Identification Number:
HI 00815 TN 49
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. 49, 01/12/2024

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

CMS is editing the following POMs sections below to include new policies and procedures. We are also archiving sections that are no longer needed or have been consolidated into revised sections

Summary of Changes

HI 00815.006 The State Buy-In Agreement

Revised to explain establishment of state buy-in. Retained definitions of categories.

  • Section B: Clarified actions for States, DC, Specified US Territories and CMS.

  • Section C: Contains introduction to the SSA PW accretion process and clarified that detailed processing instructions can be found in HI 00815.030.

HI 00815.018 When A Buy-In Coverage Period Begins

Revised content, updated information for start of State Payment of Medicare Premiums (State Buy-In)

  • Section B: Clarified begin date for state payment of Part A premiums for QMBs.

  • Section C: Clarified begin date for state payment of Part B premiums.

  • Section D: Added chart containing Summary of buy-in start dates.

  • Section E: Clarified action for an incorrect report of buy-in eligibility and added links to references that contain detailed processing instructions.

HI 00815.021 The End of State Payment of Medicare Premiums Under a Buy-in Agreement

Section C: Minor technical edits to chart

HI 00815.030 SSA DO/BO Procedures to Develop Buy-In Coverage in Initial Claims Cases — The Public Welfare Accretion Procedure

Revised content and consolidation w/ archived HI 00815.009 to clarify PW accretion processes

Section E: Added chart with details on SSA’s action to take to initiate the PW process for various states by group.

HI 00815.036 State Response to Public Welfare (PW) Accretion

Minor technical edits.

Section A: Added reference to CMS Manual for the State Payment of Medicare Premiums

HI 00815.001 State Buy-In Program General Description

Revised content and consolidated with archived HI 00815.003. Added headers to the POMS to clarify content in each section.

  • Section B: Added information on state buy-in agreement

  • Section C: Added chart updating buy-in coverage groups for 50 states and DC.

  • Section D: Listed US territories with buy-in agreements, and clarified what those agreements include.

  • Section E: Clarified requirements for Sstate payment of Part A premiums for QMBs for buy-in states and group payer states.

HI 00815.003 State Buy-In Coverage Groups

Archived: Buy-in coverage group content moved to HI 00815.001

HI 00815.009 State Buy-In Coverage Chart

Archive: State Buy-in Coverage chart information moved to new table in Section E, HI 00815.030.

HI 00815.015 Loss of a Supplemental Security Income (SSI) Payment to an Individual in a Title XIX (Medicaid) Institution

Archive: Not needed for POMS

HI 00815.012 Deemed Cash Recipients

Archived: Level of detail not needed for POMS

HI 00815.001 State Payment of Medicare Premiums (Buy-In Program)

 

A. Background

Since the start of the Medicare program in 1966, the 50 states, the District of Columbia (DC), and the U.S. territories have had the option to enter into agreements with the Centers for Medicare & Medicaid Services (CMS) to enroll certain individuals who are dually eligible for Medicare and Medicaid into Medicare and pay the premiums on their behalf (known as “state buy-in”). See the CMS Manual for State Payment of Medicare Premiums, chapter 1, sections 1.0 and 1.2.

For an individual who is determined eligible for, but not yet enrolled in Medicare, state buy-in serves to enroll the individual in Medicare Part A and/or B and directs the federal government to bill the state for the individual’s premiums. For an individual who is already enrolled in Medicare, state buy-in enables the federal government to bill the state for the individual’s Medicare premiums and stop collecting the premiums from the individual through deductions from their monthly Social Security, Railroad Retirement Board (RRB), or Civil Service Retirement benefits, or through CMS direct premium billing (Form CMS-500).

B. The State Buy-in Agreement

Each state and territory describe which Medicaid eligibility groups are eligible for state payment of Medicare premiums in their buy-in agreement with CMS. Effective January 1, 2023, all buy-in agreements are contained in the state or territory’s Medicaid State Plan filed with CMS. See the chart in HI 00815.006 for state buy-in coverage in the 50 States, DC and the three U.S. territories with buy-in agreements.

