is not required to make a correction to the MBR involving a PW since it is made by BSS. No adverse entitlement or premium adjustment can be made against the enrollee where the PW buy-in is valid, but the dates are wrong.