Effective Dates: 10/15/2026 - Present Previous | Next

TN 90 (10-26)

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

A. Background: Part A and Part B Enrollments

Low-income individuals aged 65 and over who qualify for premium Medicare Hospital Insurance ( premium Part A) may be eligible for state payment of their Part A premiums under the Qualified Medicare Beneficiary (QMB) Medicaid eligibility group. The QMB eligibility group covers Medicare Hospital Insurance (Part A) and Medical Insurance (Part B) premiums and cost-sharing (Medicare deductibles, coinsurance, and copayments) for eligible individuals.

Be aware of the QMB income and resource limits in the claimant’s state of residency to assist you in identifying who may be eligible for state payment of Part A premiums under the QMB eligibility group.

For more information on the QMB group and other related Medicare Savings Programs (MSPs), refer to HI 00801.139 and HI 00815.023.

B. Policy: Part A Buy-in States

States that have elected to pay Part A premiums for QMB-eligible individuals under their buy-in agreements with the Centers for Medicare and Medicaid Services (CMS) are known as “Part A buy-in states.”

Below is a list of the Part A buy-in states and the effective date of the state buy-in agreement modification, if later than January 1990. (If no date given, effective date was January 1990.)

Alaska

Maryland

Oregon (7/2008)

Arkansas

Massachusetts

Pennsylvania

California (1/2025)

Michigan

Rhode Island

Connecticut

Minnesota

South Dakota

Delaware

Mississippi

Tennessee (7/1990)

District of Columbia

Montana

Texas (7/1993)

Florida

Nevada

Vermont (9/1990)

Georgia

New Hampshire

West Virginia

Hawaii

New York (07/2004)

Washington (7/1990)

Idaho

North Carolina

Wisconsin (7/1990)

Indiana

North Dakota

Wyoming (11/1990)

Iowa

Ohio

 

Louisiana

Oklahoma

 

Maine

 

 

1. Individual is enrolled in Part B only

Individuals aged 65 and over who reside in a Part A buy-in state can qualify for QMB coverage if they are enrolled in Part B only (including Medicaid beneficiaries for whom SSA has established Part B through the Public Welfare Accretion process for Part B buy-in as described in HI 00815.030), and they meet other state eligibility requirements.

a. All Part A buy-in states except California

If the individual has Part B, refer them to their state Medicaid program to apply for QMB coverage. If the individual meets the state’s eligibility criteria for the QMB eligibility group, the Medicaid agency will enroll them in the QMB eligibility group and Part A buy-in.

b. California

If the individual has Supplemental Security Income (SSI) and Part B, take no action. For example, do not refer them to their county Medicaid (Medi-Cal) office to apply for QMB coverage. Inform the individual that they will automatically receive QMB coverage.

If the individual has Supplemental Security Income (SSI) and Part B, take no action. For example, i.e. do not refer them to their county Medicaid (Medi-Cal) office to apply for QMB coverage. Inform the individual that they will automatically receive QMB coverage.

Example: A SSI recipient resides in California (a Part A buy-in state) and has Part B. The field office (FO) advises the individual that California will automatically enroll them in the QMB group and Part A buy-in.

If the individual has Part B but not SSI, refer them to their county Medicaid (Medi-Cal) office to apply for QMB coverage. If the individual meets California’s eligibility criteria for the QMB eligibility group, the county Medicaid (Medi-Cal) office will enroll them in the QMB eligibility group and Part A buy-in.

Example: A California resident is enrolled in Part B and does not have SSI. The FO refers the individual to their county Medicaid (Medi-Cal) office to apply for QMB coverage.

2. Individual does not have Medicare

If an individual aged 65 and over resides in a Part A buy-in state, does not have Part A nor Part B, and may qualify for the QMB eligibility group, enroll the individual in Part B and conditional Part A (“the conditional enrollment process”). (Refer to HI 00801.140C for a description of the conditional enrollment process).

Individuals who reside in Part A buy-in states can conditionally enroll in Part A and enroll in Part B at SSA at any time of the year (without regard for Medicare enrollment periods or late enrollment penalties, if applicable). If an individual applies for Part B and conditional Part A during the General Enrollment Period (GEP), process the Part B enrollment without respect to the GEP, as explained in section C.

Example: Outside of a prescribed enrollment period and individual does not have Medicare:

A low-income individual aged 65 and over resides in Ohio (a Part A buy-in State) and does not have Medicare. The individual contacts the FO in July 2025 to enroll in Medicare. Because the individual resides in a Part A buy-in state, the FO office takes an application for Part B and conditional Part A without regard to Medicare enrollment periods or late enrollment penalties.