Buy-in agreements permit states and territories to directly enroll individuals covered under the buy-in agreement into Medicare Part A and Medicare Part B at any time, without regard for Medicare enrollment periods. States and territories pay the standard premium for individuals covered under state buy-in (i.e., states and territories do not pay a premium surcharge due to late enrollment that may otherwise have applied to an individual’s monthly premium amount).

An individual’s enrollment under a State Buy-in agreement is involuntary. States must enroll eligible individuals in buy-in even if they do not wish to enroll. A beneficiary cannot voluntarily terminate State Buy-in coverage.

Note: 

For additional information refer to CMS Manual for State Payment of Medicare Premiums, chapter 1, sections 1.2 and 1.4.

 

C. State Payment of Part B Premiums (Part B Buy-in)in the 50 States and the District of Columbia (DC)

All 50 states and DC have elected to enter into buy-in agreements to pay the Part B premiums for certain Medicaid beneficiaries who are Medicare-eligible. All states have selected one of two groups of Medicaid beneficiaries in their agreements (known as Part B buy-in coverage groups).

Part B buy-in Coverage Group Options

This Coverage Group includes:

  1. 1. 

    Cash assistance recipients and certain deemed recipients of cash assistance plus three Medicare Savings Programs (MSP) groups

  • Medicaid beneficiaries who receive cash assistance (Supplemental Security Income [SSI] and/or State Supplemental program [SSP] benefits);

  • Medicaid beneficiaries who are deemed to receive cash assistance (SSI, SSP, and at state option, beneficiaries who are deemed to receive the former Aid to Dependent Children and Families (AFDC) program); and

  • Individuals enrolled in one of three MSP groups: Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), and Qualifying Individual (QI).

  1. 2. 

    All Medicaid Beneficiaries

  • The three groups described above (Medicaid beneficiaries who receive cash assistance (SSI/SSP); Medicaid beneficiaries who are deemed to receive cash assistance (SSI/SSP, and at state option, AFDC); and individuals enrolled in the QMB, SLMB, and QI groups); and

  • All other Medicaid beneficiaries

D. Part B Buy-in in Specified U.S. Territories

The following U.S territories have elected to enter into buy-in agreements to pay the Part B premiums for all Medicaid beneficiaries who are Medicare-eligible.

  • Guam;

  • The Commonwealth of the Northern Mariana Islands; and

  • U.S. Virgin Islands

The MSPs are not included in state buy-in agreements in these territories because no territory includes these Medicaid eligibility groups in their Medicaid programs.

Note: 

For additional information about Part B buy-in coverage groups, refer to and Appendix 1D.

E. State Payment of Part A Premiums (Part A Buy-in) for Qualified Medicare Beneficiaries

All states must pay the Part A premiums for QMB-eligible individuals who do not have premium-free Part A. However, states can choose one of two methods to pay the Part A premium for QMBs -- either through their buy-in agreement or through a group payer arrangement.

Most states have expanded their buy-in agreements to also include the payment of Part A premiums for individuals who must pay a premium to enroll in Medicare Part A and who are eligible for the QMB eligibility group. These states are referred to as “Part A buy-in states.” States that do not include premium Part A for QMBs in their state buy-in agreements are referred to as “group payer states.” See HI 00815.021B.

For more information about the payment of Medicare Part A premiums for QMBs and a list of Part A buy-in and group payer states, see section HI 00801.140.

Note: 

No territories include the QMB eligibility group in their Medicaid program.

1. Part A Buy-in States

Part A Buy-in states include the payment of Medicare Part A premiums for QMBs in their buy-in agreements.

 

  • Individuals in Part A buy-in states can file for Medicare Part B with a conditional enrollment application for Medicare premium Part A at any time, without regard to enrollment periods or premium surcharges.

  • States can enroll eligible individuals already enrolled in Part B in the QMB group at any time.

    Late enrollment penalties do not apply.

2. Group Payer States

Group payer states do not include the payment of Medicare Part A premiums for QMBs in their buy-in agreements. Individuals who do have premium-free Part A in group payer states can file for premium Part A during any prescribed enrollment period. Group payer states pay Medicare Part A premiums and any applicable premium surcharges under a group payer arrangement.

