QMB Program Manual
WG-5 Medicare Part B Buy-In
Effective 8/1/11
Buy-In is the name given to the process of the state paying for either the Part A and/or Part B Medicare premium for a client.
To be eligible for Buy-In, the client must first be receiving or be eligible to enroll in Part A or Part B of Medicare. The following people are eligible for Part B. For Part A buy-in refer to QMB WG 4.
- People age 65 or over who have Medicare Part A (Hospital Insurance).
- All other people age 65 or over who are U.S. residents and are either U.S. citizens or aliens lawfully admitted for permanent residence who have resided in the U.S. continuously during the five years immediately preceding the month they apply for enrollment.
- People under age 65 who have been receiving monthly Social Security disability benefits (Title II) or railroad disability benefits for 24 months.
- People under age 65 who are eligible for Medicare because they have chronic kidney disease.
When a client becomes eligible for Buy-In, several other records are affected. If the client is receiving a Social Security check, the Part B premium will no longer be deducted from the benefit, resulting in a higher monthly Social Security payment. If the client was not receiving a Social Security check, but was being billed directly, direct billing will cease. In both cases, the client will receive a refund of any premiums deducted or paid for the months they were on Buy-In. Such premium refunds are not to be considered income when determining or reviewing eligibility for benefits.
When Buy-In coverage begins:
- Most clients’ Buy-In coverage will begin the first month the client is eligible for both Medicaid and Medicare benefits, and is a resident of Oregon.
- Buy-in coverage does not, however, always align itself with Medicare Savings Program (MSP) eligibility.
- The QMB effective date, for instance, is the first of the following month all eligibility requirements are met and verified, while SMB and SMF-only clients (P2s) are eligible for retroactive coverage back 3 months from the effective date.
- Except for the P2 SMB and SMF clients, Buy-In coverage does not extend to periods of retroactive medical eligibility unless the client had Medicare and the buy-in unit was unaware of it. In that case, the buy-in may go back to the original date of Medicaid/Medicare eligibility. MSP eligibility does not, however, go retro in this case at all.
Under Buy-In, the Department or SSA may enroll the client even though he/she does not wish to enroll. A client cannot terminate State Buy-In coverage.
If the client previously refused Part B of Medicare or withdrew from it, entitlement will be established or reestablished effective with the first month the client is eligible for Buy-In. When assistance is terminated and Buy-In ends, the client has the option to then withdraw the Part B coverage. If the client does not withdraw, the Part B premium will be the base amount, even if the client had been paying a higher penalty premium for late enrollment prior to being on Buy-In.
Buy-In procedures:
-
If the client has a Medicare Supplement, complete the
DHS 0415H and fax it to the Health Insurance Group at 503.373.0358
- When the client is eligible for Medicare but does not receive an SSB/RRB benefit, enter an SSB Resource Code with a 0 amount on CMS. This is required by the CMS system.
- Clients in NFC care are allowed a SMI deduction from their income to pay for their premiums until they become eligible for Buy-In. This should only be allowed for two months and only for NFC clients as they only have a $30 PIF. In-home and CBC clients can pay for the premium on their own as they will be subsequently reimbursed. The W204/WQY3 screens will show the Part B premium payer as Code 380 when Oregon buys in for the recipient.
- Explain the Buy-In Program to the client at intake.
- Inform the client who is enrolled in Medicare Part B that he/she will receive a refund from SSA of premiums paid or deducted for any month they were covered by Buy-In. SSA will notify the client when Buy-In enrollment is completed. The premiums should not be considered a deduction on FSMIS.
- Do not consider a refund of premiums as income when determining or reviewing eligibility for benefits.
- Consider a client enrolled in Medicare Part A only as eligible for Part B. The client will be automatically enrolled in SMIB by the Buy-In system. SSA will send the client a new Medicare identification card.
- For information on Medicare Part A buy-in see QMB WG-4. Refer the client to SSA if they have questions about continuation of Part B coverage when benefits and Buy-In are terminated. SSA will automatically notify the client of their options to drop or continue Part B coverage.
Buy-In/Field Worker Interaction:
- The buy-in unit often initiates interaction by calling the branch and asking the worker to add a MIB code to a case. It is important that is done as soon as possible or buy-in cannot proceed.
- Buy-in workers don’t know policy for our programs, nor are they a resource for coding other than the MIB. Workers need to make eligibility decisions, including effective dates, and coding decisions independently of the buy-in worker.
- Buy-in information can be found in MMIS.
- Branch contacts are as follows:
Branches 0000-1799 – Dee Burson 503-945-6594
Branches 1800-2699 – Ed Hunt 503-945-6833
Branches 2700-9999 – Elvie Gilbert 503-945-6644
Examples:
Since program eligibility effective dates and Medicare buy-in dates often don’t line up, here are some examples. Also look at SPD AR 10-063 for an in-depth description of SMB/SMF retroactive coding.
Example #1
- Client has Medicare A & B since June of 2010. No Medicaid. Applies for MSP in July 2011.
In this case eligibility does match buy-in. QMB buy-in and eligibility 08/11d as long as worker makes a decision and has all verification in August. For SMB/SMF both could go back as far as April of 2011. If there is retro eligibility for SMB/SMF, the worker would need to do a 148 back to the first month of eligibility.
Example #2
- Client has Medicare Part A since May 2002 and Part B since May of 2011. The client has had D4 since January of 2007 and the Part B is discovered by the worker in July of 2011.
In this case buy-in and eligibility don’t match. The buy-in will start in May of 2011 to pick up all of the premiums we should have paid for the client. The MSP eligibility however is different. SMB/SMF and, if service clients and over the SMF limit, SBI/CBI would start on July 1st of 2011. QMB would start September 1, 2010. A 148 is done per AR 10-063 on the SMB/SMF cases as there is retro buy-in, but no retro MSP eligibility.
Example #3
- Client has Medicare A and B on May of 2010; D4 eligible since June of 2006. Medicare discovered in July of 2011.
Buy-in goes back to May of 2010. SMB/SMF/SBI/CBI effective date is 7/1/2011. QMB eligibility date is August 1,2011.
Example #4
- Client has had OHP-OPU since January of 2010. Client starts receiving Medicare Parts A and B on April 2010. Medicare discovered in July 2011.
Buy-in starts in August, 2011. SMB/SMF/SBI/CBI effective date is 8/1/2011 because 10-day notice is required. QMB eligibility date is also September 1, 2010.
Note: The Buy-in Unit will not start the Buy-in until the client is on an eligible benefit plan (BMH, BMD, BMM, SMB, and SMF). KIT and CAWEM are not eligible benefit plans.
Example #5
- Client has had OHP-OPP since January of 2011. Client starts receiving Medicare Parts A and B on April 2011. Client’s income is in the SMB or SMF income range. MMIS won’t allow OPP and either SMB or SMF to be coded together although policy and the CMS system do.
Buy-in starts in April 2011. Call the buy-in unit to start that process. There is no Medicare Savings Program (MSP) related coding put on the case and MIB is left at 0. Medicare is coded on the MMIS panels and a reduction notice needs to be sent to the client and help with Part D enrollment offered. Sixty days after the birth the case will be recoded as appropriate and the MSP and MIB coding added.
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Oregon Department of Human Services
500 Summer St. NE E02, Salem, OR 97301-1073
Phone: (503) 945-5811
Toll-free: (800) 282-8096 (V/TTY)
