Effective Dates: 1/06/2025 - Present

Identification Number:
HI 00815 TN 56
Intended Audience:See Transmittal Sheet
Originating Office:Centers for Medicare & Medicaid Services (CMS)
Title:State Enrollment of Eligible Individuals
Type:POMS Full Transmittals
Program:
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM

Part HI – Health Insurance

Chapter 008 – Requirement for Entitlement and Termination

Subchapter 15 – State Enrollment of Eligible Individuals

Transmittal No. 56, 01/06/2025

Audience

PSC: BA, CA, CS, DS, ICDS, IES, ILPDS, IPDS, ISRA, PETE, RECONR, SCPS, TSA, TST;
OCO-OEIO: BET, BIES, CR, EIE, ERE, FCR, PETL, RECONR;
OCO-ODO: BET, BTE, CCE, CR, CST, CTE, CTE TE, DEC, DSE, LCC, PAS, PETE, PETL, RCOVTA, RECOVR;
FO/TSC: CS, CS TII, CSR, CTE, DRT, FR, OA, OS, RR, TA, TSC-CSR;

Originating Component

CMS

Effective Date

Upon Receipt

Background

Centers for Medicare & Medicaid Services (CMS) is editing this section to include new policies and procedures.

Summary of Changes

HI 00815.030 Establishing State Buy-in for Medicare Part B through The Public Welfare Accretion Process

Subsection A. General- revised content.

Subsection B. PW Process for SSI Recipients in Auto-Accrete States-Revised Content

Subsection C. The PW Process for SSI Recipients in Alert States- Revised Content

Subsection E. SSA Actions for PW Processes Revised Content

Subsection F. References-Revise Content

HI 00815.030 Establishing State Buy-in for Medicare Part B through The Public Welfare Accretion Process

A. General

The Public Welfare (PW) accretion process allows Social Security Administration field offices (FOs) to establish Medicare Part B (Medical Insurance)through state payment of the Medicare Part B premiums (Part B buy-in), making the state responsible for paying the Medicare Part B premiums, instead of the individual.

FOs should initiate the PW accretion process for certain individuals who:

 

  • •

    File an application for :

    • –

      Medicare Part A (Hospital Insurance), or

    • –

      Title II benefits and are at least age 65, or

    • –

      Medicare Part B; and

    • –

      have Medicaid coverage that is included in the state buy-in agreement.

Note: 

See the chart in HI 00815.030E for Part B buy-in coverage groups included in each state’s buy-in agreement.

B. PW Process for Supplemental Security Income (SSI) Recipients in Auto-Accrete States (1634 States)

If an individual is enrolled in Part B, resides in an auto-accrete state, and is in current pay status for SSI (or a federally administered state supplement program (SSP), they are included in the state’s buy-in coverage group and automatically receive Medicaid.

  • •

    If the FO did not obtain a Title II application at the same time the SSI application is taken, the Medicare Attainments and Leads Process (MALP) will initiate development for a Title II claim or automatically establish the Master Beneficiary Record (MBR) for an uninsured individual. See HI 00810.010 for developing entitlement to Medicare.

MCS Documentation:

Prepare a Report of Contact (RPOC) in the MCS claim segment or document in CCE stating, “Medicaid eligibility based on receipt of SSI payments,” and do not contact the Medicaid office (i.e., state public assistance agency) to verify Medicaid eligibility prior to starting a PW accretion.

  • •

    If the MCS segment will not process through EC, complete an A101, transfer the A101 to the Processing Center (PC)and upload an SSA-5002 Report of Contact into the Evidence Portal (EP). On the SSA-5002, add the remark "Medicaid based on receipt of SSI payments."

CCE Documentation:

For auto-accrete states (SI 01730.005), answer the Health Expenses and Third Party Liability Questions under the Benefits Leads tab within CCE (MS 08119.020).

C. The PW Process for SSI Recipients in Alert States

If a Medicare Part B applicant resides in an alert State, is an SSI recipient and indicates that they are eligible for Medicaid, verify the individual’s Medicaid eligibility with the appropriate State Medicaid agency. Failure to correctly verify the individual’s status may result in an erroneous PW accretion and a loss to the Medicare trust fund.

Medicaid Eligibility Verification

Verification of Medicaid eligibility may be based upon a telephone contact or, email communication between SSA and the appropriate state Medicaid Agency (for example, Idaho Department of Health and Welfare), or the database system from the appropriate state Medicaid agency. Document a SSA-5002 RPOC containing the following information and store it in Evidence Portal (EP):

  1. 1. 