HI 00815.006 Establishing State Payment of Medicare Part B Premiums (State Buy-In)

A. Overview

States, the District of Columbia (DC) and U.S. territories are responsible for ensuring that individuals included in their Buy-In Agreement with the Centers for Medicare & Medicaid Services (CMS) are enrolled in Part B buy-in. States, DC, specified U.S. territories, and CMS generally establish Part B buy-in for individuals through buy-in data exchange that involves the state, CMS, and the Social Security Administration (SSA).

In certain circumstances however, SSA should take steps to initiate Part B buy-in through the Public Welfare (PW) Accretion process for Medicaid beneficiaries who file a Medicare application and are eligible for a Medicaid group included in the state buy-in agreement. This most commonly occurs when a full-benefit Medicaid beneficiary newly qualifies for Medicare and applies for Medicare Part B before SSA has established Medicare entitlement on the Master Beneficiary Record (MBR) and before the state or territory has established Part B buy-in.

Note: 

Full-benefit Medicaid coverage generally refers to coverage for a range of items and services, beyond coverage for Medicare premiums and cost-sharing, to which certain individuals are entitled when they qualify under certain Medicaid eligibility groups included in their state’s Medicaid State Plan filed with CMS.

B. Enrollment in Part B Buy-in by States, DC, Specified U.S Territories and CMS

The U.S. territories initiate Part B buy-in for all Medicaid beneficiaries included in the buy-in agreement.

States generally initiate Part B buy-in enrollment for Medicaid beneficiaries who do not receive Supplemental Security Income (SSI).

For Medicaid beneficiaries who receive SSI, Part B buy-in is generally initiated either by CMS or the state as outlined below.

1. CMS-Initiated Part B Buy-in for SSI recipients in Auto-Accrete States

Thirty-four states and Washington D.C. have an agreement with SSA under section 1634(a) of the Social Security Act. These states are referred to as “1634” states or “auto-accrete” states and are listed in HI 00815.030. CMS establishes Part B buy-in for SSI recipients in these states.

Note: 

The exception is the state of Maryland which establishes Part B buy-in for SSI recipients itself.

  1. a. 

    Auto-accrete states have delegated authority to SSA to make Medicaid eligibility determinations for SSI recipients.

  2. b. 

    The Medicaid agency automatically enrolls the individual in Medicaid following data exchange with SSA.

  3. c. 

    SSA determines an individual eligible for SSI and establishes Medicare Part B eligibility.

  4. d. 

    CMS automatically initiates Part B buy-in for the individual through the buy-in data exchange.

    Note: 

    Ensure addresses are up-to-date within SSA systems.

2. State-Initiated Part B Buy-in for SSI recipients in Alert States (SSI Criteria States, 209(b) States)

Alternatively, states without a 1634 agreement establish Part B buy-in for SSI recipients on their own. States that have not entered into 1634 Agreements are referred to as “Alert States.” The Northern Marianas Islands, the only territory that has the SSI program, does not have a 1634 agreement with SSA and is considered an “alert state.”

In alert states, SSI recipients must submit a separate application to the Medicaid agency which determines eligibility for Medicaid benefits. CMS identifies SSI recipients who are Medicare-eligible, then the state determines Medicaid eligibility and initiates Part B buy-in enrollment for eligible individuals.

Alert states fall into two categories: SSI criteria states and 209(b) states.

  • SSI Criteria States – Consider SSI recipients as eligible for Medicaid upon completion of a Medicaid application.

  • 209(b) States – Apply more restrictive financial methodologies than SSI to determine eligibility for Medicaid.

See the CMS Manual for State Payment of Medicare Premiums, chapter 1, section 1.6.1.1 and chapter 2, section 2.5.1.

C. Public Welfare Accretion Process for SSA to initiate Part B buy-in

SSA should initiate Part B buy-in through the Public Welfare (PW) accretion process for an individual whose Medicare entitlement is not yet present on the MBR, when the individual:

  • files an application for Medicare Part B;

  • is eligible for full-benefit Medicaid; and

  • is included in the state or territory’s buy-in agreement.

Note: 

See section HI 00815.030 for processing instructions to establish Part B buy-in through the Public Welfare process.

HI 00815.018 When State Payment of Medicare Premiums (State Buy-In) Begins

A. Background

In general, an individual’s state buy-in coverage start date depends on the Medicaid eligibility group in which an individual is enrolled.

