TN 34 (06-18)

A. Background Part A and Part B Enrollments

The Qualified Medicare Beneficiary (QMB) Program is a Medicaid program that covers Medicare Part A and Part B premiums and cost-sharing for low income Medicare beneficiaries. Since 1989, the law has required State Medicaid programs to provide the QMB program to eligible beneficiaries. For more information on the QMB Program and other related Medicare Savings Programs (MSPs), see HI 00801.139 and HI 00815.024.

Medicare State Buy-in agreements facilitate the payment of Medicare premiums by States on behalf of their Medicaid recipients by removing enrollment period restrictions and any late premium enrollment penalties. As outlined in HI 00815.001, these agreements permit States to automatically enroll eligible individuals into Medicare Part B. All State Buy-in agreements include Part B for QMBs.

Starting January 1, 1990, States had the option to expand their State Buy-in agreements to include Premium-Part A for Aged QMBs. States that include Premium-Part A in their State Buy-in agreements are known as “Part A Buy-in States.” States that do not include Premium-Part A for QMBs in their State Buy-in agreements are known as “Group Payer States.”

B. Policy – Conditional enrollment process

A person not yet determined by the State to be a QMB can use the conditional enrollment process to enroll in Premium-Part A “conditionally.”

The conditional enrollment process allows a person to apply for Premium-Part A but only get the coverage if the State approves the QMB application, whereby the State will pay the Part A premiums. If the State denies the QMB application, the person will not be enrolled in Premium-Part A.

As part of the conditional enrollment process, persons must also apply for Part B if they are not already enrolled in it. However, Part B enrollments are not conditional. Part B coverage starts regardless of whether the State approves the individual’s QMB application.

The conditional enrollment process is necessary because a person must have Part A in order to qualify for the QMB Program, however, most low-income people who are not eligible for Premium-Free Part A cannot afford to pay the Part A premium before obtaining QMB benefits. The conditional enrollment process addresses this problem by allowing the individual to enroll in Premium-Part A on the condition that the State approves the person’s QMB application.

In Part A Buy-in States, the conditional enrollment can occur at any time, but in Group Payer States, the conditional enrollment can only occur during a prescribed enrollment period, as outlined in HI 00801.133.

NOTES:

• Beneficiaries are allowed to complete the conditional application process if they owe Medicare premiums.

• A conditional enrollment in Premium-Part A will not generate a bill. If the State does not approve the QMB application, the beneficiary will not get Part A coverage. However, the beneficiary is responsible for paying his or her monthly Part B premiums. Part B will terminate for non-payment of premiums, as outlined in HI 00820.035.

• A person who intends to enroll in Premium-Part A regardless of the State’s QMB determination will file an application following policies and processes in HI 00801.131 through HI 00801.138.

C. Policy — Part A Buy-in States

States that include Premium-Part A in their State Buy-in agreements are known as “Part A Buy-in States.” In Part A Buy-in States, individuals can complete the conditional enrollment process at any time (without regard to enrollment periods). Late enrollment penalties do not apply.

Below is a list of the Part A Buy-in States and the effective date of the State Buy-in agreement modification, if later than 1/90:

Example of person requesting Premium-Part A and Part B enrollment outside an enrollment period: Ms. Green resides in Ohio (a Part A Buy-in State) and does not have Medicare. She contacts her local Field Office (FO) in April 2017 because she wishes to apply for the QMB Program. Ms. Green is not eligible for Premium-Free Part A, but she qualifies for Premium-Part A. Ms. Green may file an application for Part B and “conditional enrollment” in Premium-Part A. Because Ms. Green resides in a Part A Buy-in State, the conditional enrollment can be filed at any time. The FO takes the application and processes it according to instructions in HI 00801.140E.4 of this section.