    The individual is eligible for Medicaid;

  2. 2. 

    The Medicaid case number;

  3. 3. 

    The Medicaid eligibility date (start date); and

  4. 4. 

    The location of the state Medicaid agency furnishing the information and the name and telephone number of the contact person.

Note: 

Do not answer the Health Expenses and Third-Party liability questions in SSI alert states since these states make their own Medicaid eligibility determinations.

D. PW Process for Non-SSI Recipients who appear eligible for Medicaid

If an individual appears to have Medicaid and is not an SSI recipient, they may still be eligible for Part B buy-in if they reside in a state that includes all Medicaid beneficiaries in its buy-in coverage group. Prior to starting a PW accretion for these individuals, verify Medicaid eligibility with the appropriate state Medicaid agency. Follow the process in HI 00815.030C above.

If the individual appears to have Medicaid, is not an SSI recipient, and resides in a state that does not include all Medicaid beneficiaries in its buy-in agreement, do not use the PW accretion process. SSA FOs should reference the information in the chart in HI 00815.030E to determine if a state includes all Medicaid beneficiaries in its buy-in group.

E. SSA Actions for PW Processes

The table below describes streamlined processes for CCE and MCS across 4 categories of states:

  1. 1. 

    auto-accrete states that include all full-benefit Medicaid beneficiaries in buy-in;

  2. 2. 

    auto-accrete states that include only full benefit Medicaid beneficiaries who receive cash assistance (or are deemed to receive it) in buy-in;

  3. 3. 

    alert states that include all full-benefit Medicaid beneficiaries in buy-in; and

  4. 4. 

    alert states that include only full benefit Medicaid beneficiaries who receive cash assistance (or are deemed to receive it) in buy-in.

Among these 4 categories, the table notes which states are Part A group payer states and/or have a federally administered SSP.

 

Auto-Accrete States

Actions

Category 1: Buy-in agreement includes all Medicaid groups (21states: AL, AZ, AR, CA, CO, DC, DE,FL, GA, IN, IA, MD, MI, MS, NJ, NM, NC, OH, SC, WA, WY)

 

* AL, AZ, CO, NJ, NM, SC = group payer states

(consider conditional enrollment via HI 00801.140)

 

 

 

CA, DE, IA, MI, NM, NJ = federal administration of state supp.

Individuals who receive SSI and/or federally-administered state supplemental payments (SSP)

  1. 1. 

    Title II claim: Initiate state buy-in (use PW accretion), apply cash assistance (SSI/SSP) start date (first date they are eligible for Part B and SSI). Don’t contact Medicaid as you may verify SSI through the SSA system. Use SSI claim # or HUN (housed-under number). If using MCS, use HI19 to initiate state buy-in. If using CCE, use Health Insurance screen, choose “Currently Receiving Medicaid” and choose “Initiate State Buy-in.”

  2. 2. 

    Concurrent claim Title II (or uninsured Medicare-only) and SSI for individuals ages 65 or older: Use processes for Title II above.

    Non-SSI Recipients (reminder they are included in the buy-in agreement and thus are eligible for Part B buy-in)

    1. 1. 

      Title II or Medicare-only claim (insured or uninsured): Contact the Medicaid agency to verify current Medicaid enrollment. Once verified, initiate buy-in and use the buy-in start date for non-cash assistance individuals described in HI 00815.018 C and D  (e.g., if Sally is enrolled in both Part B and Medicaid starting January 1, start the PW accretion March 1). Use SSI claim # or HUN (housed-under number) and document the contact information for the state. If using MCS, use HI19 to initiate state buy-in. If using CCE, use Health Insurance screen, choose “Currently Receiving Medicaid” and choose “Initiate State Buy-in.”

      Reminders:

      For individuals who do not have evidence of lawful presence status (use RS 00204.025), do not initiate buy-in. In MCS, don’t use HI19. In CCE, answer “Currently Receiving Medicaid” as “no”.

 

Category 2: Buy-in agreement only includes cash Assistance Medicaid groups (14 states: , KY, LA, ME, MA, MT, NY, PA, RI, SD, TN, TX, VT, WV, WI)

* KY = group payer states (consider conditional enrollment HI 00801.140)

 

 

^ PA, RI, VT = federal administration of state supp.

Individuals who receive SSI and/or federally-administered SSP

 

  1. 1. 