The exception is for individuals covered by a new or modified buy-in agreement. Buy-in coverage can begin no sooner than three months after the effective date of a new or modified buy-in agreement.

For more information about the start date of buy-in coverage, see CMS Manual for State Payment of Medicare Premiums, chapter 1, sections 1.13.1 and 1.14.1 and appendix 1.C.

B. Beginning of State Payment of Part A Premiums (Part A Buy-in) for Qualified Medicare Beneficiaries

Part A Buy-in for the Medicare Saving Program (MSP) Qualified Medicare Beneficiary (QMB) eligibility group begins the month the individual is enrolled in premium Part A and QMB.

C. Beginning of State Payment of Part B Premiums (Part B Buy-in)

See also the chart in Section D. for an explanation of these provisions.

Individuals who Receive or are Deemed to Receive Cash Assistance or are Enrolled in an MSP .

Part B buy-in generally begins the first month in which the individual meets the requirements both for eligibility in the buy-in coverage group (i.e., the start date of the individual’s Medicaid coverage) and eligibility for Medicare Part B for:

  • Medicaid beneficiaries who are cash assistance recipients or who are deemed to be recipients of cash assistance; and

  • Individuals enrolled in the following three MSP groups:

    • QMB;

    • Specified Low-Income Medicare Beneficiary (SLMB); and

    • Qualifying Individual (QI).

Note for SSI recipients: 

In states with 1634 agreements (1634 states or auto-accrete states), Part B buy-in starts no later than the first month an individual is entitled to SSI and Part B. SSI recipients are automatically eligible for Medicaid based on their receipt of SSI.

Example: If the individual is eligible for Part B and SSI in January, Part B buy-in is effective January 1.

In alert states, Part B buy-in may begin later than the first month the individual is entitled to SSI and eligible for Part B. Alert states separately determine SSI recipients eligible for Medicaid.

Example: If the individual is eligible for SSI and Part B in January and their Medicaid effective date is March 1, Part B buy-in is effective March 1.

Other Medicaid Beneficiaries who do not receive or are Deemed to Receive Cash Assistance or are Enrolled in an MSP.

Part B buy-in begins the second month after the individual meets the requirements for both:

  • eligibility in the buy-in group (i.e., the start date of the individual’s Medicaid coverage) and

  • eligibility for Medicare Part B for all other Medicaid eligibility groups included in the buy-in agreement.

Example: If an individual is eligible for Medicaid and Part B in January, buy-in is effective March 1.

An individual can be simultaneously enrolled in the QMB or SLMB MSP group and a full-benefit Medicaid eligibility group. For an individual who is simultaneously enrolled in one of these MSP groups and a full-benefit Medicaid eligibility group, Part B buy-in begins on the earlier of the buy-in start applicable to the MSP or Medicaid eligibility group.

Exception: State liability for retroactive Medicare Part B premiums for full-benefit Medicaid beneficiaries under a buy-in agreement is limited to a period of no greater than 36 months prior to the date of the Medicare enrollment determination pursuant to 42 CFR § 407.47(f) beginning January 1, 2024. CMS may approve shorter or longer retroactive buy-in periods upon state request .

D. Summary of Buy-in Start Dates

See the chart below for buy-in start dates as outlined in the CMS Manual for State Payment of Medicare Premiums, chapter 1, appendix 1.C.

Start dates may be adjusted if:

  • the individual is covered by a new or modified buy-in agreement (coverage can start no sooner than three months after the effective date of a new or modified buy-in agreement); or

  • to avoid retroactive payments beyond 36 months (or different limits approved by CMS) after January 1, 2024.

    Medicaid Eligibility Group

    Part A Buy-in Start Date

    Part B Buy-in Start Date

    Cash assistance (SSI/SSPs) and deemed recipients of cash assistance who are categorically needy

    N/A

    Part B buy-in starts the first day of the month an individual qualifies for Medicare Part B and is eligible for Medicaid.

    In auto-accrete states, Part B buy-in starts the first month the individual is both entitled to SSI and eligible for Part B. In alert states, Part B buy-in starts the first month an SSI recipient is eligible for Medicaid and Part B.