Example of person requesting Premium-Part A and Part B enrollment during an enrollment period: Ms. Adler resides in Pennsylvania (a Part A Buy-In State) and does not have Medicare. She contacts her local FO in January 2018 because she wants Medicare coverage but can’t afford the premiums. Ms. Adler may file an application for “conditional enrollment” in Premium-Part A. Because Ms. Adler resides in a Part A Buy-in State, the Part B and conditional Part A enrollment can be filed at any time. The application is not processed as a General Enrollment Period (GEP) application. The FO takes the application and processes it according to instructions in HI 00801.140E.4 of this section.

Example of beneficiary with Part B enrollment and not eligible for Premium-Free Part A requesting enrollment: Mr. Nelson resides in Maryland (a Part A Buy-in State) and has Medicare Part B only. He is not eligible for Premium-Free Part A. He contacts his local FO in September 2017 because he needs help paying his premiums. Mr. Nelson does not need to file an application for Premium-Part A because he resides in a Part A Buy-in State. The FO refers Mr. Nelson to his State to file for the QMB Program, according to instructions in HI 00801.140E.3 of this section. (Note: If Maryland approves Mr. Nelson’s application for the QMB Program, the State will enroll him in State Buy-in because he already has Part B. He will automatically get Premium-Part A, and the State will pay all his premiums.)

D. Policy — Part A Group Payer States

States that did not include Premium-Part A for QMBs in their State Buy-in agreements are known as “Group Payer States.” In Group Payer States, individuals must complete the conditional enrollment process during a prescribed enrollment period. In Group Payer States, the Part A premiums and any applicable late enrollment penalties are paid under a group payer arrangement with the Centers for Medicare & Medicaid Services (CMS). The following chart lists Group Payer States:

Example of person requesting Premium-Part A conditional enrollment during an enrollment period: Ms. Brown resides in Alabama (a Group Payer State) and does not have Medicare. She contacts her local FO in March 2018, because she wants Medicare coverage but can’t afford the premiums. Ms. Brown is not eligible for Premium-Free Part A, but she qualifies for Premium-Part A. Ms. Brown may file an application for Part B and “conditional enrollment” in Premium-Part A. Since Ms. Brown resides in a Group Payer State, the application for both Part B and conditional Part A must be filed during a prescribed enrollment period. Because Ms. Brown filed her application during the GEP, the FO takes the application and processes it according to instructions in HI 00801.140E.2 of this section.

Example of person requesting Part A conditional enrollment outside an enrollment period: Ms. Bright resides in South Carolina (a Group Payer State) and does not have Medicare. She contacts her local FO in April 2018 because she wants to enroll in Part A, but cannot afford the premiums. Ms. Bright is not eligible for Premium-Free Part A, but she qualifies for Premium-Part A. Ms. Bright may not file an application for “conditional enrollment” in Part A because she is applying outside a prescribed enrollment period. The FO advises Ms. Bright that she may apply for “conditional enrollment” in Part A during the next GEP.

E. Procedures for processing Part A coverage

Use the following procedures to process a request for Part A coverage based on the State in which the beneficiary resides and any other Part A or Part B entitlement information. Determine whether the beneficiary resides in a Part A Buy-In State or a Group Payer State, as outlined in HI 00801.140B and HI 00801.140C of this section, before processing the request.

1. All States – Individual has Part A

If an individual has Premium-Free Part A or Premium-Part A and appears to meet QMB income and resource requirements, briefly explain the QMB provisions and refer him or her to the State for further information.

However, if the individual is eligible for Part B State Buy-In as a cash-assistance recipient, “deemed” cash-assistance recipient, or enrollment in a Medicaid eligibility group separate from the QMB program, establish Part B Buy-in coverage, as appropriate. For more information on Part B State Buy-In procedures, see HI 00815.001.

NOTE: States use Beneficiary and Earnings Data Exchange (BENDEX) and State Data Exchange (SDX) to verify Part A entitlement and establish QMB eligibility.

