42 C.F.R. Subpart C—State Buy-In Agreements
Title 42 - Public Health
(a) Statutory basis. (1) Section 1843 of the Act, as amended through 1969, permitted a State to enter into an agreement with the Secretary to enroll in the SMI program certain individuals who are eligible for SMI and who are members of the buy-in group specified in the agreement. A buy-in group could include certain individuals receiving Federally-aided State cash assistance (with the option of excluding individuals also entitled to social security benefits or railroad retirement benefits) or could include all individuals eligible for Medicaid. Before 1981, December 31, 1969 was the last day on which a State could request a buy-in agreement or a modification to include a coverage group broader than the one originally selected. (2) Section 945(e) of the Omnibus Reconciliation Act of 1980 (Pub. L. 96–499) further amended section 1843 to provide that, during calendar year 1981, a State could request a buy-in agreement if it did not already have one, or request a broader coverage group for an existing agreement. (3) Several laws enacted during 1980–1987 had the effect of requiring that the buy-in groups available under section 1843 of the Act be expanded to include certain individuals who lose eligibility for cash assistance payments but are treated as if they were cash assistance recipients for Medicaid eligibility purposes. (4) Section 301(e)(1) of the Medicare Catastrophic Coverage Act of 1988 (Pub. L. 100–360) amends section 1843 of the Act to restore the 1981 provisions on a permanent basis, effective “after 1988.” (5) The same section 301, as amended by section 608(d)(14)(H) of the Family Support Act of 1988 (Pub. L. 100–485), further amended section 1843 of the Act, beginning January 1, 1989, to establish a new buy-in category consisting of Qualified Medicare Beneficiaries and to provide that a State may request a buy-in agreement if it does not already have one, or request a broader buy-in group for the existing agreement. (b) Definitions. As used in this section, unless the context indicates otherwise— Cash assistance means any of the following kinds of monthly cash benefits, authorized by specified titles of the Act and, for convenience, represented by initials, as follows: AABD stands for aid to the aged, blind or disabled under the first title XVI of the Act in effect until December 31, 1973. AB stands for aid to the blind under title X of the Act. AFDC stands for aid to families with dependent children under Part A of title IV of the Act. APTD stands for aid to the permanently and totally disabled under title XIV of the Act. OAA stands for old-age assistance under title I of the Act. SSI stands for supplemental security income for the aged, blind, and disabled under the second title XVI of the Act, effective January 1, 1974. SSP stands for State supplementary payments, whether mandatory or optional, to an aged, blind, or disabled individual under the second title XVI or the Act. Qualified Medicare Beneficiary or QMB means an individual who meets the definition in §400.200 of this chapter and, therefore, is eligible to have the State Medicaid agency pay Medicare cost sharing amounts on his or her behalf. Railroad retirement beneficiary means an individual entitled to receive an annuity under the Railroad Retirement Act of 1974. State means one of the 50 States, the District of Columbia, Guam, Puerto Rico, the Virgin Islands, American Samoa, or the Northern Mariana Islands, except when reference is made to “the 50 States”. State buy-in agreement or buy-in agreement means an agreement authorized by section 1843 of the Act, under which a State secures SMI or premium HI coverage for individuals who are members of the buy-in group specified in the agreement, by enrolling them and paying the premiums on their behalf. (c) Basic rules. (1) A State that has a buy-in agreement in effect must enroll any individual who is eligible to enroll in SMI under §407.10. (2) Any State that does not have a buy-in agreement in effect may request buy-in for any one of the groups specified in §§407.42 and 407.43. (3) Any State that does have an agreement may request a modification to cover a broader buy-in group or cancel its current agreement and request a new agreement to cover a narrower group. [56 FR 38080, Aug. 12, 1991; 56 FR 50058, Oct. 3, 1991] (a) Categories included in the buy-in groups. The buy-in groups that are available to the 50 States, the District of Columbia, and the Northern Mariana Islands are specified in paragraph (b) of this section in terms of the following categories: (1) Category A: Individuals who— (i) Receive SSI or SSP or both; and (ii) Are covered under the State's Medicaid plan as categorically needy. (2) Category B: Individuals who— (i) Under the Act or any other provision of Federal law are treated, for Medicaid eligibility purposes, as though they were receiving SSI or SSP; and (ii) Are covered under the State's Medicaid plan as categorically needy. (3) Category C: Individuals who are receiving AFDC. (4) Category D: Individuals who, under the Act or any other provision of Federal law, are treated, for Medicaid eligibility purposes, as though they were receiving AFDC. (5) Category E: Individuals who, in accordance with §435.114 or §435.134 of this chapter, are covered under the State's Medicaid plan despite the increase in social security benefits provided by Public Law 92–336. (6) Category F: Individuals who are Qualified Medicare Beneficiaries.1 1 Rules for buy-in for premium hospital insurance for QMBs are set forth in §406.26 of this chapter. (7) Category G: All other individuals who are eligible for Medicaid. (b) Buy-in groups available. Any of the 50 States, the District of Columbia, and the