Conditional Medicare Part A Buy-In for Qualified Medicare Beneficiaries, OPS190601 (Published June 26, 2019)
Most individuals who are age 65 or older get Medicare Part A. Individuals (and their spouses) who have 40+ quarters of work history with SSA are entitled to “Free” Part A and do not pay a monthly premium. Individuals without a work history, or who do not have enough work credits to get Medicare Part A for free, are considered “uninsured” by SSA and must pay both Part A and Part B premiums, or may be eligible to have DHS pay for them.
NOTE: Most “uninsured” individuals can be identified by their Medicare claim number (or HIB number), which will usually end with the letter “M” or “T” (Ex. 123456789M).
If an individual must pay the Medicare Part A premium, DHS will pay it through Buy-In only if the individual is one of the following:
A Qualified Medicare Beneficiary (QMB). To qualify as a QMB, an individual must be entitled to Medicare Part A, have income not exceeding 100% of the Federal Poverty Income Guidelines (FPIG), and resources not exceeding twice the SSI limit.
QMB's include the following:
Healthy Horizons categorically needy (PH80) and cost-sharing (PG00) recipients. If the Payer field on Exchange 3 shows an individual is paying their Part A premium, they will be enrolled in Buy-In through auto-accretion (See 388.61, Exchange 7 Auto-Accrete Process). If the individual has Part B Buy-In and is considered “uninsured” for Part A, the CAO must manually accrete them for Part A Buy-In after Part B has been approved by CMS (See 388.62, Manual Accrete Process). If the individual does not have Medicare and needs to apply for Part A to become eligible for Medicare, the CAO will tell the individual to contact SSA.
NMP and MNO recipients getting MA benefits in category PAN, PJN, PMN, PVN, PAW, PJW, PMW, PW, PI, TA or TJ are eligible for Buy-In of Part A if they meet the Healthy Horizons eligibility criteria. These individuals are enrolled in Buy-In with program status code 80.
State Blind Pension (SBP). A blind individual eligible for SBP may receive QMB benefits if they meet Healthy Horizons eligibility conditions.
SSI recipients. The individual gets benefits in category A, J, or M.
Special SSI Recipient Status individuals. Recipients of category PA, PJ, or PM benefits whose NMP was extended after their SSI benefits were closed. This includes the following:
Disabled Adult Children (DAC) assigned program status code 81.
Lynch v. Rank Pickle Amendment individuals assigned program status code 84.
A Qualified Disabled Working Individual (QDWI). To qualify as a QDWI, an individual must be a working disabled person under age 65 who lost their premium-free Part A when they returned to work. The individual’s income may not exceed 200% FPIG and resources may not exceed twice the SSI limit.
The SSA will identify a QDWI, send the individual a letter confirming their QDWI status, and tell the individual to contact the CAO. The CAO will have the individual complete an application.
NOTE: To confirm that an individual is a QDWI, the CAO should review their Medicare information on Exchange 3 (BENDEX). The Basis code under the Part A column of the Part A and B tab should be “W,” which indicates a “Working Disabled” individual.
Important:
A QDWI is eligible for payment of Part A premiums
only. A QDWI is not eligible for any other MA benefits.
Updated August 29, 2018 Replacing February 14, 2012