A. General

The monthly operation of the State buy-in program is accomplished through automated data exchange among the States, SSA, and CMS. However problems do arise which cannot be resolved through the normal data exchange. These cases require processing by CMS Premium Module Clerical Support Staff in Central Office. The majority of buy-in problems will be reported by a Social Security district office or by individual States. However, other CMS components, the ROs, or intermediaries and carriers may report buy-in problems.

B. Form CMS-1957 (SSO Report of State Buy-In Problem)

The form CMS-1957 (SSO Report of State Buy-In Problem) was developed to facilitate the resolution of problem cases relating to State buy-in. In most instances, the DO/BO will have become aware of a problem through a beneficiary complaint. Some of the more common types of buy-in problems which lend themselves to reporting on the CMS-1957 are:

1. Part B Medicare claims denied due to failure of the individual to have Part B coverage or due to termination of Part B.

2. Erroneous Part B premium deduction from Social Security benefit check or continued direct billing for Part B premiums after the buy-in effective date.

3. Failure by SSA to start or to resume Part B premium deductions or direct billing after the date buy-in has terminated.

4. Erroneous termination of Part B coverage during a period of buy-in coverage.

5. SSI accretion and/or deletion actions in an accrete State.

C. Routing of the CMS-1957

1. CMS-1957 is designed to accumulate the information needed to resolve the problem case. The completed form may be routed to the State or local welfare office or to CMS Central Office for resolution of the problem. The SSA DO/ BO completes Part I, Report of Problem by SSO, and Part II SSI status at SSO (if applicable). The DO/BO may need to contact the local welfare office in order to be able to complete the identification block in the upper right hand side of the form. Subsequent processing of the form will depend upon arrangements negotiated among the Social Security and CMS ROs and each State. Usually the arrangements depend upon whether verification of buy-in status is to be obtained from the local welfare office (Part III) or the State (Part IV).

   NOTE: In Massachusetts, Minnesota, New Mexico, New York, Virginia, Vermont, and Washington obtain verification of buy-in from the local welfare office in accordance with regional supplemental instructions before forwarding the CMS-1957 to the parallel DO or the State Agency.

2. The Social Security district office parallel to the State Agency is located in the State capital except in the following States:

   • Delaware - Wilmington

     District of Columbia - Washington, D.C. (DT)

     Florida - Jacksonville

     Guam - Agana

     Maryland - Baltimore (DT)

     South Dakota - Huron

     Nevada - Reno

3. The address of CMS Premium Module is:

   CMS, OIS,
   Division of Exceptions Processing
   Buy-in Workload
   P.O. Box 11977
   Baltimore, Maryland 21207

D. Control of CMS-1957s Pending in Servicing DO/BO

Establish a holding file for the control copy of each CMS-1957 which is initiated. This file may be used if a request for additional development is received. It will preclude redevelopment if the case is not corrected.

Annotate a followup date in the upper right hand corner of the control copy of the CMS-1957 based on the following timeframes:

1. Original CMS-1957 sent to CMS Premium Module - 90 days.

2. Original CMS-1957 sent to parallel DO - 45 days

3. Original CMS-1957 sent to local welfare office or to State Agency - 45 days.

If the servicing DO/BO receives a request for additional development, it should furnish the information and diary the case an additional 45 days.

The servicing DO/BO should receive a response to each CMS-1957 it sends to the local welfare office, the parallel DO, or the State Agency. If a response is not received by the expiration of the diary date, request status.

If the original copy of the CMS-1957 or other satisfactory documentation is received by the servicing DO/BO specifying that no action is necessary or that no action can be taken, or that the corrective action has been taken (and it is verified by the servicing DO/BO) the material in the holding file may be destroyed.

Refer to HI 00815.094 for instructions concerning follow-up action on CMS-1957s sent to the Premium Module in CMS Central Office.