2. Group Payer State - Individual not eligible for Premium-Free Part A (Individual may or may not have Part B)

If individual is not eligible for Premium-Free Part A, appears to meet QMB income and resource requirements, and resides in a Group Payer State, explain the QMB program and the conditional enrollment process for Premium-Part A. Inform the individual that he or she must apply for Part A during a prescribed enrollment period.

a. Individual not in a prescribed enrollment period

If the individual is not in a prescribed enrollment period, as outlined in HI 00801.133, do not take an application for conditional Part A enrollment. Inform the individual of their next available enrollment period to submit their application.

b. Individual in a prescribed enrollment period

If the individual is in a prescribed enrollment period and wishes to apply for Premium Part A through the conditional enrollment process:

• Take an application for Premium-Part A (and Part B, if not already enrolled).

• Include the following statement(s) in the “Remarks” section of the application:
  “I wish to enroll in Part A (hospital insurance). I understand that:

• I’m not eligible for Premium-Free Part A. By enrolling, I’m buying Part A coverage.

• I must also have Part B (medical insurance).

• I must pay monthly premiums for Part A and Part B coverage.

• I only want Part A coverage if my State approves my application for the Qualified Medicare Beneficiary (QMB) program. I do not want Part A coverage to begin before my State starts paying my monthly premiums. I understand that if I lose my QMB status, I must pay the monthly premiums to keep my Part A coverage.”

• Refer the individual to the appropriate State office to apply for the QMB program. Emphasize the importance of promptly contacting the State.

NOTE: The State will query the State Verification & Exchange System (SVES) to verify the conditional enrollment. If the State approves the QMB application, it will add the individual to its Part A Group Payer account. This action will establish the Part A effective date on SSA and CMS records.

For MCS processing of QMB Group Payer States, see SM 03040.025D.1. For POS processing of QMB Group Payer States, see SM 03040.025D.2. Once the State adds the individual to the Group Payer account, the MBR will then show a “HI CONTS PRD-MM/YYYY” (with whatever date the State decides to Buy-in). (Example: HI CONTS PRD-07/2017) The code “Z99” will be changed to the State’s code and “HI 3PTY Penalty-00%” will be changed to equal the current HI PREM Penalty amount (Example: 10%). The MBR will automatically remove the penalty once the once the START date in the HI PREM field reflects 00%. For information on the Part A late enrollment penalty removal, see HI 01005.010A.3.

3. Part A Buy-in State - Individual has Part B and is not eligible for Premium-Free Part A

If the individual appears to meet the QMB income and resource requirements, is enrolled in Part B (either individually or as a member of a State Buy-in coverage group) and resides in a Part A Buy-in State:

• Do not take the application for Premium-Part A; and

• Refer the individual to the State to apply for the QMB program. Emphasize the importance of promptly contacting the State.

NOTE: The State will use BENDEX and SDX to verify the Part B enrollment. If the State approves the QMB application, it will automatically enroll the individual in Part A through its State Buy-in agreement. Part A Buy-in States can enroll QMBs in Part A Buy-in at any time.

4. Part A Buy-in State - Individual does NOT have Part B and is not eligible for Premium-Free Part A

If an individual does not have Part B, is not eligible for Premium-Free Part A, appears to meet QMB income and resource requirements, and resides in a Part A Buy-in State, explain the QMB program and the “conditional enrollment” process for Premium-Part A. Individuals residing in a Part A Buy-in State can file a conditional Part A enrollment at any time.

a. FO Processing Instructions:

If the individual wishes to apply for Premium-Part A through the conditional enrollment process:

• Take an initial claim for Part B and conditional Part A through MCS (select claim type 5=UNINS MED ONLY on APPL screen).

• Develop proofs of age, citizenship or LAPR and residency.

• Review the earnings record for accuracy. A reduced premium for Part A may apply if the individual or spouse has 30-39 quarters of coverage. For additional information on the Part A premium reduction, see HI 01005.007.

