Using Buy-In Data to Close Medicare A/B TPL Resources, PMA18885388 (Published April 19, 2018)
The Medicare Savings Program (MSP) or “Buy-In” was formed by Congress to help low-income Medicare beneficiaries pay their share of Part A and B premiums and in some instances, deductibles and copayments. Buy-In is jointly handled by the Department of Human Services (DHS), the Centers for Medicare and Medicaid Services (CMS) and the Social Security Administration (SSA).
Buy-In Information is available on Exchange 7 and must be reviewed at the time of application or renewal. This information is considered verified upon receipt.
NOTE: The CAO may accept SSA’s MSP Model Application on the SSA’s website as an application for Buy-In. The date that the CAO receives the Model Application is considered the date of application.
The Buy-In program transfers medical costs from the Medical Assistance (MA) program to the federally funded Medicare program; and helps with Medicare costs for individuals who are above the eligibility limits for MA. DHS pays the monthly Medicare premiums and Medicare becomes the primary payer for medical bills. Medicare providers are not allowed to bill any remaining balance to individuals that have Medicare and full MA.
NOTE: Medicare providers are not allowed to bill any remaining balance on medical bills to individuals that have Medicare and full MA. However, this does not apply to individuals who only receive Medicare cost-sharing benefits. Cost-sharing benefits only provide for Buy-In of Medicare Part A and Part B, and the payment of Medicare deductibles and coinsurance.
Medicare beneficiaries are eligible for different Buy-In programs, depending on their income and resources. There are four kinds of Buy-In programs:
1. Qualified Medicare Beneficiary (QMB) Program – Helps pay for Part A and/or Part B premiums, deductibles, coinsurance and copayments.
NOTE: QMBs may also be eligible for Healthy Horizons MA benefits; these beneficiaries as known as “Dual Eligible QMBs” or “QMB Plus.”
2. Specified Low-Income Medicare Beneficiary (SLMB) Program – Helps pay Part B premiums only.
NOTE: SLMBs may also be eligible for NMP or MNO benefits. These beneficiaries are known as “Dual Eligible SLMBs” or “SLMB Plus.”
3. Qualifying Individual (QI) Program – Helps pay Part B premiums only.
4. Qualified Disabled Working Individual (QDWI) Program – Helps pay Part A premiums only.
NOTE: The CAO will use Healthy Horizons rules when determining eligibility for QMB, SLMB and QI benefits. (See Chapter 319, Healthy Horizons.) Eligibility for QDWI benefits is determined by the SSA.
The chart below shows the Medicaid benefits available to a Buy-In recipient based on their program.
|
Medicaid Benefits for Buy-In Recipients |
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|
|
Type of Medicaid Benefit |
|||
|
Buy-In Program |
Medicare Part A Premium |
Medicare Part B Premium |
Medicare Cost-Sharing |
Full Medicaid Benefits |
|
QMB |
YES |
YES |
YES |
NO |
|
QMB Plus |
YES |
YES |
YES |
YES |
|
SLMB |
NO |
YES |
NO |
NO |
|
SLMB Plus |
NO |
YES |
NO |
YES |
|
QI |
NO |
YES |
NO |
NO |
|
QDWI |
YES |
NO |
NO |
NO |
Buy-In may be authorized retroactive three months from the date of application. Any individual with Medicare who applies for MA or Buy-In should be reviewed for retroactive Buy-In eligibility. If a Medicare recipient applying for MA has no need for retroactive MA, but indicates an interest in retroactive Buy-In eligibility, then Buy-In may be authorized for the retroactive months if the individual paid Medicare premiums for those months. The CAO will process an NCE in eCIS and a manual accrete on Exchange 7 for the retro Buy-In period. (See Section 388.62, Manual Accrete Process.) 55 Pa. Code § 140.335(a)
Exception: There are no retroactive benefits under Healthy Horizons Cost-Sharing QMB program (PG). 55 Pa. Code § 140.335(b)
NOTE: If an individual is determined ineligible for retroactive Buy-In, the CAO will send a rejection notice telling the applicant that the rejection is for retroactive Buy-In and the reason.
To confirm that an individual has Medicare, the CAO should review Exchange #3, (BENDEX) to see the Title II benefit information obtained from the SSA’s Master Beneficiary Record (MBR). Due to federal reporting requirements, the CAO must ensure that an individual’s Third-Party Liability (TPL) information for the Medicare coverage is entered in eCIS.
Supplemental Security Income (SSI) recipients (categories A, J and M) are automatically eligible for Buy-In of Part B when they become eligible for Medicare. When an SSI recipient becomes eligible for Medicare, SSA sends an alert to CMS to have them auto-accreted to Buy-In. Buy-In coverage for these individuals starts the first month that the individual is eligible for both Medicare and SSI and is a resident of Pennsylvania.
Important: If Buy-In is closed while an individual is getting SSI, the SSA will not reopen Buy-In. The CAO will need to reopen Buy-In by using the manual accrete process.
NMP and MNO spend-down recipients are eligible for Buy-In, provided that Buy-In eligibility is determined prior to any spend-down. The important factor in the determination for Buy-In and spend-down is that the Medicare Part A or Part B premium must not be used as a medical expense when determining eligibility for spend-down. If an individual is eligible for both Buy-In and spend-down, the CAO will authorize in the spend-down category with program status code ‘21’ or ‘22’; and use the manual accrete process to enroll the individual in Buy-In.
NOTE: A spend-down recipient is only eligible for Buy-In of Medicare Part A if they meet the eligibility as a Qualified Medicare Beneficiary (QMB) prior to spend-down.
Updated August 28, 2018, Replacing April 19, 2018