An individual’s eligibility for Buy-In of Part A and Part B ends when any of the following takes place:
Death – Buy-In coverage ends in the month of death.
The Buy-In system will automatically send a request to close Buy-In (Part A and/or B) using transaction code ‘53’ and the month/year of death if the CAO enters the client’s date of death into the eCIS case record.
If the case is closed and no date of death is entered in eCIS, the CAO is responsible for manually closing the Buy-In using code '53.'
Important: It is extremely important that CAO workers enter the date of death timely and correctly in eCIS. If Buy-In is closed without a date of death, the system will auto-close it with transaction code ‘51’ for the next month and DHS will not be reimbursed for any months after the date of death.
Move out of the state – Buy-In coverage ends on the last day of the last month that the individual lived in Pennsylvania.
Loss of entitlement to Part A benefits – When an individual under age 65 loses entitlement to Part A, Buy-In coverage ends the same month that Part A entitlement ends.
No longer meets Buy-In eligibility requirements – Buy-In coverage ends in the last month that the individual meets the eligibility requirements for Buy-In.
An individual may still be eligible for MA when a change in Buy-In eligibility occurs. When Buy-In eligibility ends, the CAO will review information in the case record to determine whether the individual is eligible for MA in a non-Buy-In category.
When closing a Buy-In category and opening a new, non-Buy-In category in eCIS, it is the CAO’s responsibility to review the individual’s Buy-In status on Exchange 7 to determine if a manual delete is required to close Buy-In coverage. (See Section 388.51, Deleting Individuals from Buy-In.)
NOTE: When an individual receiving Buy-In becomes eligible for LTC or HCBS waiver services, and their program status code changes to ’00,’ the individual no longer meets eligibility requirements for Buy-In and the CAO must process a manual delete to close Buy-In.
388.51 Deleting Individuals from Buy-In
There are four ways an individual can be deleted from the Buy-In system:
1. CMS/SSA Closing – These are initiated by the SSA based on information they have received, such as notice of death, moved out of state or deemed ineligible for Medicare by SSA.
2. Exchange 7 Auto-Closing when Unknown to eCIS – If a case is auto-accreted by CMS and the individual is not open in a MA or TANF cash assistance category, the Buy-In system will send a request to CMS to close Buy-In.
3. Exchange 7 Auto-Closing – When a Buy-In category is closed, a closing request is automatically sent to a special holding file in the Buy-In system. After 30-45 days, the Buy-In system checks the individual’s status in eCIS to determine if they are open or closed for MA benefits.
If the eCIS budget is closed and the individual is not open in any other MA or TANF category, the system will close Buy-In.
NOTE: The CAO should check the Exchange 7 Buy-In Match Results screen in the middle of the next month to make sure the individual was deleted from Buy-In. If Buy-In did not close, the CAO must process a manual delete to close Buy-In.
If the individual is open in any other MA or TANF category in eCIS, the system WILL NOT close Buy-In. It is the responsibility of the CAO to decide if the individual should be deleted from Buy-In and process a manual delete to close Buy-In.
4. Manual Closing – A manual delete is done on the Exchange 7 Buy-In Action Request screen in Exchange 7 and consists of three items: type (Part A or Part B), transaction code (’51’/ ‘53’ for deceased individuals) and (end) date.
Important:Due to Federal regulations governing “hardship” conditions, Buy-In can only be retroactively terminated up to two months from the current billing month. No overpayments can be done unless it is proven the individual intentionally falsified information.
Example: Buy-In eligibility ended 06/2016. In 03/2018, the CAO discovers Buy-In coverage was never closed. Since the current billing month is 03/2018, the CAO can only request termination retroactive to 01/2018.
Updated August 31, 2018, Replacing February 14, 2012