    42 CFR § 407.47(b)

    QMB

    Part A buy-in starts the month an individual is enrolled in premium Part A and has QMB status. 42 CFR § 406.26(b)

    In Group Payer states only: If an individual enrolls during the General Enrollment Period or later, as early as the first day of the month after enrollment in either actual or conditional Part A.

    Part B buy-in starts the first day of the month an individual qualifies for Medicare and has QMB status.

    42 CFR § 407.47(c)

    SLMB

    N/A

    Part B buy-in starts the first day of the month an individual qualifies for Medicare and is a member of the coverage group.

    42 CFR § 407.47(c)

    QI

    N/A

    Part B buy-in starts the first day of the month an individual qualifies for Medicare and is a member of the coverage group.

    42 CFR § 407.47(c)

    Other Full-benefit Medicaid Eligibility Categories[1]

    [2]

     

    N/A

    Part B buy-in starts the first day of the second month after an individual qualifies for Medicare and is a member of the coverage group.

    42 CFR § 407.47(d)

E. Effect of Incorrect Report of Buy-In Eligibility

If a state erroneously reports an individual as a member of its buy-in coverage group, buy-in coverage nevertheless begins in accordance with HI 00815.018B and HI 00815.018C.

Once a State enrolls an individual in buy-in, the State cannot cancel the enrollment retroactively. (A cancellation of the entire enrollment may only occur during the same Current Operating Month (COM) that buy-in was established). However, the state can subsequently terminate the individual’s buy-in coverage as described in HI 00815.021, which outlines when buy-in ends.

Please refer to SM 03040.245 for Special Situations and HI 00815.030 for Procedures to Develop buy-In Coverage in Initial Claims.

HI 00815.021 The End of State Payment of Medicare Premiums Under a Buy-in Agreement

 

A. Background

The state or the Centers for Medicare & Medicaid Services (CMS) can end (delete) a state’s payment of Medicare Part A or Part B premiums under the state’s buy-in agreement (also known as “Part A or Part B buy-in”) based on the circumstances indicated below, as outlined in the CMS Manual for the State Payment of Medicare Premiums, chapter 1, sections 1.14.2 and 1.13.2. States must notify CMS through a Medicare Part A and/or Medicare Part B deletion request when an individual loses eligibility for state buy-in coverage. The end of state buy-in has important implications for beneficiaries. For information about beneficiary impact and options for relief when buy-in ends, see HI 00815.042.

 

B. End of a State Payment of Part A Premiums for Qualified Medicare Beneficiaries

The Qualified Medicare Beneficiary (QMB) program is a Medicaid program through which states cover Part A and Part B premiums and cost-sharing for eligible low-income Medicare beneficiaries, as described in HI 00801.139. All states must pay Part A premiums for individuals who are enrolled in the QMB program and not entitled to "premium-free" Part A coverage. States can choose one of two methods to pay Part A premiums for QMBs:

  1. 1. 

    Under their buy-in agreement,"Part A buy-in state" or

  2. 2. 

    Through a group payer arrangement, "group payer state"

See HI 00801.140 for more information about the state payment of Part A premiums for QMBs.

The duration of the state's payment of Part A premiums ends with earliest of the events specified below:

 

If the event is...

AND...

THEN...

Termination Initiated by...

Loss of QMB status

If the state determines the beneficiary is no longer eligible for QMB and completes a termination of QMB coverage consistent with Medicaid regulations

The Part A buy-in coverage period ends no earlier than the last day of the month in which the beneficiary is enrolled in QMB.

State

Death

 

Coverage ends on the last day of the month in which the beneficiary dies.

CMS or State

Entitlement to Medicare Premium-free Part A

If a beneficiary becomes entitled to premium-free Part A

Part A buy-in coverage ends on the last day of the last month the beneficiary is entitled to premium Part A, at which point the beneficiary will be entitled to premium-free Part A. See HI 00820.015 for information about the termination of premium Part A.

CMS or State

Termination of Part A buy-in agreement

If the state terminates its Part A buy-in agreement (i.e, removes payment of Part A premiums for QMBs from the buy-in agreement)

Coverage through the buy-in agreement will end. However, payment of the Part A premiums for QMBs must continue without interruption under the group payer arrangement.

