March 2009

BUY-IN PROCESS

MEDICAREMany people receiving Social Security

benefits are entitled to Medicare.

Medicare has four parts: Part A (Hospital) Part B (Medical) Part C (Medicare Advantage Plans) Part D (Prescription Drug Coverage)

Part A is often free, but Medicare recipients pay a premium for Part B, C, and D.

What Is Buy-In?Buy-In is when the State of Kansas pays the Medicare Part A and B premium for a Medicaid consumer.

Paying Medicare premiums is a huge cost savings for the state as Medicare is the number one Third Party Insurance.

Difference between Buy-In and Medicare Saving Programs (QMB/LMB)

Buy-In QMB LMB/ELMB

Part B Premium

Paid by State Paid by State & Federal

Paid by State & Federal

Medicare Part A & B (co-pays &

deductibles)

No benefit Covered No benefit

Medicare Part D

Subsidy

No benefit Covered Covered

Part A Buy-InIn those instances when a consumer

is charged a premium for Medicare Part A, the State of Kansas can pay (Buy-In) the Part A premium for some people who are eligible for QMB or QWD; however, we will not discuss that process in this slideshow.

This slide show will deal strictly with how the Buy-In process works as it relates to Medicare Part B.

Who Is Eligible for Buy-In?

Persons must be eligible for Medicare and be eligible for

one of the following programs for the State of Kansas to

“buy” their premium for them:SIQMBLMB/ELMBMS (Met Spenddown, HCBS, WH,

PACE, NF)MA CM (Medical Assistance Caretaker

Medical)

Effective Date of Buy-In

The first month the State of Kansas pays the premium is called the “first month of Buy-In” or “the effective date of Buy-In”.

The assistance program for which the consumer is eligible determines the “first month of Buy-In”.

When Does Buy-In Start?Program Buy-In Begins

SI 1st month of eligibility

QMB 1st month of eligibility

LMB 1st month of eligibility

MS + MSP program and consumer was on buy-in before

1st month of eligibility

MS + MSP program 1st month of QMB/LMB eligibility or 3rd full consecutive month of Medicaid eligibility, whichever is first

MS only and consumer was on buy-in before

1st month of eligibility

MS only 3rd full month of consecutive Medicaid eligibility

When does Buy-In start in this example?

SSI consumer applies forMedicaid 6/8. She requests

prior medical back to Aprilwhen her SSI began.

AnswerApril is the first eligible month of SI, soApril is the first month of Buy-In. It may

take 90 to 120 days to get it started, but

when it does, the consumer will bereimbursed for any Medicare premiums she

has paid since April.

What About MS?MS is different. If a consumer has MS, but

does not haveQMB or LMB, the effective date of Buy-In

depends onwhether this is the first time the

consumer is being“bought-in” or if the consumer was

“bought-in” previously.

If previously bought-in by Kansas, Buy-In will begin with the first full Medicaid month, not exceeding 6 months prior to the current month.

But if this is the first time a spenddown is met, Buy-in coverage will begin the third consecutive

month of full medical eligibility.

How many months of Medicare premiums do I allow on a spenddown case? It depends on the programs! Let’s take a look at some examples.

MS ExampleMrs. Kim applied on 5/10. She had

not been bought-in previously. She had excess income for LMB/ELMB. She decided to pursue a spenddown as she had a large due & owing bill. A base period of (5/1 to 10/31) is established and her due and owing bill is allowed when the case is processed on 5/28.

Answer to MS Example

If she met the spenddown on 5/28, May would be

the first full Medicaid eligibility month. July

would be the 3rd consecutive month of full medical

eligibility when Buy-in would occur.

MS Example #2

Same Consumer (Mrs. Kim) applied on 5/10, but instead of meeting her spenddown right away, the case was approved with an unmet spenddown. You allowed 2 months of Medicare premiums (May & June) against the spenddown, since she could not be bought-in for those 2 months regardless of when the spenddown is met.

AnswerShe meets the spenddown on 7/8. July is the 1st full Medicaid month. The first month of Buy-in will be September. At this point, you can allow July and August (as well as May & June’s) Medicare premiums against Mrs. Kim’s spenddown as well, since you know they won’t be “bought-in”.

What About Multiple Programs?

When a consumer is eligible for two different

programs, the one with the earlier effective date of

Buy-In determines the first month of Buy-In.