Northern Mariana Islands may buy-in for one of the following groups: (1) Group 1: Categories A through G. (2) Group 2: Categories A through F. (3) Group 3: Categories A through E. (4) Group 4: Categories A, B, and F, individuals in categories C and D who are not social security or railroad retirement beneficiaries, and individuals in category E who are included in that category (in accordance with §435.134 of this chapter) because they received OAA, AB, APTD, or AABD in August 1972 or would have been eligible to receive such cash assistance for that month if they had applied or had not been institutionalized. (5) Group 5: Categories A and B, individuals in categories C and D who are not social security or railroad retirement beneficiaries, and individuals in category E who are included in that category (in accordance with §435.134 of this chapter) because they received OAA, AB, APTD, or AABD in August 1972 or would have been eligible to receive such cash assistance for that month if they had applied or had not been institutionalized. (6) Group 6: Categories A, B, and F, and individuals in category E who are included in that category (in accordance with §435.134 of this chapter) because they received AABD in August 1972 or would have been eligible to receive AABD for that month if they had applied or had not been institutionalized. This option is available only to those States that had an AABD program as of December 31, 1973. (7) Group 7: Categories A and B, and individuals in category E who are included in that category (in accordance with §435.134 of this chapter) because they received AABD in August 1972 or would have been eligible to receive AABD for that month if they had applied or had not been institutionalized. This option is available only to those States that had an AABD program as of December 31, 1973. [56 FR 38081, Aug. 12, 1991] (a) Categories included in buy-in groups. The buy-in groups that are available to Puerto Rico, Guam, the Virgin Islands, and American Samoa, which are not covered by the SSI program, are described in paragraph (b) of this section in terms of the following categories: (1) Category A: Individuals receiving OAA, AB, APTD, or AFDC. (2) Category B: Individuals who, under the Act or any other provision of Federal law, are treated, for Medicaid eligibility purposes, as though they were receiving AFDC. (3) Category C: Individuals who, in accordance with §436.112 of this chapter, are covered under the State's Medicaid plan despite the increase in social security benefits provided by Public Law 92–336. (4) Category D: Individuals who are Qualified Medicare Beneficiaries.1 1 Rules for buy-in for premium hospital insurance for QMBs are set forth in §406.26 of this chapter. (5) Category E: All other individuals who are eligible for Medicaid. (b) Buy-in groups available. Puerto Rico, Guam, the Virgin Islands, and American Samoa may choose any of the following coverage groups: (1) Group 1: Categories A through E. (2) Group 2: Categories A through D. (3) Group 3: Categories A through C. (4) Group 4: Individuals in category D, and individuals in categories A and B who are not social security or railroad retirement beneficiaries. (5) Group 5: Individuals in categories A and B who are not social security or railroad retirement beneficiaries. (6) Group 6: Individuals in category D, individuals in category A who are receiving OAA, and individuals in category C who are included in that category (in accordance with §436.112 of this chapter) because they received OAA for August 1972 or would have been eligible to receive OAA for that month if they had applied or had not been institutionalized. (7) Group 7: Individuals in category A who are receiving OAA, and individuals in category C who are included in that category (in accordance with §436.112 of this chapter) because they received OAA for August 1972 or would have been eligible to receive OAA for that month if they had applied or had not been institutionalized. (8) Group 8: Individuals in category D and individuals in category A who are receiving OAA and are not social security or railroad retirement beneficiaries. (9) Group 9: Individuals in category A who are receiving OAA and are not social security or railroad retirement beneficiaries. [56 FR 38082, Aug. 12, 1991] (a) Termination by the State—(1) Termination after advance notice. A State may terminate its buy-in agreement after giving CMS 3 months, advance notice. (2) Termination without advance notice. A State may terminate its buy-in agreement without advance notice if— (i) The State gives CMS written certification to the effect that it is no longer legally able to comply with one or more of the provisions of the agreement; and (ii) Submits a supporting opinion from the appropriate State legal officer, if CMS requests such an opinion. (b) Termination by CMS. If CMS, after giving the State notice and opportunity for hearing, finds that the State has failed to comply substantially with one or more of the provisions of the agreement, other than the requirement for timely payment of premiums, CMS will give the State written notice to the effect that the agreement will terminate on the date indicated in the notice unless, before that date, CMS finds that there is no longer that failure to comply. (Rules for collection of overdue premiums, including assessment of interest and offset against FFP due the State, are those set forth in the Notice published on September 30, 1985 at 50 FR 39784.) (a) General rule. The beginning of an individual's coverage period depends on two factors: (1) The individual's meeting the SMI eligibility requirements and the requirements for being a member of the buy-in group; and (2) The effective date of the buy-in agreement or agreement modification