Identification Number:
HI 00815 TN 34
Intended Audience:See Transmittal Sheet
Originating Office:Centers for Medicare & Medicaid Services (CMS)
Title:State Enrollment of Eligible Individuals
Type:POMS Transmittals
Program:Medicare,Medicaid
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. 34, 10/12/2021

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

Updating POMS sections with new policy and procedure.

Summary of Changes

HI 00815.021 When A Buy-In Coverage Period Ends

 

HI 00815.042 Enrollee's Rights After Termination of Buy-In Coverage

 

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 that helps pay the 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 otherwise 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. .See 42 CFR §435.916(f). While the state is making this determination, the state must maintain Medicaid coverage and must not terminate the beneficiary from buy-in. See 42 CFR § 435.930(b).Further, if the state determines the beneficiary continues to qualify under another Part B buy-in group category, Part B buy-in coverage must continue without interruption. SeeCMS 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. See 42 CFR § 435.916(d).

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 redetermination pursuant to 42 CFR § 435.916(f)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 00815.042 Implications and Options for Beneficiaries When State Payment of Medicare Premiums (State Buy-in) Ends

A. Implications for Beneficiaries When State Buy-in Coverage Ends

A beneficiary's buy-in coverage period can end due to the following events:

  • Loss of eligibility in a coverage group;

  • Death;

  • Loss of entitlement to Medicare Premium-free Part A; and

  • Termination of buy-in agreement.

When a state ends buy-in because a beneficiary lost eligibility for a Medicaid category included in the state’s Part B buy-in coverage group , Medicare enrollment generally continues without interruption with the beneficiary assuming responsibility for paying the premiums.

  • If the beneficiary receives Social Security (Old Age, Survivors and Disability Insurance (OASDI), Railroad Retirement Board (RRB), or Civil Service Retirement benefits, the Social Security Administration (SSA) deducts the Part B premium amount from the beneficiary's monthly benefit payment

  • If the beneficiary’s monthly benefit amount is less than the Part B premium amount due, SSA applies the beneficiary’s monthly benefits to the total premium amount due and bills the beneficiary for the remaining balance of the premiums as described in SM 00850.475.

  • If the beneficiary does not receive Social Security, RRB, or Civil Service Retirement benefits, CMS sends a bill to the beneficiary for Medicare Part A and/or Part B premiums.

  1. 1. 

    Part A Premium Liability After Buy-in Ends

    Part A premiums paid under a Part A state buy-in agreement: SSA treats a beneficiary who loses buy-in as if they enrolled during the Initial Enrollment Period (IEP). Upon loss of buy-in, the beneficiary is responsible for Part A base premium amount even if they had been paying a late enrollment penalty prior to buy-in enrollment.

Part A premiums paid under a Part A group prayer arrangement:Upon loss of state payment of Part A premiums, the beneficiary becomes responsible for the premium amount the state paid ( i.e., the Medicare Part A premium may be subject to a late enrollment penalty if the state had been paying one).

  1. 2. 

    Part B Premium Liability After Buy-In Ends

Because all states, the District of Columbia, and certain U.S. territories pay the beneficiary’s Part B premium under a state buy-in agreement, SSA treats a beneficiary who loses Part B buy-in as if they enrolled during the IEP. The beneficiary pays the base premium, even if they had a late enrollment penalty before the state enrolled them in Part B buy-in.

After Part B buy-in coverage ends, SSA may deduct from the beneficiary’s monthly benefit payment up to three months’ worth of Part B premiums (current month plus two retroactive months). If the beneficiary does not receive a monthly benefit payment, CMS mails a bill, Medicare Premium Bill (Form CMS-500), to the beneficiary as described in HI 01001.030. If a beneficiary cannot afford to pay three months of Part B premiums at once, advise the beneficiary of their two options to obtain financial relief from retroactive billing of Part B premiums (see HI 00815.042C.).

 

B. Voluntary Withdrawal (Termination) From Medicare

When state buy-in coverage ends, SSA mails the beneficiary a notice of state buy-in termination (“buy-out notice”). The buy-out notice describes the option to withdraw from Medicare Part A and/or Part B.

  1. A. 

    If the beneficiary files a voluntary termination request within 30 days of the buy-out notice date, Medicare coverage ends the month buy-in has ended, avoiding beneficiary premium liability after buy-in coverage ends.

  2. B. 

     If the beneficiary files a voluntary termination request during the six months following the loss of buy-in coverage, Medicare coverage ends at the end of the month in which the beneficiary filed the notice.

  3. C. 

    C. If the beneficiary waits more than six months after buy-in coverage ends to file a voluntary terminations request, Medicare coverage ends at the end of the month after the month in which the beneficiary notifies SSA or CMS that they wish to withdraw.

Advise the beneficiary that he or she may have to wait to enroll and may be subject to a late enrollment penalty for the duration of entitlement to Part B coverage. See HI 00820.015B Termination of Premium-HI for the Aged, HI 00820.045 Voluntary Termination of SMI, HI 00820.060 Voluntary Termination Interview, and HI 00820.065 Tailoring Interview to the Individual Situation.

C. Options for Financial Relief from Retroactive Part B Premium Billing

As mentioned in HI 00815.042A, SSA may deduct from the beneficiary’s monthly benefit payment up to three months (current month plus two retroactive billing months) worth of Part B premiums when Part B buy-in coverage ends. If the beneficiary does not receive a monthly benefit payment, CMS bills the beneficiary directly. Advise beneficiaries they have two options to obtain financial relief from retroactive Part B premium billing.

  • Premium Waiver- Beneficiaries who believe they cannot afford to pay the retroactive premiums can request a premium waiver by submitting a Request for Waiver of Overpayment Recovery (Form SSA-632-BK).If SSA grants the waiver request and has already deducted retroactive Medicare premiums from the beneficiary's benefit payment, SSA refunds the waived amount to the beneficiary as described in HI 00830.015 Premium Waiver Determinations.

  • Installment Payments for Retroactive Premiums- Beneficiaries may request an installment plan from their local SSA field office if they indicate they cannot afford to pay the retroactive premiums in one lump sum and a waiver is not possible. Installment payments must be at least $15 per month. For more information about installment payments, see HI 00805.180 Payment of Premium Arrearage and HI 00830.060 Installment Payments for Retroactive Premiums.

D. Reenrollment After Termination Following Buy- In Coverage

Advise individuals whose Medicare coverage has terminated following a period of buy-in that they may reenroll for Medicare Part B during the General Enrollment Period (GEP).


HI 00815 TN 34 - State Enrollment of Eligible Individuals - 10/12/2021