CMS

Note: CMS may modify the effective stop date of a Part A buy-in termination (deletion) request submitted by a state based on processing rules described in the CMS Manual for the State Payment of Medicare Premiums, chapter 2, section 2.6.1.4. CMS terminates (deletes) Part A buy-in coverage effective at the end of the month in the month the state's deletion request is received, even if the individual lost eligibility in an earlier month.

C. End of a Part B Buy-in Coverage Period

Under their buy-in agreements, states pay the Part B premiums for certain Medicare-eligible Medicaid beneficiaries (members of their Part B buy-in coverage group). The state’s Part B buy-in coverage group includes multiple Medicaid eligibility categories identified in its buy-in agreement.

The Part B buy-in coverage period ends with the earliest of the events specified below:

IF the event is...

AND...

THEN...

Termination Initiated by...

Loss of membership in the state's buy-in coverage group

 

Coverage ends the last day of the month in which the beneficiary is enrolled in any Medicaid category included in the buy-in coverage group.

State

Death

 

Coverage ends on the last day of the month in which the beneficiary dies.

CMS or State

Loss of entitlement to Medicare Premium free Part A

If a beneficiary is:

  • under age 65 and

  • is no longer entitled to Medicare Premium-free Part A (i.e., has lost Social Security Disability Insurance (SSDI) benefits due to excess earnings)

 

Part B buy-in coverage, if applicable, ends on the last day of the last month for which the beneficiary is entitled to Premium-free Part A

CMS

Termination or modification of the buy-in agreement

If the state's buy-in agreement is terminated or modified to restrict coverage to a narrower buy-in group

Coverage for the beneficiary ends on the last day of the last month for which the agreement is in effect for the beneficiary's buy-in group.

CMS

Note: If the state determines an individual is no longer eligible for a Medicaid coverage group in the state Part B buy-in coverage group, the state's must follow the steps described in section D below.

Note: CMS may modify the effective stop date of a Part B buy-in termination (deletion) request submitted by a state based. on processing rules as described in the CMS Manual for the State Payment of Medicare Premiums, chapter 2, section 2.6.1.3. Part B deletion requests cannot be earlier than two months before the month in which the state notifies CMS of the deletion, even if the individual lost eligibility in an earlier month.

D. State Requirements for Part B Buy-in When a Beneficiary Experiences a Change in Circumstance That Affects Medicaid Eligibility

If a beneficiary enrolled in a Medicaid eligibility category included in the state’s buy-in group experiences a change in circumstance and the state determines the beneficiary ineligible for that Medicaid category, the state must promptly redetermine eligibility on all other bases in order to determine if the beneficiary qualifies for a different Medicaid category, including those included within the Part B buy-in coverage group. While the state is making this determination, the state must maintain Medicaid coverage and must not terminate the beneficiary from buy-in. Further, if the state determines the beneficiary continues to qualify under another Medicaid eligibility group in the buy-in coverage group, Part B buy-in coverage must continue without interruption.

See CMS Manual for the State Payment of Medicare Premiums, chapter 1, section 1.4 for additional information about state requirements under their buy-in agreements.

Note on loss of Supplemental Security Income (SSI): Loss of SSI constitutes a change in circumstances that may affect a beneficiary’s Medicaid eligibility and thus triggers a redetermination.

CMS transmits an informational “SSI deletion” notification record to states upon notification from SSA that a beneficiary has lost SSI eligibility.

The alert is not a notification that CMS has deleted the record or that the state must submit a deletion transaction. Rather, the alert is intended to prompt the state to conduct a Medicaid redetermination if the individual is no longer eligible for the Medicaid eligibility group based on receipt of SSI (e.g., no longer has a qualifying disability).

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 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 Public Welfare (PW) accretion process when 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 eligible for 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.

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 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."

  • 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. See HI 00810.010 for developing entitlement to Medicare.

SSI CCE Documentation:

For auto-accrete states (SI 01730.005), answer the Health Expenses and Third Party Liability Questions under the Benefits Leads tab within SSI CCE (MS 08819.020).

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, email communication between SSA and the appropriate state Medicaid Agency (for example, California Department of Health Care Services), or database system from the appropriate state Medicaid agency. Document a 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 below 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 (20 states: AL, AZ, AR, CA, CO, DC, FL, GA, IN, IA, MD, MI, MS, NJ, NM, NC, OH, SC, WA, WY)

 

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

 

^ CA, 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.” Reminder - For all initial claims, retroactivity for buy-in may not exceed 36 months.