Multiple ProgramsMr. Paul applied on 5/2. The case was processed

on 5/28 and Mr. Paul was eligible for QMB effective 6/1. He also had a spenddown under the MS program for the base period of 5/1 -10/31 which was met on 5/28 with due & owing bills. May would be the first full Medicaid month. July (3rd consecutive month) would be the effective day of Buy-in for the MS program.

The effective date of Buy-In under QMB would be the first eligible QMB month of June. The effective date for the QMB program is earlier, so the first month of Buy-In would be June. Only one month of Medicare (May) premium could be allowed against the spenddown.

Practice ExampleWhen Does Buy-in Start?

Mrs. Lydia applied on 5/1. She has not been bought-in previously. She is eligible for LMB during the prior medical period as well as for the current time period. A spenddown is set up for the current base period of 5/1 -10/31. She met the spenddown on 9/22. May through August are unmet SD months. September & October are met SD months. A new spenddown will be established for November -April and November will be an unmet SD month.

AnswerMrs. Lydia is eligible for two different programs. The effective date of Buy-In for LMB would be 2/1. The effective date of Buy-In for MS could not yet be determined since coverage must be continuous and November is in the new unmet base period. The first month of Buy-In is the earlier of the two which is LMB, so Buy-In begins with the first month of LMB. No Medicare premiums could be used to meet the spenddown.

Another Practice Example

Miss Sophie applied on 6/9. She has too much income for LMB but could qualify for expanded LMB. She doesn’t need MS during the prior medical period, but does during the current period as she anticipates meeting a spenddown.

True or FalseShe can choose expanded LMB during the prior period and MS for the current period. Her Buy-In will start with the first month of expanded LMB (March) and will continue on (even though her spenddown is unmet) since she was bought-in previously.

TRUE At the time of application, Miss Sophie must choose

between expanded LMB and MS. She can not choose Expanded LMB for the prior medical period and MS for the current period.

If she chooses Expanded LMB, Buy-In will begin 3/1 (the first month of Expanded LMB). A special medical indicator of LL would need to be entered on the PICK screen in order for Buy-In to occur. The LL special medical indicator would stay there for as long as the client remained Expanded LMB eligible.

If the consumer chooses MS, Buy-In could not begin until the spenddown was met. It would start with the 2nd month following the month spenddown was met.

Computers Are Talking!!!

KAECSESasks EATSSfor a TPQYwhen an application isregistered.

EATSS (akaSWSS)responds andMEIN & MEREare populatedwith Medicareclaim numberand effectivedates ofMedicare.

After youauthorize thebenefit,KAECSES sendsMEIN informationto MMIS.

MMISidentifies whoneeds to beaccreted(added) toBuy-In andsends thenames toCMS.

CMS responds toour request. If theyapprove the request(1161 on MMIS),then they billKansas for thepremium and notifySSA to adjust theirrecords. If theydeny the request,central office isnotified and alertsand reports aregenerated.

Bendex information onEATSS (aka SWSS) isupdated and a Bendexreport should begenerated to KAECSES.

KHPA is Billed

Each month CMS sends a humongous bill (for Buy-In)to Kansas. We have to separate the bill by fundingstreams which is why it is so important to use the QO,LO, LL, LM & LS special medical indicators correctly. They allow us to claim either 100% federal match orpartial federal match for Buy-In payments where wemight not otherwise be able to.

So remember to use them appropriately!!

Automatic AccretionBuy-In accretion is determined by

eligibility and entitlement status of the MMIS Medicare Coverage Window at the time of the Buy-In run date. The Buy-In run is completed in 2 stages.

Transactions are created about the 8th or 9th when the CMS file is received. The actual file isn’t sent until after the 20th . Changes between the first run and the final file creation are accepted by the MMIS.

Accretion RequestA request is sent to CMS to Buy-In all

consumers not previously bought-in who show current eligibility at the time of the Buy-In run and who meet one of the following criteria:Are QMB or LMB eligible, or Are Medicaid eligible and have met Buy-In

criteria. MMIS will not send an accretion request if there

is not current eligibility on MMIS. It determines the Buy-In effective date based on the eligibility segments and the Medicare effective date.

Do’s and Don’tsWhen processing the application or

making changes, don’t:Enter a claim number on MEREChange a claim number on MEREEnter a Y on MEIN for Medicare Part A or B

fields without verifying the consumer receives the benefits.