that covers the group to which the individual belongs, and which may not be earlier than the third month after the month in which the agreement or modification is executed. (b) Application of general rule: Medicaid eligibles who are, or are treated as, cash assistance recipients. For Medicaid eligibles who are, or are treated as, cash assistance recipients (that is, are members of categories A through E of §407.42(a) or categories A through C of §407.43(a)), coverage begins with the later of the following: (1) The first month in which the individual— (i) Meets the SMI eligibility requirements specified in §407.10; and (ii) Is a member of one of those categories. (2) The month in which the buy-in agreement is effective. (c) Application of general rule: Qualified Medicare Beneficiaries. For individuals who are QMBs (that is, are members of category F of §407.42 or category D of §407.43(a)), coverage begins with the later of the following: (1) The first month in which the individual meets the SMI eligibility requirements specified in §407.10, and has QMB status. (2) The month in which the buy-in agreement or agreement modification covering QMBs is effective. (d) Application of general rule: Other individuals eligible for Medicaid. For individuals who are members of category G of §407.42(a) or category E of §407.43(a), coverage begins with the later of the following: (1) The second month after the month in which the individual— (i) Meets the SMI eligibility requirements specified in §407.10; and (ii) Is determined to be eligible for Medicaid. (2) The month in which the buy-in agreement or agreement modification is effective. (e) Coverage based on erroneous report. If the State erroneously reports to SSA that an individual is a member of its coverage group, the rules of paragraphs (a) through (d) of this section apply, and coverage begins as though the individual were in fact a member of the group. Coverage will end only as provided in §407.48. [56 FR 38082, Aug. 12, 1991] An individual's coverage under a buy-in agreement terminates with the earliest of the following events: (a) Death. Coverage ends on the last day of the month in which the individual dies. (b) Loss of entitlement to hospital insurance benefits before age 65. If an individual loses entitlement to hospital insurance benefits before attaining age 65, coverage ends on the last day of the last month for which he or she is entitled to hospital insurance. (c) Loss of eligibility for the buy-in group. If an individual loses eligibility for inclusion in the buy-in group, buy-in coverage ends as follows: (1) On the last day of the last month for which he or she is eligible for inclusion in the group, if CMS determines ineligibility or receives a State ineligibility notice by the 25th day of the second month after the month in which the individual becomes ineligible for inclusion in the group. (2) On the last day of the second month before the month in which CMS receives a State ineligibility notice later than the time specified in paragraph (c)(1) of this section. A notice received by CMS after the 25th day of the month is considered to have been received in the following month. (d) Termination or modification of buy-in agreement. If the State's buy-in agreement is terminated, or modified to substitute a narrower buy-in group, coverage ends on the last day of the last month for which the agreement was in effect, or covered the broader buy-in group. [53 FR 47204, Nov. 22, 1988, as amended at 56 FR 38082, Aug. 12, 1991] (a) Deemed enrollment. When coverage under a buy-in agreement ends because the agreement terminates, or is modified to substitute a narrower buy-in group, or because the individual is no longer eligible for inclusion in the buy-in group, the individual— (1) Is considered to have enrolled during his or her initial enrollment period; and (2) Will be entitled to SMI on this basis and liable for SMI premiums beginning with the first month for which he or she is no longer covered under the buy-in agreement. (b) Voluntary termination. (1) An individual may voluntarily terminate entitlement acquired under paragraph (a) of this section by filing, with SSA or CMS, a request for disenrollment. (2) Voluntary disenrollment is effective as follows: (i) If the individual files a request within 30 days after the date of CMS's notice that buy-in coverage has ended, the individual's entitlement ends on the last day of the last month for which the State paid the premium. (ii) If the individual files the request more than 30 days but not more than 6 months after buy-in coverage ends, entitlement ends on the last day of the month in which the request is filed. (iii) If the individual files the request later than the 6th month after buy-in coverage ends, entitlement ends at the end of the month after the month in which request is filed.1 1 For requests filed before July 1987, entitlement ended on the last day of the calendar quarter after the quarter in which the disenrollment request was filed. [53 FR 47204, Nov. 22, 1988, as amended at 56 FR 38082, Aug. 12, 1991]
Title 42: Public Health
PART 407—SUPPLEMENTARY MEDICAL INSURANCE (SMI) ENROLLMENT AND ENTITLEMENT
Subpart C—State Buy-In Agreements
§ 407.40 Enrollment under a State buy-in agreement.
§ 407.42 Buy-in groups available to the 50 States, the District of Columbia, and the Northern Mariana Islands.
§ 407.43 Buy-in groups available to Puerto Rico, Guam, the Virgin Islands, and American Samoa.
§ 407.45 Termination of State buy-in agreements.
§ 407.47 Beginning of coverage under a State buy-in agreement.
§ 407.48 Termination of coverage under a State buy-in agreement.
§ 407.50 Continuation of coverage: Individual enrollment following end of coverage under a State buy-in agreement.