  2. 2. 

    Concurrent claim Title II (and 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).

  3. 3. 

    Title II or Medicare-only claim: Contact the Medicaid agency to verify current Medicaid enrollment. Once verified, initiate buy-in and use the non-cash assistance buy-in start date for non-cash assistance individuals described above (e.g., if Sally is eligible for 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.” Reminder - For all initial claims, retroactivity for buy-in may not exceed 36 months.

Category 2: Buy-in agreement only includes cash Assistance Medicaid groups (15 states: DE, KY, LA, ME, MA, MT, NY, PA, RI, SD, TN, TX, VT, WV, WI)

* KY = group payer states

^ DE, 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 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.” Reminder - For all initial claims, retroactivity for buy-in may not exceed 36 months.

  2. 2. 

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

    Non-SSI Recipients (reminder they are NOT included in the buy-in agreement and thus are ineligible for Part B buy-in)

  3. 3. 

    Title II and Medicare-only 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

 

^ HI, NV = federal administration of state supp.

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

 

  1. 1. 

    Title II and 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 eligible for 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.” Reminder - For all initial claims, retroactivity for buy-in may not exceed 36 months.

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

  2. 2. 

    Title II and Medicare-only claim: Contact the Medicaid agency to verify Medicaid enrollment. Once verified, use the non-cash assistance buy-in start date for non-cash assistance individuals described above (e.g., if Mr. Smith is eligible for 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.” Reminder - For initial claims, retroactivity for buy-in may not exceed 36 months.

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 – may need conditional enrollment)

* IL, MO, NE = group payer states

^ N/A = federal administration of state supp.

SSI Recipients

 

  1. 1. 

    Title II 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 eligible for 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.” Reminder - For initial claims, retroactivity may not exceed 36 months.

    Non-SSI Recipients (reminder they are NOT included in the buy-in agreement and thus are ineligible for Part B buy-in)

  2. 2. 

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

HI 00815.036 State Response to Public Welfare (PW) Accretion

A. States' responsibilities for verifying all PW accretions

States are responsible for verifying all PW accretions by matching the data they receive from the Social Security Administration (SSA) via the State Data Exchange (SDX) file against their data in the State Medicaid Eligibility File.

  • If the State determines that a PW accretion is erroneous, the State may protest the action. A State has two months following the month in which it received notification of the PW accretion on its billing file to annul the accretion or establish a closed period of State Buy-in coverage, in accordance with CMS Manual for the State Payment of Medicare Premiums, chapter 2, section 2.9.

  • If the state does not react timely, the state becomes responsible for the premium liability until it submits a deletion action to the Third Party System (TPS). In this situation, the Commissioner’s Decision is applicable and limits the retroactivity of deletions to processing month minus two. The State is liable for all premiums from the month of accretion to the month of deletion, see HI 00815.063D Systems Processing of State Responsibility Items.

B. State directs protest to the Centers for Medicare & Medicaid Services (CMS)

The State Agency must direct its protest to the CMS Regional Office (RO) and CMS Central Office (CO).

EXCEPTION: If the beneficiary for whom the state received the PW accretion resides in an auto-accrete state and is in current SSI pay status on the SDX, but the Medicare Claim Number (also referred to as HICN – Health Insurance Claim Number) is missing from the unearned income field, the state must ask the SSA Field Office (FO) to use the following force finder procedures: SM 02001.040 MBR/SSR Interface Edits, Alerts and Diaries; and SM 01301.325 Query.

The state should follow up with the FO if the Medicare Claim Number is not established within 90 days.

NOTE: The CMS RO, in the course of the PW investigation, may also ask the FO to establish the Medicare Claim Number in the unearned income field via the force finder procedure. See HI 00815.082 - SSA Field Office Procedures for Resolving Individual State Buy-In Problem Cases Due to Problem with SSR-MBR Interface. See HI 00815.088 - Servicing DO/BO Processing of CMS-1957.


HI 00815 TN 49 - State Enrollment of Eligible Individuals - 1/12/2024