Example: During a prescribed enrollment period and individual does not have Medicare. A low-income individual resides in Ohio (a Part A buy-in State) and does not have Medicare. The individual contacts the FO in March 2025 to enroll in Medicare. The FO takes an application for Part B and conditional Part A. Do not process as a GEP application. Refer to A101/EF101 instructions in section E.

C. Policy - Conditional enrollment process

An individual not yet approved for QMB eligibility can use the conditional enrollment process to enroll in premium Part A “conditionally.” Conditional enrollment most commonly applies to individuals in group payer states (refer to HI 00801.140D) but may apply in limited cases in Part A buy-in states (refer to HI 00801.140B2).

The conditional enrollment process allows an individual to apply for premium Part A but only get the coverage if the state approves QMB eligibility, whereby the state will pay the Part A premiums. If the state denies the QMB eligibility, the individual will not be enrolled in premium Part A. If a state determines it will not buy in, the conditional application is cancelled rather than denied. The beneficiary must file a new unconditional application during a regular enrollment period such as the General Enrollment Period (GEP) unless they qualify for a Special Enrollment Period (SEP) as outlined in section 1.11 in CMS Manual System Pub 100-24 Overview.

To complete conditional enrollment, individuals must also apply for Part B if they are not already enrolled. However, Part B enrollment is not conditional. Part B coverage starts regardless of whether the state approves the individual’s QMB eligibility.

NOTES: 

 

  • •

    Payment of past premiums is not a prerequisite to enrollment. HI 01001.345

  • •

    A conditional enrollment in premium -Part A will not generate a bill. If the state does not approve the QMB eligibility, the beneficiary will not get Part A coverage. However, the beneficiary is responsible for paying monthly Part B premiums or, and Part B will terminate for non-payment of premiums if unpaid, as outlined in HI 00820.035.

  • •

    An individual person who intends to enroll in premium -Part A regardless of the state’s QMB eligibility determination will file an application following policies and processes in HI 00801.131 through HI 00801.138.

    •Note that the Z99 code is a placeholder. Technicians must verify actual HI enrollment by checking the HIQR screen and should not rely on the Z99 code to determine enrollment status.

D. Policy — Part A Group Payer States

States that pay Part A premiums for QMBs using a group payer arrangement with CMS are known as “group payer states.”

Group payer states can only approve QMB coverage if the individual is enrolled in:

  • •

    Part B AND premium Part A; or

  • •

    Part B and conditional Part A (refer to conditional enrollment in section C). The conditional enrollment process in a group payer state must be completed during a prescribed enrollment period. Group payer states pay any applicable late enrollment penalties for premium Part A.

The chart lists group payer states:

Group Payer States

Alabama

Kentucky

South Carolina

Arizona

Missouri

Utah

Colorado

Nebraska

Virginia

Illinois

New Jersey

 

Kansas

New Mexico

 

 

1. Individual not in a prescribed enrollment period

If the individual is not in a prescribed enrollment period, as outlined in HI 00801.133, do not take an application for Part B and conditional Part A enrollment. Inform the individual of the next available enrollment period to submit their application. If the individual insists on filing an application for Part B, process the application as a disallowance.

Example: Outside of a Medicare Enrollment Period and does not have Medicare

A low-income individual in South Carolina (a group payer state) contacts the local FO in July 2025 to enroll in Medicare. Because the individual resides in a group payer state, they cannot enroll in Part B and conditional Part A outside of a Medicare enrollment period. The FO advises the individual to apply for Part B and conditional Part A during the next General Enrollment Period (GEP) or a Special Enrollment Period (SEP).

Example: Outside of Medicare Enrollment Period and is enrolled in Part B only

A low-income individual in South Carolina, enrolled in Part B, contacts the local FO in July 2025 to enroll in premium Part A. Because the individual resides in a group payer state, they cannot enroll in conditional Part A outside of a Medicare enrollment period. The FO advises the individual to apply for conditional Part A during the next GEP or SEP.

2. Individual is within a prescribed enrollment period

During a prescribed Medicare enrollment period, enroll an individual in Part B and conditional Part A or just conditional Part A if they already have Part B according to instructions in section C. Refer the individual to their state to apply for QMB coverage.

If the state approves the QMB eligibility, the state will pay the individual’s Part A premiums, including any applicable late enrollment penalties.

