HI 00815: State Enrollment of Eligible Individuals
A. Premium Collection for Individual Is Continuing or Claims for Part B Reimbursement Are Denied
| SSI Query Shows: | MBR Query Shows: | Action: | |
|---|---|---|---|
| 1. | Current Pay (PSY:C0l) HI Number present in the unearned income history (UMIH) field (Type A) Income. | SISC in SID line reflects non-pay status (SISC is not E, S, or C) | Force a SSR finder to update the MBR by requesting a type M offline query. See SM 02001.040 and SM 01301.325. Be sure that identifying data on the MBR and SSR are consistent; otherwise, the SSR/MBR interface cannot occur. Verify that the requested action was accomplished by obtaining a second MBR 14 days after inputting the Type M off- line query. If the forced finder corrects the MBR’s SID line, the following occurs: 1) the Third Party System (TPS) is updated on the 25th of the month; 2) the TPS updates the Third Party line of the MBR by the 13th of the following month; 3) the erroneous premium deduction is stopped in next month’s check. Erroneous deductions should be refunded 14 days after the Third Party line is corrected, e.g., SISC code corrected March 2; TPS updated March 25; Third Party line of MBR corrected April 12, premium refund made about April 26; benefit check May 3 no longer has premium deduction. If the finder does not correct the SID line, or if it does but does not result in the Third Party line correction as described above, send a CMS-1957 to CMS Central Office at the address shown in HI 00815.088C.3. Attach a print- out of the full SSI record and all MBR replies. Add remark to the CMS-1957, “SID field correction attempted via force finder on (show date) at the top of the form”. |
| 2. | Current Pay (Psy: CO1) SSID does not contain X-reference to HI number (“Type A” income in the unearned income history (UMIH of the SSI query). | No SID Line | Be sure that the identifying data on the MBR and SSR are consistent; otherwise, the SSR/MBR interface cannot occur. Transmit SSA-1719B/C entering HI alpha numeric number in the unearned income field. See SM 01305.225E. This will force a finder record to correct the MBR and HI records. When an individual is receiving SSI on one SSN and has an established HI record as a primary beneficiary on another SSN, do not use the SSA-1719B/C procedure. The SSR must be reestablished on the proper SSN. Use PR1 procedures (SM 01015.020) or if not possible, T30/start date procedures (SM 01801.001 ff.) |
| 3. | Current Pay (PSY:CO1) | SISC in SID line is E, S, or C. Third Party line does not show current Buy-in status | Send CMS-1957 to CMS Central Office at the address shown in HI 00815.088C.3 recent SSR update of MBR is shown in the MBR’s Transaction History field, i.e., BACOM SSI update. In this case allow for TPS interface to update MBR’s Third Party line by the 13th of the month following the month BACOM SSI update is made. |
| 4. | Current Pay(PSY: C01) | SISC in SID line is E, S, or C. Third Party billing codeand third- party entitlement date in third-party line are correct and there is no Part B third-party termination date (TTDS) present | If the individual complains that premium billing notices are still being sent, request a BCM. If the BCM has the individual in billing status, send an SSA-5002 HB to the appropriate PSC. Annotate the remarks field - “SSR/MBR correct, beneficiary being billed for SMI premiums - State Buy-in case, please correct the BCM in accordance with SM 00711.310 ”. Attach copies of SSR, MBR and BCM to the 5002 form. |
| 5. | Current Pay (PSY: C01) | SISC in SID line is E, S, or C. Third Party billing | Send CMS-1957 to CMS Central Office at the address shown in HI 00815.088C.3. code in the Third Party line is correct. Third Party entitlement date (TEDS) is in- correct |
| 6. | Current Pay (PSY: C01) | SISC in SID line is E, S, or C. Third Party line shows current Buy-in status. State Buy-in indicator in the HI portion is not a 1. | Send CMS-1957 to CMS Central Office at the address shown in HI 00815.088C.3. Annotate the remarks space “SSR/MBR correct, Buy-in indicator not in Enrollment Database (EDB)- process “U” RIC"". |
| 7. | Not in Current Pay (PSY: Other than C01) | SISC in SID line is other than E, S, or C. No current Buy-in in the Third Party line | Contact local welfare office to determine whether individual should be on Buy-in, based on eligibility for some non-SSI assistance (e.g., AFDC, MAO) Send CMS-1957 to local welfare office if appropriate. (See Chart in HI 00815.009 for State Coverage Groups). |
B. SSA Has Failed to Initiate Premium Collection From the Individual Following a Buy-In Deletion
| SSI Query Shows: | MBR Query Shows: | Action: | |
|---|---|---|---|
| 1. | Not in Current Pay (PSY: Not C01) | SISC of E,S, or C in SID line Third Party line shows no Part B Third Party termination date (TTDS) present | See Action explanation in “Current Pay” (A.1. above) to force a finder to the MBR and SSR and verify that identify data are consistent; otherwise the necessary interface cannot occur. Verify that requested action is accomplished by getting another MBR printout 14 days after the type M offline query. If the SID line is not corrected send a CMS Central Office at the address shown in HI 00815.088C.3. Attach the query responses. Add the remark to the CMS-1957, “SID field correction attempted via force finder on (date).” |
| 2. | Not in current Pay (PSY: Not C01) | SISC other than E, S, or C in SID line Buy-in currently shown in Third Party line. | Send CMS-1957 to CMS Central Office at the address shown in HI 00815.088C.3. See Action explanation A.1 above regarding time frame for correcting Third Party line after line SSI update of MBR. |
| 3 | No in Current Pay (PSY: Not C01) | SISC other than E. S or C in SID line. Buy-in not currently shown in the Third Party line. | Advise individual that the problem has been resolved, according to current computer printouts. |
C. Problem Involves a Prior Period
If a beneficiary alleges:
Beneficiary State Buy-in accretion date should be earlier, or
The beneficiary should have had a period of State Buy-in coverage in the past (e.g., “I should have been on Buy-in for March through September of last year.” ), forward a CMS-1957 to CMS Central Office in accordance with the procedures in HI 00815.088.