    Title II claim:Initiate state buy-in (use PW accretion), apply cash assistance (SSI/SSP) start date (first date they are enrolled in Part B and SSI). Don’t contact Medicaid as you may verify SSI through the SSA system. Use SSI claim # or HUN (housed-under number). If using MCS, use HI19 to initiate state buy-in. If using CCE, use Health Insurance screen, choose “Currently Receiving Medicaid” and choose “Initiate State Buy-in.”

  2. 2. 

    Concurrent claim Title II (or uninsured Medicare-only) and SSI for individuals ages 65 or older: Use processes for Title II. Use processes for Title II.

    Non-SSI Recipients(reminder they are NOT included in the buy-in agreement, therefore, SSA will NOT make a determination for buy-in). 

    1. 1. 

      Title II claim or Medicare-only (insured or uninsured) claim: Take no action; do not contact the Medicaid agency, and do not initiate buy-in.

Alert States

Actions

Category 3: Buy-in agreement includes ALL Medicaid groups (7 states: AK, HI, KS, NV, OR, UT, VA)

* KS, UT, VA = group payer states (consider conditional enrollment via HI 00801.140)

 

^ HI, NV = federal administration of state supp.

Individuals who receive SSI and/or federally-administered state supplemental payments (SSP)

 

  1. 1. 

    Title II and uninsured Medicare-only claim: Contact the Medicaid agency to verify Medicaid enrollment. Once verified, use start date for cash assistance for buy-in start date (e.g., buy-in starts the first month the individual is enrolled in Part B, has SSI and is enrolled in Medicaid). Use SSI claim # or HUN (housed-under number) and document the contact information for the state. If using MCS, use HI19 to initiate state buy-in. If using CCE, use Health Insurance screen, choose “Currently Receiving Medicaid” and choose “Initiate State Buy-in.”

  2. 2. 

    Concurrent claim Title II (or uninsured Medicare-only) and SSI for individuals ages 65 or older: Use processes outlined in number 1.

    Non-SSI Recipients (reminder they are included in the buy-in agreement and are thus eligible for Part B buy-in)

  1. 1. 

    Title II claim or Medicare-only (insured and uninsured) claim: Contact the Medicaid agency to verify Medicaid enrollment. Once verified, use the buy-in start date for non-cash assistance individuals described above, per HI 00815.018 C and D (e.g., if  Smith is enrolled in Part B and Medicaid start date in January, start the PW accretion March 1). Use SSI claim # or HUN (housed-under number) and document the contact information for the state. If using MCS, use HI19 to initiate state buy-in. If using CCE, use Health Insurance screen, choose “Currently Receiving Medicaid” and choose “Initiate State Buy-in.”  

Reminders:For individuals who do not have evidence of lawful presence status (use RS 00204.025), do not initiate buy-in. In MCS, don’t use HI19. In CCE, answer “Currently Receiving Medicaid” as “no”.

Category 4: Buy-in agreement ONLY includes cash Assistance Medicaid groups (9 states: CT, ID, IL, MN, MO, NE, NH, ND, OK)

* IL, MO, NE = group payer states (consider conditional enrollment via HI 00801.140)

^ N/A = federal administration of state supp.

SSI Recipients

  1. 1. 

    Title II claim or uninsured Medicare-only claim: Contact the Medicaid agency to verify Medicaid enrollment. Once verified, use start date for cash assistance for buy-in start date (e.g., buy-in starts the first month the individual is enrolled in Part B and enrolled in Medicaid). Use SSI claim # or HUN (housed-under number) and document the contact information for the state. If using MCS, use HI19 to initiate state buy-in. If using CCE, use Health Insurance screen, choose “Currently Receiving Medicaid” and choose “Initiate State Buy-in.

  2. 2. 

    Concurrent claim Title II (or uninsured Medicare-only) and SSI for individuals ages 65 or older: Use processes outlined in number 1.

Non-SSI Recipients (reminder they are NOT included in the buy-in agreement, therefore, SSA will NOT make a determination for buy-in).

  1. 1. 

    Title II claim or Medicare-only (insured or uninsured) claim: Take no action; do not contact the Medicaid agency, and do not initiate buy-in.

 

F. References

HI 00801.140 Premium-Part A Enrollments for Qualified Medicare Beneficiaries (QMBs) – Part A Buy-In States and Group Payer States

HI 00805.005 Eligibility for SMI

HI 00810.010 How the Medicare Attainments and Leads Process Works

MS 02003.003 Health Insurance – Title XIX/Medicaid (HI19)

MS 08119.020 – Health Expenses and Third Party Liability

RS 00204.025 Evidence Requirements for Establishing U.S. Lawful Presence


HI 00815 TN 56 - State Enrollment of Eligible Individuals - 1/06/2025