Example: Individual does not have Medicare

An individual resides in Alabama (a group payer state) and contacts the local FO in March 2025. Since the individual resides in a group payer state and has applied during the GEP, the FO processes the application for Part B and conditional Part A and refers the individual to the state to apply for QMB coverage.

Example: Individual has Part B

An individual resides in Alabama (a group payer state), is enrolled in Part B, and contacts the local FO in March 2025 to enroll in premium Part A. Since the individual resides in a group payer state and has applied during the GEP, the FO processes the application for conditional Part A and refers the individual to the state to apply for QMB coverage.

E. Procedures for Processing Part A Coverage

The table describes SSA processes for uninsured individuals who wish to apply for QMB coverage through their state.

Type of State

Scenario

Action

Processing Instructions

Part A buy-in state37 states (AL, AK, AR, CA*, CT, DE, DC, FL, GA, HI, ID, IN, IO, LA, ME, MD, MA, MI, MN, MS, MT, NV, NH, NY, NC, ND, OH, OK, OR, PA, RI, SD, TN, TZ, VT, WA, WV, WI, WY)

An individual has Part B(I ncludes Medicaid beneficiaries SSA has enrolled in Part B through a Public Welfare Accretion described in HI 00815.030),

 Refer the individual to the state to apply for QMB coverage. Emphasize the importance of promptly contacting the state per HI 00801.140.B1.a

*CA only- Follow instructions in HI 00801.140.B.1.b

N/A

 

Individual is not enrolled in Medicare
  1. 1. 

    Take an application for premium Part A on a conditional basis (and Part B).

  2. 2. 

    Include the following statement(s) in the “Remarks” section of the application: “I wish to enroll in Part A (hospital insurance). I understand that:

    1. a. 

      a. I’m not eligible for Premium-Free Part A.

    2. b. 

      b. I only want Part A if my state approves my application for Qualified Medicare. Beneficiary (QMB) coverage.

    3. c. 

      c. I must also have Part B (medical insurance).

    4. d. 

      I am responsible for paying Part B premiums.

    5. e. 

      If I get QMB coverage, I will be enrolled in Part A and the state will pay my Part A and B premiums.

  3. 3. 

    Refer the individual to the state to apply for QMB coverage (unless they are an SSI recipient residing in CA). Emphasize the importance of promptly contacting the state.

  4. 4. 

    Explain to the individual they may receive a bill and must pay Part B premiums until QMB begins.

  5. 5. 

    Provide a screenshot (RMKS screen MS 03505.040) to the individual, as a receipt of conditional Part A enrollment.

    Note: 

    The individual can take the screen shot (RMKS screen MS 03505.040) to the state as proof they enrolled in conditional Part A when applying for the QMB program. This will assist the state in properly identifying the nature of the QMB eligibility and assist the state on how to properly process the case.

FO Instructions:

  • •

    Take an initial claim for Part B and conditional Part A through MCS (select claim type 5=UNINS MED ONLY on APPL screen).

  • •

    Develop proofs of age, citizenship or immigration status, and residency.

  • •

    Review the earnings record for accuracy. A reduced premium for Part A may apply if the individual or spouse has 30-39 quarters of coverage. For additional information on the Part A premium reduction, refer to HI 00801.134 and HI 01005.007.

  • •

    Prepare an A101. If problems occur with the A101 and the technician cannot process the application through an A101, then prepare an EF101. Instructions for screen completion for the A101 are in MS 03514.000 and EF101 are in T2PE 009.000. Refer to SM 03040.230, MS 03514.011, MS 03514.012 (code of “Z99” for conditional applications only, which means the individual is not entitled to Premium HI).

For MCS processing procedures for QMB Part A Buy-in states, refer to SM 03040.025C.1.

PC Instructions:
  • •

    Propagate the A101/EF101 into MACADE.

  • •

    Refer to SM 00850.700 for applicable MACADE Health Insurance (HI) screens and coding.

Note: 

After processing the A101/EF101, the MBR will show (as applicable) the HI AGE and the SMI AGE lines with a PERIOD of Q, and the HI 3PTY line with the Z99 state buy-in code, and SMI 3PTY line with any applicable State buy-in code, if included on the A101/EF101

Note: 

If the beneficiary resides in a Part A buy-in State, POS cannot process the enrollment. Refer the beneficiary to contact their State to file for QMB status. (Per SM 03040.025C2. )

Group Payer

State

13 states

(AL, AZ, CO, IL, KS, KY, MO, NE, NJ, NM, SC, UT, VA)

Individual is within a prescribed enrollment period

  1. 1. 

