Identification Number:
EM-08071 REV
Intended Audience:All RCs/ARCs/ADs/FOs/TSCs/PSCs/ OCO//OCO-CSTs/ODARHQ/CMS
Originating Office:ORDP OISP
Title:Processing Instructions - Premium HI for Individuals in Part A Buy-In States Who Do Not Have Medicare Part B – Instructions Will Follow Shortly
Type:EM - Emergency Messages
Program:Medicare
Link To Reference:HI 00801.134, HI 00801.138, HI 00801.139, HI 00801.140, HI 00815.023, SM 00850.355, SM 00850.700, SM 03040.025
 
Updated Retention Date: September 08, 2018

Retention Date: March 08, 2018
Retention Date: September 08, 2016
Retention Date: March 08, 2016
Retention Date: September 3, 2015
Retention Date: March 3, 2015
Retention Date: November 8, 2013


In Part A buy-in states, some low income individuals that appear eligible for Medicare Part A and Part B buy-in as qualified Medicare beneficiaries (QMB) are experiencing difficulty enrolling in Part B at their local Social Security offices. QMB's are individuals who are eligible for Medicaid payment of their Medicare premiums, deductibles, and coinsurance. The confusion seems to occur with individuals who want to file for Premium Part A, do not have Part B, and are outside of an enrollment period.

If an individual contacts the field office (FO) and appears to meet the QMB eligibility requirements, resides in a Part A buy-in State, wishes to file for Premium Part A, and does not have Part B, the individual may file an application for Part B and conditional enrollment in Premium Part A. Since the individual resides in a Part A buy-in State, the application does not have to be filed in an enrollment period; it may be filed at any time.

Currently, MCS will not accept a Part B and conditional Part A enrollment filed outside of an enrollment period for an individual who resides in a Part A Buy-in State. MCS will generate exception message number 20604 – Check BIC M Decision Status – SMI Application Not in Enrollment Period. To address this exception, the FO needs to input the claim into MCS and then prepare an A101/EF101 for the Part B and conditional Part A award when the exception is received.

POMS instructions are being updated. Until national instructions are published, follow these processing instructions:

FO Processing Instructions:
      · Take an initial claim for Part B and conditional Part A through MCS (i.e. select claim type 5 = UNINS MED ONLY on APPL screen)
      · Develop proofs of age, citizenship or LAPR, and residency.
      · Review the earnings record for accuracy. A reduced Hospital Insurance Premium (HI) may apply if the individual or spouse has 30-39 quarters of coverage (see HI 01005.007, Reduced Hospital Insurance (HI) Premium).
      · Prepare an A101. If problems occur with the A101 prepare an EF101. Instructions for screen completion for the A101 are in MCS 014.000 and EF101 are in T2PE 009.000.
    Include the following entries:
          Ø Part A entitlement on the HI Data screen (HIDA or EFHIDA);
              § START equal to the current operating month (COM)
              § BASIS of 'A'
              § TYPE of 'P'
              § PERIOD of 'Q'
              § FILING date;
          Ø HI THIRD PARTY DATA (HITP or EFHITP);
              § START equal to PREMIUM HI START
              § CODE of Z99
              § CATEGORY of 'Q'
          Ø HI Premium/Reduction (HIPR or EFHIPR)
              § START equal to PREMIUM HI START
              § PENALTY PERCENTAGE OF 00
              § Complete the following fields if applicable:
                  · HAS 30 QTR
                  · STOP
                  · 30 QTR SSN
          Ø Part B entitlement on the SMI Data screen (SMID or EFSMID);
              § START equal to COM
              § BASIS of 'A'
              § PERIOD of 'Q'
              § FILING date
              § MED-RET-US, if applicable
          Ø SMI THIRD PARTY DATA (SMTP or EFSMTP);
              § Do not code THIRD PARTY DATA for Part B. See NOTE below.
          Ø SMI PREMIUM HISTORY/VARIABLE SMI (SMPR or EFSMPR);
              § START equal to SMI START
              § PENALTY PERCENTAGE of 000
    NOTE:
    Refer the individual to the appropriate State office to file for QMB benefits. Emphasize the importance of promptly contacting the State. The individual may be billed for Part B premiums until state buy-in begins.

PSC Processing Instructions:
      · Propagate A101/EF101 into MACADE.
      · NOTE: Technicians should ensure that all coding referred to above are included on the screens of their MACADE action (see SM 00850.700).
If the enrollee does not contact the State and does not pay the Part B premiums when billed, Part B will terminate for nonpayment of premiums (HI 00820.035). Conditional Premium Part A will not generate a bill.


Direct all program–related and technical questions to your RO support staff or PSC OA staff. RO support staff or PSC OA staff may refer questions or problems to their Central Office contacts.
EM-08071 REV - Processing Instructions - Premium HI for Individuals in Part A Buy-In States Who Do Not Have Medicare Part B – Instructions Will Follow Shortly - 08/11/2008