Revision 13-4; Effective December 1, 2013

 

Medicare beneficiaries who have low incomes and limited resources may also receive help from the Medicaid program. For persons who are eligible for full Medicaid coverage, Medicare health coverage is supplemented by services that are available under the Medicaid program, according to eligibility category. For persons enrolled in both programs, any services that are covered by Medicare are paid for by the Medicare program before any payments are made by the Medicaid program, since Medicaid is always the "payer of last resort." Certain other Medicare beneficiaries may receive help with Medicare premium and cost-sharing payments through the Medicaid program.

 

A-9100 Medicare Benefits

Revision 11-4; Effective December 1, 2011

 

Medicare under Title XVIII provides health care benefits for most persons, beginning at age 65.

Medicare is a federal program administered by the Social Security Administration (SSA) and is divided into four parts:

  • Part A is hospital insurance with no premium for its coverage unless a person has not earned sufficient quarters of coverage under Social Security.
  • Part B is a supplementary insurance for physician fees and other services outside a hospital or skilled nursing facility setting for which the person must request coverage and pay a monthly premium.
  • Part C is the Medicare Advantage Plans that are offered by private companies approved by Medicare (see below for a more detailed description).
  • Part D provides prescription coverage.

In most cases, the Part B and Part D premium is deducted from the Social Security or Railroad Retirement check. The recipient is responsible for calendar-year deductibles and co-pay liabilities for both Parts A and B.

The Part C premium is handled by the private company that offers the benefit as a Medicare Advantage Plan. This plan provides the Medicare Part A (hospital insurance) and Part B (medical insurance) coverage. Most of the plans also include coverage for prescription drugs. In addition, some plans offer extra coverage such as vision, hearing, dental, and/or health and wellness programs. The Medicare Advantage Plan has its own benefits and coverage that differs from the traditional Medicare benefits. Medicare pays a fixed amount every month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare. However, each Medicare Advantage Plan can charge different out-of-pocket costs and have different rules for how one gets services.

SSA administers Medicare for people age 65 or older and for people who have been determined disabled by SSA. People who are younger than 65 get Medicare after getting Social Security disability benefits for at least two years.

There are exceptions to the two-year waiting period, including:

  • a chronic renal disease that requires a kidney transplant or maintenance dialysis (SSA determines if a person with a chronic renal disease diagnosis meets the requirements for the exception to the waiting period); or
  • Lou Gehrig's disease (amyotrophic lateral sclerosis).

Medicare is available to a person who has paid into the Medicare trust account through payroll taxes (sometimes called the Federal Income Contributions Act (FICA)). Most employers are required to withhold FICA taxes but there are some exceptions. Federal government employees have only been eligible to participate in Social Security since 1984. As a result, some older employees have opted to remain with the former Civil Service Retirement System. Some state and local government employee retirement plans also are not covered by Social Security.

If a person receives Medicare, the person is either:

  • 65 years old or older; or
  • determined disabled by SSA.

 

A-9200 Medicare Buy-In

Revision 11-4; Effective December 1, 2011

 

To ensure that Medicaid recipients who are entitled to Medicare receive maximum health care protection, the state pays for certain recipients' Medicare Part B premiums. This process is called buy-in. For those persons who have dual entitlement, Medicare becomes the payer of first resort, with Medicaid paying deductibles and co-insurance for Medicaid-covered services.

If recipients in ME-Nursing Facility, ME-State School, ME-Waivers and ME-Community Attendant are not eligible for QMB or SLMB, they are not eligible for buy-in.

 

A-9210 Eligibility Requirements for Medicare Buy-In

Revision 11-4; Effective December 1, 2011

 

Recipients are eligible for buy-in if they are:

  • 65 or older and U.S. citizens;
  • 65 or older and lawfully admitted aliens who have lived in the U.S. five consecutive years;
  • under 65 and have received or been eligible to receive Social Security or Railroad Retirement disability benefits for 24 consecutive months; or
  • under 65 and qualify for Medicare Part A because of chronic renal disease.

If recipients in ME-Nursing Facility, ME-State School, ME-Waivers and ME-Community Attendant are not eligible for QMB or SLMB, they are not eligible for buy-in.

 

A-9220 Time Frames for Medicare Buy-In Enrollment

Revision 13-4; Effective December 1, 2013

 

Persons who have Medicare Part B coverage at the time they are certified for Medicaid are enrolled as follows:

  • SSI and Temporary Assistance for Needy Families (TANF) recipients are enrolled for buy-in effective the first month they receive a cash payment.
  • ME-Pickle recipients who are RSDI pass-on recipients are enrolled in continuous buy-in.

    Example: The recipient was denied SSI on Dec. 31 due to a cost of living increase. The recipient applied for ME-Pickle in February and was certified eligible on March 5. Medical effective date is Jan. 1. Medicare Part B buy-in is effective Jan. 1. The recipient will be reimbursed by SSA for any premiums withheld from the recipient's RSDI check.
     
  • ME-Disabled Adult Child (DAC) recipients who are RSDI pass-on recipients are enrolled in continuous buy-in.

    Example: The recipient was denied SSI on Dec. 31 due to a cost of living increase. The recipient applied for ME-DAC in March and was certified eligible on April 10. Medical effective date is Jan. 1. Medicare Part B buy-in is effective Jan. 1. The recipient will be reimbursed by SSA for any premiums withheld from the recipient’s RSDI check.
     
  • ME-Nursing Facility, ME-State School, ME-Waivers, ME-Non-State Group Home and ME-State Group Home recipients who are QMB-eligible, whose certification was accomplished as a program transfer, and whose certification has no break in Medicaid coverage are eligible for continuous buy-in.

    Example: The MQMB recipient has SSI and RSDI income and enters a nursing facility in January. SSI is denied effective Feb. 28. The recipient qualifies for QMB and Medicaid. The medical effective date for MQMB is March 1. The recipient is entitled to continued Medicare buy-in and is reimbursed for any premium withheld from the RSDI check.
     
  • Recipients who are denied in error and are recertified have continuous enrollment for buy-in. This is true except for those recipients in ME-Nursing Facility who are not eligible for QMB benefits.

    Example: The MQMB recipient is enrolled in Medicaid, ME-Nursing Facility. During the first year's review process, the recipient was denied due to excess resources effective Jan. 31. During a subsequent application in March, the eligibility specialist discovers the recipient should not have been denied in January and grants a medical effective date of Feb. 1, reopening the case. The recipient is entitled to continued Medicare buy-in and is reimbursed for any premium withheld from the RSDI check.
     
  • ME-Nursing Facility recipients who are also QMB-eligible are enrolled for buy-in effective the month of their eligibility for QMB benefits.

    Example: The recipient is certified for ME-Nursing Facility and is also eligible for MQMB. Certification is Jan. 15, and the MQMB effective date is Feb. 1. Medicare buy-in is effective Feb. 1. The recipient will be reimbursed by SSA for any premiums withheld after the effective date of buy-in.
     
  • Recipients eligible for QMB who do not have Medicare Part B coverage at the time of Medicaid certification are enrolled in buy-in when they meet Medicare criteria. These recipients remain on the buy-in rolls while they are eligible for Medicare, Medicaid and QMB benefits.

When a recipient is enrolled in buy-in, SSA stops charging for Part B premiums. Usually this occurs the month after SSA has acknowledged receiving the recipient's name as an addition to the buy-in rolls. If premiums have been withheld from the monthly benefit, the recipient's check should reflect an upward adjustment by the third month after the month of certification.

Address questions about the buy-in status of a recipient who has been certified for at least three months to:

CCC_Data_Integrity_Program@hhsc.state.tx.us