    Take an application for premium Part A on a conditional basis (and Part B, developing for buy-in using HI 00815.030 , if not already enrolled).

  2. 2. 

    Include the following statement(s) in the “Remarks” section of the application: “I wish to enroll in Part A (hospital insurance). I understand that:

    1. a. 

      I’m not eligible for Premium-Free Part A.

    2. b. 

      b. I only want Part A if my state approves my eligibility for Qualified Medicare Beneficiary (QMB) coverage.

    3. c. 

      I must also have Part B (medical insurance).

    4. d. 

      I am responsible for paying Part B premiums.

    5. e. 

      If I get QMB coverage, I will be enrolled in Part A and the state will pay my Part A and B premiums.

  3. 3. 

    Refer the individual to the state to apply for QMB coverage. Emphasize the importance of promptly contacting the state.

  4. 4. 

    4. Explain to the individual they may receive a bill and must pay Part B premiums until QMB begins.

  5. 5. 

    5. Provide a screenshot (RMKS screen MS 03505.040) to the individual, as a receipt of conditional Part A enrollment.

Note: 

The individual can take the screenshot (RMKS screen MS 03505.040 ) to the state as proof they enrolled in conditional Part A when applying for the QMB program. This will assist the state in properly identifying the nature of the QMB application and assist the state on how to properly process the case.

For MCS processing of QMB Group Payer States, refer to SM 03040.025D1.

For POS processing of QMB Group Payer States, refer to SM 03040.025D2.

Individual is not within a prescribed enrollment period

If the individual is not in a prescribed enrollment period, as outlined in HI 00801.133, do not take an application for conditional Part A enrollment. Inform the individual of the next available enrollment period to submit the application. (If the individual insists on filing an application for Part B, process the application as a disallowance.)

N/A

HI Premium Penalty Changes Upon State Buy-In Enrollment

When a conditional enrollment is processed, the MBR may display Part A information even though no actual Part A entitlement has been established on the EDB or HIQR. This occurs because the “Z99” buy-in code functions as a temporary placeholder pending State action on the buy-in request. Specifically, the MBR will show a “HI CONTS PRD-MM/YYYY” entry reflecting the month and year of the conditional enrollment or anticipated State buy-in effective date (for example, HI CONTS PRD-07/2017).

The MBR will also display the buy-in code “Z99” and may show an associated “HI 3PTY Penalty” amount. Technicians should not interpret the presence of the Z99 code as confirmation of Part A entitlement. The Z99 code only indicates that a conditional enrollment record exists and that the State has not yet added the individual to the Group Payer account.

Until the State replaces the Z99 code with an actual State buy-in code on the MBR, or the placeholder code is otherwise removed from the MBR, no Part A entitlement exists on the EDB or HIQR.

Once the State adds the individual to the Group Payer’s account, the MBR must be updated to replace the “Z99” placeholder code with the applicable State buy-in code. At that time, the “HI 3PTY Penalty-00%” field will update to reflect the current HI PREM penalty amount (for example, 10%).

The MBR will automatically remove the penalty once the START date in the HI PREM field reflects 00%. For information on Part A late enrollment penalty removal, refer to HI 01005.010.A.3

F. References

HI 00801.126 Health Insurance (HI) for the Uninsured

HI 00801.131 Eligibility for Premium HI

HI 00801.133 Enrollment and Coverage Period

HI 00801.134 Premium Reduction for Aged Individuals With At Least 30 Quarters of Coverage

HI 00801.138 Application for Premium HI

HI 00801.139 Qualified Medicare Beneficiary (QMB) Provisions

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

HI 00815.023 Medicare Savings Program Income Limits

HI 00820.035 Termination of SMI Entitlement

HI 01005.007 Reduced Hospital Insurance (HI) Premium

HI 01005.010 Premium Increase for Delay in Enrollment

SM 00850.700 BIC M-Conditional Enrollments for Premium HI-Qualified Medicare Beneficiaries (QMB)

SM 03040.000 Enrollment Business Function

SM 03040.025 Uninsured Medicare and Qualified Medicare Beneficiary (QMB)

SM 03040.230 Qualified Medicare Beneficiary (QMB) Premium HI Third Party

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0600801140
HI 00801.140 - Premium-Part A Enrollments for Qualified Medicare Beneficiaries (QMBs) Part A Buy-In States and Group Payer States - 10/15/2026
Batch run: 10/15/2026
Rev:10/15/2026