If MERE is incorrect, do attempt to resolve the problem. If the problem can not be resolved, refer to the supervisor or the Buy-In Specialist.

MEIN Didn’t Update Problem #1 -SSNIf the KAECSES SSN is inaccurate, the MEIN

process will generally fail. A common sign of an incorrect SSN is the absence of a complete TPQY or Bendex record on EATSS when Social Security or Medicare coverage is known to exist. If the TPQY is incomplete, Check the case record. If the SSN on SSDO is

incorrect, correct SSDO and send another TPQY request. Do not update MEIN manually if the SSN on KAECSES is incorrect as sending a TPQY request on the corrected SSN will automatically update MEIN.

Occasionally consumers have multiple SSN’s. Use the number that contains complete Medicare information.

MEIN Didn’t UpdateProblem #2 - Medicare Through RRMedicare information through the

Railroad Retirement Board (RRB) isn’t on EATSS; therefore, MEIN must be completed manually on these consumers. An alert is generated.

Verify RRB claim number and start dates.

Contact the HELP Desk. They will have to manually update the MEIN screen with the information from the RR Board.

MEIN will update MMIS.

MEIN Didn’t UpdateProblem #3 -Dual Entitlements

TPQY information will not update MEIN for some clients with dual entitlements based on the Medicare status on EATTS.An alert is generated.Verify Medicare claim number and start

dates. Contact HELP Desk. They will manually

update the MEIN screen with the information. MEIN will update MMIS.

Accretion FailedProblem #4 - Medicare Claim Number

Accretion to Buy-In will fail if the Medicare Claim Number on KAECSES is not correct.If the Medicare Claim Number on MEIN is

incorrect, verify the correct number. EATSS auto populates with the TPQY.

Contact HELP DESK to manually update MEIN to reflect the correct claim number and reauthorize the benefit.

If MEIN does not update MERE, refer to your supervisor or Area Buy-In Specialist.

Accretion FailedProblem #5 - Previous Denials

Accretion to Buy-In will fail if MEIN information is not sent to MMIS. If information was not sent to MMIS, the information on the PF12 screen is blank, but MEIN is complete.

Accretion FailedProblem #5 - Previous Denials This problem has to do with KAECSES

programming. KAECSES is programmed to attempt to send MEIN information to MMIS for 150 days. If it can not be sent (i.e. the application is denied), then after 150 days, no further attempts are made to send the MEIN information. If the consumer subsequently reapplies, and is approved, the MEIN information is not sent to MMIS because KAECSES has already tried to send it (for the denied app) for the prerequisite 150 days.

Accretion FailedProblem #5 - Previous Denials

To resolve, contact HELP Desk. They will go into MEIN and remove the middle initial and Press *ENTER*. Then they will go back into MEIN and put the middle initial back in. Since the MEIN information has changed, KAECSES will now send the information.

What About People Who Have Refused Medicare?Great news!! We don’t have to do anything

special because the MEIN programming handles it for us. What happens is:-TPQY shows Medicare Part B refused but that the consumer has free Medicare Part A-MEIN is programmed to plug a Part B start date

on MEIN-The Buy-In accretion request is sent to CMS-CMS enrolls the person for Medicare and accretes

him or her to Buy-In at the same time.

Alerts & ReportsAlerts are generated when:

TPQY does not update the MEIN screenReports are available related to Buy-In. Four

of the most common are:-Buy-In Deletion (SARS SWYO1BC1-R01 (Part

B)-Buy-In Deletion (SARS SWYO1BC1-R02 (Part

A)-TPQY Report (SARS SWYO181F-R02)-Bendex Report (SARS SWYO181E-R02)

Buy-In Deletion ReportOnce a month after Buy-In run, a report is generated which lists scheduled Buy- In deletions for the next month.

*** items are informational only

Deletions due to deaths and closures are correct and need no action.

Deletions due to unauthorized benefits and/or suspended months (if not QMB) must be corrected to avoid deletion. The case must be authorized prior to the 2nd Buy-In run following closure (or suspension) to prevent deletion.

In ClosingIn closing, when Buy-In goes smoothly it

helps our consumers have more spendable income in their pocket as well as reducing state expenditures. Staff throughout the state have shown over and over that you

are dedicated to making that happen. Your efforts are appreciated. Thank

you!