All individuals who are eligible for Medicare Part B must pay a monthly premium for coverage (regardless of their employment history). DHS will pay the Medicare Part B premium for individuals who are receiving Medicare Part A and qualify for Buy-In of Medicare Part B. The individual does not have to apply for or be receiving Part B before Buy-In can begin.
Some individuals decide they do not want Medicare Part B – usually due to the premium costs – and choose to “opt out” of taking the coverage. If the Medicare status field on Exchange 3 (BENDEX) shows code “R,” “T,” or “W” it means the individual has either refused coverage from the start, was terminated for non-payment of premiums, or withdrew from the program later.
These individuals are still eligible for Buy-In of Part B if they meet the income and resource requirements. The CAO will reopen their Part B coverage by processing a manual accrete using the current month of eligibility only. (See Section 388.62, Manual Accrete Process.)
NOTE: Retroactive coverage should not be done for these individuals.
An individual is eligible to enroll in Medicare Part B if he or she:
Is age 65 or older and a U.S. citizen, or a lawfully admitted non-citizen with five years of residency in the United States, who is entitled to premium-free Medicare Part A or paying Part A premiums under Title II.
Is age 65 or older and receiving Medicare Part A regardless of immigration status.
Is under age 65 and receiving Social Security Disability (SSD) under Title II or Railroad Disability benefits; and 24 months have gone by since he or she was determined disabled by the SSA. For these individuals, Medicare entitlement begins in the 25th month.
Is eligible for Medicare Part A because of End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS, also known as Lou Gehrig’s Disease).
NOTE: Children in categories such as PH/95 may need to be enrolled in Buy-In because of ESRD. The CAO must add them by processing a manual accrete. (See Section 388.62, Manual Accrete Process.)
Buy-In of Medicare Part B is available to an individual who is eligible for Part B; and is getting MA benefits as one of the following state coverage groups:
A Qualified Medicare Beneficiary (QMB) QMBs include the following:
Healthy Horizons recipients. Healthy Horizons benefits include categorically needy benefits and cost-sharing benefits. Cost-sharing benefits provide for Buy-In of Medicare Part A, (if the individual must pay for Part A) and Part B, and the payment of Medicare deductibles and coinsurance.
NOTE:Children in categories such as PH95 may need to be enrolled in Buy-In because of ESRD. The CAO must enroll them by completing manual accrete actions. (See Section 388.62, Manual Accrete Process.)
NMP recipients 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 B if they meet the Healthy Horizons eligibility criteria. These individuals are enrolled in Buy-In with program status code 80.
State Blind Pension (SBP) recipients. A blind individual eligible for SBP may receive QMB benefits if they meet Healthy Horizons eligibility conditions.
SSI Recipients (A, J, or M). The individual gets benefits in category A, J, or M.
NOTE: If the SSA has not enrolled the individual in Buy-In after three months of Medicare eligibility, the CAO will enroll them in Buy-In by processing a manual accrete. (See Section 388.62, Manual Accrete Process.)
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.
Disabled Employed Individuals assigned program status code 85. The CAO must process a manual accrete to enroll these individuals. See Section 388.62, Manual Accrete Process.)
NOTE: For more information, see Chapter 387, Supplemental Security Income.
TANF recipients who are eligible for SSI but have chosen to get TANF and are:
Getting Transitional Medical Assistance (TMA) after their TANF benefits were closed because of an increase in earned income (MG71), or an increase in spousal support (MG23); or
Eligible for a TANF cash payment but do not get it because the amount is less than the $10 minimum monthly payment.
Recipients of Placement Maintenance or Adoption Assistance under Title IV-E of the Social Security Act.
Recipients of TANF who at the same time got a pension from the Veterans Administration in December 1978.
A Specified Low-Income Medicare Beneficiaries (SLMB). To qualify as a SLMB, an individual must be entitled to Medicare Part A, have income that exceeds 100% FPIG but is less than 120% FPIG, and resources not exceeding twice the SSI limit.
NOTE: SLMBs are eligible for payment of Part B premiums only. If an NMP or MNO recipient is also eligible for Buy-In of Part B as a SLMB, the CAO will enroll the individual in Buy-In using program status code 66.
Exception: NMP recipients in categories PA, PJ or PM with program status code 00 are eligible for Buy-In of Part B if they meet the SLMB income and resource limits. To determine their eligibility for SLMB Buy-In, the CAO will review the eligibility iteration in eCIS to see if the individual’s net income and resources that were counted for the failed PH80 budget are within SLMB limits. The CAO must process a manual accrete to enroll these individuals in Buy-In. (See Section 388.62, Manual Accrete Process.)
A Qualifying individual (QI). To qualify as a QI, an individual must be entitled to Medicare Part A, have income that exceeds 120% FPIG but is less than 135% FPIG, and resources not exceeding twice the SSI limit.
NOTE: QIs are eligible for payment of Part B premiums only. They are not eligible for any other MA benefits.
Updated August 31, 2018, Replacing February 14, 2012