HI 01001.200 Complaints Involving Alleged State Buy-In Coverage
An individual may complain that he is entitled to SMI under a State buy-in agreement
after the carrier has denied his claim for benefits on the ground that he is not entitled
to SMI. In many such cases the individual is entitled to SMI, but the State did not
correctly identify the individual in submitting its list of enrollees. Most carriers
and State Welfare agencies have arrangements under which the State will, upon request,
check the individual's eligibility before the carrier denies the claim. However, when
this process cannot be used (e.g., because there was no indication of welfare involvement
in the claims process), individuals may complain to the DO. Complaints may also be
made by individuals who are enrolled under a State buy-in agreement but have received
premium billing notices, an incorrect notice that their coverage has terminated, or
other improper notices. In these cases the DO contacts the welfare department to verify
whether or not the individual is covered by a buy-in agreement, and relays the correct
information to in accordance with HI 00815.088.