• Prepare an A101. If problems occur with the A101 and the technician cannot process the application through MCS, then prepare EF101. Instructions for screen completion for the A101 are in MCS 014.000 and EF101 are in T2PE 009.000. Include the following entries:

  Part A entitlement of the HI Data screen (HIDA or EFHIDA):

  • START equal to the current operating month (COM)

  • BASIS of ‘A’

  • Type of ‘P’

  • PERIOD OF ‘Q’

  • FILING date

  HI THIRD PARTY DATA (HI 3 PTY code-HITP OR EFHITP)

  • STATE equal to PREMIUM HI START

  • CODE of ‘Z99’ for conditional applications only (means the individual is not entitled to Premium-HI); tell the individual to contact the State for QMB determination)

  • CATEGORY of ‘Q’

  HI Premium/Reduction (HIPR or EFHIPR)

  • START equal to PREMIUM HI START

  • HI PENALTY PERCENTAGE OF 00

  • Complete the following fields if applicable:

  • HAS 30 QTR

  • STOP

  • 30 QTR SSN

  Part B entitlement on the SMI Data screen (SMID or EFSMID)

  • START equal to COM

  • BASIS of ‘A’

  • PERIOD OF ‘Q’

  • FILING date

  • MED-RET-US, if applicable

  SMI THIRD PARTY DATA (SMTP or EFSMTP);

  Do not code THIRD PARTY DATA for Part B. See NOTE below.

  SMI PREMIUM HISTORY/VARIABLE SMI (SMPR or EFSMR)

  • START equal to SMI START

  • PENALTY PERCENTAGE OF 000

• Refer the individual to the appropriate State office to apply for the QMB program. Emphasize the importance of promptly contacting the State to apply. Explain to the individual that he or she may receive a bill and he or she must pay Part B premiums until QMB begins.

• If applicable, add discussion comments in the “Remarks” section of the application and provide a screen shot to the individual, so he or she has a receipt of conditional Part A enrollment.
  NOTE: The individual can take the screen shot to the State as proof that he or she enrolled in conditional Part A when applying for the QMB program. This will assist the State in properly identifying the nature of the QMB application and assist the State on how to properly process the case.

b. Program Service Center (PSC) Processing Instructions

For MCS processing procedures for QMB Part A Buy-in states, see SM 03040.025C.1. For POS processing procedures for QMB Part A Buy-in states, see SM 03040.025C.2

Complete the following steps:

• Propagate A101/EF101 into MACADE.

• Refer to SM 00850.700 for MACADE screen coding and action.

NOTE: After processing the A101, the MBR will show the HI AGE line, SMI AGE line and HI3PTY line with the State Buy-in code, and SMI3PTY line with the State Buy-in code. Refer to the listing of Part A Buy-in States in HI 00801.140B of this section.

5. All States – Individual wants to enroll in Premium-Part A regardless of QMB eligibility

If an individual is not eligible for Premium-Free Part A and appears to meet QMB income and resource requirements, explain the QMB program and the “conditional enrollment” process for Premium-Part A. If the individual wishes to apply for Premium-Part A, regardless of whether the State approves his or her QMB application, follow existing policies and processes outlined in HI 00801.131 through HI 00801.138.

F. References

HI 00801.126 HI for the Uninsured

HI 00801.131 Eligibility for Premium HI

HI 00801.133 Enrollment and Coverage Period

HI 00801.134 HI Premium Reduction for Aged Individuals With At Least 30 Quarters of Coverage

HI 00801.138 Application for Premium HI

HI 00801.139 Qualified Medicare Beneficiary (QMB) Provisions

HI 00815.001 State Buy-In Program General Description

HI 00815.024 SSA’s Role in Medicare Savings Programs (MSP) Applications

HI 00820.035 Termination of SMI Entitlement

HI 01005.007 Reduced Hospital Insurance (HI) Premium

HI 01005.010 Premium Increase for Delay in Enrollment

SM 00850.700 Conditional Enrollments for Premium HI-Qualified Medicare Beneficiaries (QMB)

SM 03040.000 System Processing Instructions

SM 03040.025 Uninsured Medicare and Qualified Medicare Beneficiary (QMB)

SM 03040.230 Qualified Medicare Beneficiary (QMB) Premium HI Third Party