An official State of Texas website.
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: