100-24 State Payment of Medicare Premiums: Chapter 1 - Program Overview and Policy

Program Overview and Policy
Chapter 1
Table of Contents
(Rev. 7; Issued: 01-16-2025)
Transmittals for Chapter 1
1.0 Introduction
1.1 Definitions
1.2 Background
1.3 Medicare Eligibility and Enrollment
1.3.1 Premium-free Part A
1.3.2 Premium-Part A
1.3.3 Medicare Part B
1.3.4 The Part B Immunosuppressive Drug Benefit
1.3.5 Medicare Enrollment
1.3.5.1 – Medicare Enrollment Table
1.3.6 – Medicare Part A and B Re-enrollment
1.4 Requirements for Enrolling Individuals Under Buy-in Agreements
1.4.1 – General Requirements
1.4.2 – Medicare Enrollment Under a State Buy-Agreement
1.4.3 – Limitations on States Liability for Retroactive Part B Premiums
1.4.4 – Medicare Eligibility Redeterminations
1.5 Effect of Buy-in on an Individual
1.6.1 Cash 1.6 Buy-in Coverage Group One: Cash Assistance and Deemed Recipients of Cash
Assistance
Assistance and Deemed Recipients of Cash Assistance
1.6.1.1 – Supplemental Security Income (SSI) Program Recipients
1.6.1.2 – Full-benefit Medicaid Eligibility for SSI Recipients
1.6.1.3 – Part B Buy-in for SSI Recipients
1.6.1.4 – Qualified Medicare Beneficiary Group Eligibility for SSI
Recipients

1.6.1.5 – State Supplement Programs (SSPs) Recipients
1.6.1.6 – Deemed Recipients of Cash Assistance
1.6.2 Buy-in Coverage Group Two: Cash Assistance Recipients and Deemed
Recipients of Cash Assistance Plus Three Medicare Savings Program Groups
1.6.2.1 – Medicare Savings Program Eligibility and Enrollment
1.6.2.2 – Verification of Certain Income and Resources for the Medicare
Savings Programs
1.6.2.3 – Medicare Savings Programs Determinations Based on Part D
Low-Income Subsidy (LIS) Leads Data
1.6.2.4 – Qualified Medicare Beneficiary Group
1.6.2.5 – Effective Date of Qualified Medicare Beneficiary Group
Coverage
1.6.2.6 – Automatic Enrollment of SSI Recipients into the Qualified
Medicare Beneficiary Group
1.6.2.7– Specified Low-Income Medicare Beneficiary Group
1.6.2.8– Qualifying Individual Group
1.6.3 Buy-in Coverage Group Three: All Medicaid Eligibility Groups
1.7 – State Payment of Part A Premiums for Qualified Medicare
1.8 Conversion From Part A Group Payer to Part A Buy-in Status
1.9 Federal Financial Participation (FFP) for Medicare Costs
1.10 Streamlined Enrollment Under a Buy-in Agreement
1.11 – Qualified Medicare Beneficiary Group Enrollment for Individuals Who Need to
Pay a Premium to Enroll in Part A
1.12 Policy Regarding Which Entity Initiates Buy-in
1.12.1 Part B Buy-in for Cash-Related Recipients (SSI/SSPs)
1.13 Definition of Part B Buy-in Coverage Period
1.13.1 – Beginning of Part B Buy-in Coverage
1.13.2 – End of Part B Buy-in Coverage
1.14 Definition of Part A Buy-in Coverage Period
1.14.1 Beginning of Part A Buy-in Coverage
1.14.2 End of Part A Buy-in Coverage
1.15 Implications and Options for Beneficiaries When State Buy-in Coverage Ends

1.15.1 Voluntary Withdrawal (Termination) From Medicare
1.15.2 SSA Options for Financial Relief from Retroactive Premium Billing
Appendix 1.A Dual Eligibility Categories and Assistance with Medicare Part A and Part B Costs
Appendix 1.B Dual Eligibility Category Descriptions
Appendix 1.C Medicaid Effective Dates and Buy-in Start and Stop Dates
Appendix 1.D Policies Related to Buy-in in the 50 States, the District of Columbia, and
Specified U.S. Territories

1.0 Introduction
(Rev. 7; Issued:01-16-2025; Effective01-16-2025; Implementation: 01-16-2025)
Since the inception of the Medicare program in 1966, section 1843 of the Social Security Act
(“the Act”) has afforded states the option to enter into an agreement with the federal government
under which the state commits to enrolling certain individuals dually eligible for Medicare and
Medicaid (dually eligible individuals) in Medicare Part B with the state paying the Part B
premiums on their behalf. Under section 1818(g) of the Act, starting January 1, 1990, states
could amend these agreements to pay the Part A premiums for certain dually eligible individuals
who must pay a premium to enroll in Medicare Part A. Section 1903(a)(1) and (b) of the Act
authorizes Federal Financial Participation (FFP) for the payment of Part A and/or Part B
premiums and cost-sharing for certain dually eligible individuals.
The Centers for Medicare & Medicaid Services (CMS), through authority delegated by the
Department of Health and Human Services (HHS), administers this process of state payment of
Medicare premiums, historically referred to as “state buy-in.”
This chapter sets forth consolidated policy guidance regarding the state buy-in program for the
50 states and the District of Columbia. Forthcoming program instructions will apply to the U.S.
territories identified in 42 CFR 407.42 and 407.43.
NOTE: This manual contains links to the Social Security Administration (SSA) Program
Operations Manual System (POMS) as of January 1, 2024.1
1.1 Definitions
(Rev. 6; Issued:04-26-24; Effective:04-26-24; Implementation:04-26-24)
Buy-in Agreement means an agreement authorized or modified by sections 1843 or 1818(g) of
the Act, under which a state secures Part B or premium Part A coverage for “eligible
individuals” (see definition below) who are members of the buy-in group specified in the
agreement, by enrolling them and paying the premiums on their behalf. See 42 CFR 407.40(b).
Starting January 1, 2023, a state’s Medicaid state plan (“state plan”) pages, including any
modifications under a state’s Medicaid state plan amendments (SPAs), related to buy-in policy
constitute the “buy-in agreement” between the state and CMS for purposes of sections 1843 and
1 The Social Security Administration’s Program Operating Manual System (“SSA POMS”) is the main reference for
SSA employees to conduct daily business, including actions related to the state payment of Medicare premiums. As
a courtesy to states, CMS provides links to the SSA POMS as of the time the manual was published. Changes may
occur after release. To access the SSA POMS, go to https://secure.ssa.gov/apps10/poms.nsf/Home?readform.

1818(g) of the Act and supersedes the free-standing buy-in agreements that all states and U.S.
territories originally signed with CMS. See 42 CFR 407.40(b).2
Buy-in Group (also known as a “buy-in coverage group”) means a coverage group described in
section 1843 of the Act that is identified by the state and is composed of multiple Medicaid
eligibility groups specified in the buy-in agreement. 42 CFR 407.40(b).
Eligible Individual (for Part B) means an individual who is entitled to Medicare Part A or who
is age 65 or over, is a resident of the United States and is either a U.S. citizen, or an alien
lawfully admitted for permanent residence who has resided in the U.S. continuously during the
five years immediately preceding the month the individual applies for enrollment under Part B,
and has not been convicted of crimes specified in 42 CFR 407.10(b). See section 1836 of the
Act; 42 CFR 407.10.
Entitled to Medicare Part A refers to individuals who receive Part A, either without payment of
a premium (premium-free Part A) under 42 CFR 406.5(a) or by paying a premium (premium Part
A) under 42 CFR 406.5(b).
General Enrollment Period (GEP) for Part B means the annual period (January 1 through
March 31) for an individual to apply for Part B if the individual did not apply during their Initial
Enrollment Period (IEP). See 42 CFR 407.15.
General Enrollment Period (GEP) for Premium Part A means the annual period (January 1
through March 31) for an individual to apply for Premium Part A if the individual did not apply
during their IEP. See 42 CFR 406.21(c).
Group Payer Arrangement is a method which certain third parties (e.g., states) use to pay the
Parts A and/or Part B premiums for a class of beneficiaries. See 42 CFR 406.32(g) and 408.80;
SSA POMS HI 01001.230 at https://secure.ssa.gov/poms.nsf/lnx/0601001230.3 States that do not
include Part A in their buy-in agreements must pay the Part A premiums for Qualified Medicare
Beneficiaries (QMBs) using the group payer arrangement.
Initial Enrollment Period (IEP) means the seven-month period that begins three months before
the month an individual first becomes eligible to enroll in premium Part A or Part B and ends
three months after that first month of eligibility. See 42 CFR 406.21(b) and 407.14.
Member of a Buy-in Coverage Group means an individual who is a member of the buy-in
coverage group that the state has elected to include in its buy-in agreement. States may only
2 To execute agreements under section 1843 of the Act, the Secretary and states initially executed free-standing
written agreements that defined the then-scope of a state’s buy-in agreement and bound the state to follow federal
regulations and guidance under section 1843 of the Act.
3 States may not use the group payer arrangement to pay the Part B premiums on behalf of individuals whose
premiums are deducted from monthly Social Security benefits or whose premiums are paid under a state buy-in
agreement. See 42 CFR 408.82(b)(2).

cover under state buy-in an eligible individual who is a member of the buy-in group. See 42 CFR
406.20, 407.40, 407.42, and 407.43.
Premium Increase for Late Enrollment (also known as “Late Enrollment Penalty”) means the
additional amount that may be charged to an individual who enrolls in premium Part A or Part B
after expiration of the individual’s IEP or who reenrolls after previous coverage. For Part B, the
premium is increased ten percent for each cumulative period of 12 full months during which an
individual could have been, but was not enrolled in Part B. See 42 CFR 408.22. For premium
Part A, effective for premiums due for July 1986 and after, the premium increase is limited to ten
percent and is payable for twice the number of full 12-month periods determined under the
regulations. See 42 CFR 406.32(d).
Premium Part A means the hospital insurance benefits provided under Medicare Part A for
certain individuals who do not qualify for Part A without monthly premiums under 42 CFR
406.5(a) and can only enroll in Part A by paying a premium. See 42 CFR 406.5(b) and 406.20.
Special Enrollment Period (SEP) means a period outside of the IEP and GEP during which an
individual can enroll in premium Part A or Part B. There are several SEPs, including an SEP for
an individual who is or was covered by an employer group health plan under 42 CFR 406.24 and
407.20, an individual who volunteered outside of the U.S. under 42 CFR 406.25 and 407.21, and
certain individuals who were enrolled in TRICARE coverage under section 1837(l) of the Act.
Additionally, starting January 1, 2023, there are five SEPs for exceptional circumstances,
including: for individuals impacted by an emergency or disaster; for individuals affected by a
health plan or employer misrepresentation; for formerly incarcerated individuals; for individuals
who lose Medicaid coverage;4 or for other exceptional circumstances. See 42 CFR 406.27 and
407.23; SSA POMS HI 00805.382 at https://secure.ssa.gov/poms.nsf/lnx/0600805382.
4 The loss of Medicaid SEP starts the month the state notifies the individual they have lost all Medicaid coverage
and ends six months after the Medicaid termination. For more information about this SEP, see SSA POMS HI
00805.385 at https://secure.ssa.gov/poms.nsf/lnx/0600805385.

1.2 Background
(Rev. 6; Issued:04-26-24; Effective:04-26-24; Implementation:04-26-24)
Medicare provides health insurance coverage to individuals age 65 and older and certain persons
under age 65 with disabilities or End-Stage Renal Disease (ESRD). Medicare Part A provides
coverage generally of inpatient care, and most beneficiaries are entitled to these benefits without
paying an additional premium based on eligibility for Social Security or Railroad Retirement
Board (RRB) benefits. Some individuals are eligible to obtain entitlement to Part A benefits by
enrolling in premium Part A. Medicare Part B, which is optional and requires payment of a
premium, covers most other types of health coverage, including limited prescription drug
coverage. Medicare Part D, also optional, requires a premium, and covers outpatient prescription
drugs. Medicare Parts A, B, and D all require payment of cost-sharing (e.g., deductibles,
coinsurance, and copayments).
Under the state buy-in program, states, the District of Columbia, and U.S. territories can enter
into buy-in agreements that make it easier to enroll certain Medicaid beneficiaries into Medicare
Part B and pay the premiums on their behalf (“Part B buy-in”). See section 1843 of the Act; 42
CFR 407.40, et seq. All states, the District of Columbia, and three U.S. territories (the
Commonwealth of Northern Mariana Islands, Guam, and the U.S. Virgin Islands), have elected
to enter into a Part B buy-in agreement with CMS.
Since January 1, 1990, states have had the option to expand their buy-in agreements to enroll
QMBs in premium Part A and pay the premiums on their behalf (“Part A buy-in”). See sections
1.7 and 1.11 for more information about paying Part A premiums for QMBs.
For an individual who is determined eligible for but not yet enrolled in Medicare, state buy-in
serves to enroll the individual in Medicare Part A and/or B and directs the federal government to
bill the state for their premiums. For an individual who is already enrolled in Medicare, state
buy-in means the federal government will start billing the state for the individual’s Medicare
premiums and stop billing the individual for these costs through deductions from their monthly
Social Security benefits (Old Age, Survivors, and Disability Insurance (OASDI) program)5 or
through bills CMS directly mails certain beneficiaries.6
The impact of state buy-in is significant for many beneficiaries. Low-income individuals who
receive assistance with Medicare premiums save critical funds to use for other life necessities,
5 OASDI benefits include Old Age Insurance Benefit Payments (also known as Social Security retirement benefits)
and Social Security Disability Insurance (SSDI).
6 CMS sends the beneficiary a Medicare Premium Bill (CMS-500) (see https://www.cms.gov/Medicare/CMS-
Forms/CMS-Forms/Downloads/CMS500.pdf) for Medicare Parts A and/or B if the beneficiary’s premium liability
exceeds the amount of the beneficiary’s Social Security benefit or Office of Personnel Management (OPM) or
Railroad Retirement Board (RRB) annuity or the beneficiary is not receiving any of these benefits. Most
beneficiaries pay the standard Part B premium amount ($174.90 in 2024). States also pay the standard Part B
premium amount on behalf of individuals enrolled in buy-in. See SSA POMS HI 01001.004 at
https://secure.ssa.gov/apps10/poms.nsf/lnx/0601001004.

including food and housing. Upon state buy-in, individuals who were paying the Medicare
premiums through deductions from their Social Security or RRB benefits see a notable increase
in their monthly payments, and individuals eligible but not enrolled in Medicare are able to
enroll in the program and access Medicare services. Buy-in agreements also enable individuals to
enroll in Medicare at any time of the year, without regard for Medicare enrollment periods and
late enrollment penalties.
Buy-in agreements simplify the process for states to assist their low-income residents with
Medicare expenses. Maximizing the number of Medicaid beneficiaries who are also enrolled in
Medicare is advantageous to the individuals and can also result in cost savings for states.
Medicare pays primary to Medicaid for Medicare Part A (inpatient hospital and skilled nursing
facility services) and Medicare Part B (outpatient medical care). In addition, Medicaid
beneficiaries who are enrolled in both Medicare Parts A and B may join Medicare-Medicaid
integrated care plans, which can improve coordination of care for dually eligible beneficiaries.
The state’s regular Federal Medical Assistance Percentage (FMAP) rate applies to state
expenditures for Medicare Parts A and B premiums and cost-sharing for certain Medicaid
eligibility categories (see section 1.9).
1.3 Medicare Eligibility and Enrollment
(Rev. 6; Issued:04-26-24; Effective:04-26-24; Implementation:04-26-24)
CMS regulations require states to enroll members of a buy-in group in buy-in if they meet the
requirements for Medicare Parts A and/or B (an “eligible individual” as defined in section 1.1).
See 42 CFR 406.26(a) and 407.40(c).
This section summarizes Medicare eligibility requirements and enrollment processes to help
states understand which Medicaid beneficiaries may qualify for Medicare and become dually
eligible.
1.3.1 Premium-free Part A
(Rev. 6; Issued:04-26-24; Effective:04-26-24; Implementation:04-26-24)
Certain individuals qualify for premium-free Part A if they have enough Social Security work
credits to qualify for monthly OASDI benefits.7 Most Medicare beneficiaries get premium-free
Part A.
An individual age 65 or over meets the requirements for premium-free Part A if the individual:
• Already gets Old Age Insurance Benefit Payments (Social Security retirement benefits)
7 An individual accrues Social Security work credits when the individual pays Medicare payroll taxes while
working. See 20 CFR part 404, subpart B.

or an Age and Service Annuity from the RRB (RRB retirement benefits);
• Is eligible to get Social Security or RRB retirement benefits but has not filed for them
yet; or
• Is a government employee who paid the Medicare payroll tax while working for the
required amount of time.
An individual under age 65 meets the requirements for premium-free Part A if the individual has
received Social Security Disability Insurance (SSDI) or a disability annuity from RRB (RRB
disability benefits) for 24 months; or
An individual of any age who has ESRD meets the requirements for premium-free Part A if the
individual:
• Has the requisite work credits; or
• Is a spouse or dependent child8 of an individual who has the requisite work credits.
All individuals who qualify for Medicare on the basis of ESRD and individuals who qualify for
Medicare based on the receipt of SSDI receive premium-free Part A.
NOTE: An individual who has ALS (Amyotrophic Lateral Sclerosis, also called Lou Gehrig’s
disease) qualifies for premium-free Part A the month the individual’s SSDI benefits begin.
For more information about eligibility for premium-free Part A, see section 10 of the Medicare
General Information, Eligibility and Entitlement Manual at https://www.cms.gov/regulations-
and-guidance/guidance/manuals/downloads/ge101c02.pdf.
1.3.2 Premium Part A
(Rev. 7; Issued:01-16-2025; Effective01-16-2025; Implementation: 01-16-2025)
Individuals who lack the requisite Social Security work credits to qualify for OASDI can obtain
premium Part A. See 42 CFR 406.5(b). CMS directly bills such individuals for Part A premiums.
See 42 CFR 406.32(e).
Individuals age 65 or older qualify for premium Part A under section 1818 of the Act and 42
CFR 406.20(b) if they are U.S. residents:
• Receiving benefits under Part B or are in the process of enrolling in it;
8 For information about qualifying for ESRD Medicare as a dependent child, see SSA POMS HI 00801.201 at
https://secure.ssa.gov/poms.nsf/lnx/0600801201.

• 	Not otherwise entitled to Part A; and
• 	Either:
o 	U.S. citizens; or
o 	Lawful permanent residents who have resided in the U.S. continuously during the
five years immediately preceding the month they applied for enrollment in
Medicare.9
In addition, individuals with disabilities under age 65 who return to work may qualify for
premium Part A (premium Part A for the Working Disabled) if they meet all of the following
criteria:
• 	Were entitled to premium-free Part A on the basis of entitlement to SSDI;
• 	Have lost premium-free Part A (premium-free Part A continues 8 and 1/2 years after a
return to work, including a 9-month trial work period, as described in SSA POMS DI
55001.001B.2.b at https://secure.ssa.gov/poms.nsf/lnx/0455001001);
Are not otherwise entitled to Part A; and
• 	Continue to have a qualifying disability. (See section 1818A of the Act; 42 CFR
406.20(c).)
Individuals who enroll in premium Part A for the Working Disabled can also enroll in Part B,
but they are ineligible to enroll in Part B alone. See SSA POMS HI 00801.170 at
https://secure.ssa.gov/poms.nsf/lnx/0600801170.
NOTE: Individuals with disabilities who return to work may, if determined eligible and the
state provides the coverage at issue, qualify for full-benefit Medicaid, including mandatory
Medicaid coverage for working individuals under 1619(b) of the Act and optional Medicaid
buy-in groups for working individuals described in sections 1902(a)(10)(A)(ii)(XIII) (XV),
and (XVI) of the Act. Working individuals with disabilities who are otherwise ineligible for
Medicaid benefits may qualify for the Qualified Disabled and Working Individual (QDWI)
Medicare Savings Program group through which Medicaid covers their Part A premiums.10
9 The five years of continuous residence may begin prior to the date that the lawful admission for permanent resident
is granted. See SSA POMS HI 00805.005 at https://secure.ssa.gov/apps10/poms.nsf/lnx/0600805005 and SSA
POMS GN 00303.800 at https://secure.ssa.gov/apps10/poms.nsf/lnx/0200303800.
10 The QMB group is not available to individuals who enroll in premium Part A for working disabled individuals.
See section 1905(p)(1)(A) of the Act; 42 CFR 400.200 and 435.123. For more information about the QMB group,
see section 1.6.2.4.

For more information about the QDWI eligibility group, see section 1.6.2.
Individuals may qualify to pay a reduced monthly Part A premium under certain
circumstances.11 See 42 CFR 406.32(c).
For more information about eligibility for Premium Part A, section 10 of the Medicare General
Information, Eligibility and Entitlement Manual at https://www.cms.gov/regulations-and-
guidance/guidance/manuals/downloads/ge101c02.pdf.
1.3.3 Medicare Part B
(Rev. 7; Issued:01-16-2025; Effective01-16-2025; Implementation: 01-16-2025)
Unlike Part A, there is always a premium for Part B.12An individual who receives OASDI, RRB,
or Office of Personnel Management (OPM) government retirement benefits must pay the Part B
premium through a deduction from their monthly benefits. The exception to mandatory
deduction is if a state pays the individual’s premiums under a buy-in agreement. See section
1840(h) of the Act.
CMS directly bills individuals for their Medicare premiums if they do not receive OASDI, RRB
or OPM benefits. SSA manually bills individuals whose OASDI is less than the premium amount
owed,13 for Part B premiums. See section 1840(e) of the Act; 42 CFR 408.60.
Individuals who are entitled to Part A are also eligible to enroll in Medicare Part B. See section
1836 of the Act. Individuals who lack the requisite OASDI work history for premium-free Part A
can enroll in Part B alone (or can enroll in both Part B and premium Part A) if they are age 65 or
older and meet the citizenship and residency requirements for Part B. See 42 CFR 407.10(a)(2).
In other words, they must be:
• Age 65 or older;
11 Individuals may qualify for a reduced premium if they have obtained 30 work credits; are married for at least one
year to a worker with at least 30 work credits; were married for at least one year to a worker who attained 30 work
credits prior to their death; are divorced from a worker after 10 years of marriage and the worker attained 30 work
credits at the time the divorce was final; or are divorced from a worker after 10 years of marriage and the worker
died and had 30 work credits at the time the divorce was final. See 42 CFR 406.32(c).
12 Note that Medicare Advantage plans can reduce the standard Medicare Part B premium as an additional benefit
for plan enrollees. The reduction must be less than the standard Part B premium amount and cannot be paid to the
beneficiary or used to reduce a late enrollment penalty. If an individual receives a Part B premium deduction from a
Medicare Advantage plan and is enrolled in Part B buy-in, CMS will notify the state of the amount of the premium
reduction through the regular exchange of buy-in data.
13 If the amount of the Part B premium exceeds the individual’s OASDI payment, SSA applies the full of amount of
the benefit payment to the premium, and SSA directly bills the beneficiary for the remaining balance owed. See SSA
POMS HI 01001.041 at https://secure.ssa.gov/poms.nsf/lnx/0601001041.

• U.S. residents; and
• Either:
o U.S. citizens; or
o Lawful permanent residents who have resided in the U.S. continuously during the five
years immediately preceding the month of application for enrollment in Medicare.14
1.3.4 The Part B Immunosuppressive Drug Benefit
(Rev. 7; Issued:01-16-2025; Effective01-16-2025; Implementation: 01-16-2025)
Starting January 1, 2023, certain individuals who lose Medicare coverage based on ESRD 36
months after a successful kidney transplant are eligible for a limited Part B Immunosuppressive
Drug (Part B-ID) benefit that covers immunosuppressive drug therapy under Part B, as required
by section 402 of the Consolidated Appropriations Act, 2021 (CAA, 2021).
The Part B-ID benefit solely covers immunosuppressive drugs and no other Medicare items,
services, or prescription drugs.
Individuals are charged a monthly premium for Part B-ID ($110.40 in 2025), and most are
directly billed by CMS. Current premium amounts can be found in the “What’s the
Immunosuppressive Drug Benefit” section of the ESRD Medicare webpage at:
https://www.medicare.gov/basics/end-stage-renal-
disease#:~:text=Beginning%20January%201%2C%202023%2C%20Medicare,substitute%20for
%20full%20health%20coverage.
States pay the Part B-ID premium as well as cost-sharing (Part B-ID benefit deductible and
coinsurance) for individuals determined eligible for the QMB eligibility group. See section
1.6.2.4. States pay the Part B-ID premium for individuals determined eligible for the Specified
Low Income Medicare Beneficiary (SLMB) or QI (Qualifying Individuals) eligibility groups See
sections 1.6.2.7 and 1.6.2.8.
On or after January 1, 2023, individuals are eligible for Part B-ID if they:
• Lose Medicare entitlement on the basis of ESRD 36 months after a successful kidney
transplant;
• Are not otherwise enrolled in Medicare or certain other forms of health coverage; and
• Complete an attestation through SSA certifying that they do not have or expect to obtain
certain other forms of health coverage, including employer coverage, Medicaid that
14 The five years of continuous residence may begin prior to the date that the lawful admission for permanent
resident is granted. See SSA POMS HI 00805.005 at https://secure.ssa.gov/poms.nsf/lnx/0600805005
and SSA POMS GN 00303.800 at https://secure.ssa.gov/apps10/poms.nsf/lnx/0200303800.

includes immunosuppressive drugs, and Marketplace coverage.
Individuals can enroll in Part B-ID by calling SSA at 1-877-465-0355 or completing the CMS
Form 10798 and mailing it to SSA. Medicare enrollment periods do not apply to Part B-ID so
individuals can enroll in the benefit at any time.
For more information about the Part B-ID benefit, see section 40.9 of the Medicare General
Information, Eligibility and Entitlement Manual at https://www.cms.gov/regulations-and-
guidance/guidance/manuals/downloads/ge101c02.pdf; SSA POMS HI 00805.400 at
https://secure.ssa.gov/apps10/poms.nsf/lnx/0600805400.
1.3.5 Medicare Enrollment
(Rev. 6; Issued:04-26-24; Effective:04-26-24; Implementation:04-26-24)
In the absence of a buy-in agreement, individuals may only sign up for premium Part A or Part B
during a prescribed Medicare enrollment period (i.e., their IEP, the GEP or an SEP for which
they are eligible). Individuals can first sign up for premium Part A or Part B during their IEP. If
they miss the IEP, they can enroll during the annual GEP but may pay a premium increase for
late enrollment. For an explanation of the premium increase for Part B and premium Part A, see
section 1.1. Individuals who qualify for an SEP can enroll in Medicare without having to wait for
the GEP and are usually not subject to a late enrollment penalty (LEP).
Medicare enrollment periods do not apply to premium-free Part A, or the Part B-ID benefit
described in section 1.3.4. Some individuals are automatically enrolled in Medicare, while others
have to file for it, as described in section 1.3.5.1.

1.3.5.1 Medicare Enrollment Table
(Rev. 7; Issued:01-16-2025; Effective01-16-2025; Implementation: 01-16-2025)
Automatic Enrollment Individual Enrollment15
Premium-free Part A: Individuals automatically
get premium-free Part A if they are:
• Age 65 and over and receive Social Security
or RRB retirement benefits; or
• Under age 65 who receive Social Security
or RRB disability benefits for 24 months.
These individuals will also automatically get Part B
if they live in the U.S., the Northern Mariana
Islands, the U.S. Virgin Islands, Guam, or American
Samoa. Individuals can choose to subsequently
decline Part B.
Part B: During their IEP for Part B, CMS mails the
individual a welcome packet that contains
background information and a Medicare card with
the Part A and B effective dates. The mailing
informs the beneficiary that:
They do not pay a premium for Part A, which will
start on the coverage date on the card; and
They do owe a premium for Part B but can decline
Part B coverage by signing the back of the card and
returning the card before the Part B effective date.
Premium-free Part A: Individuals can file for
Medicare premium-free Part A at SSA if they are:
• Age 65 and over and have not yet filed for
Social Security or RRB benefits;
• An individual who qualifies for Medicare on
the basis of ESRD; or
• A government employee age 65 and over who
has paid the Medicare payroll tax for the
required number of quarters.
Individuals who file for Part A are enrolled in Part B
unless they decline it.
Premium Part A: Individuals who qualify for
premium Part A (i.e. those who do not qualify for
premium-free Part A) must apply for Medicare at
SSA. They can enroll in Part B only or premium Part
A and Part B.
NOTE: An individual can enroll in Medicare Part B
without enrolling in premium Part A. Conversely, an
individual cannot enroll in premium Part A unless the
individual is receiving Part B benefits or files an
application to enroll.
Delayed Premium Part A and Part B: Individuals
who did not enroll in premium Part A or Part B during
their IEP can enroll during the GEP or during an
applicable SEP.
Part B-ID: Individuals apply for Part B-ID through
SSA. Medicare enrollment periods do not apply to
Part B-ID.
15 An individual can sign up for Medicare Part A and Part B through SSA’s toll-free number 1-800-772-1213, TTY
1-800-325-0778, by making an appointment at their local Social Security office, and with some exceptions, on the
ssa.gov website. An individual can sign up for Part B-ID by calling SSA’s toll-free number at 1-877-465-0355 and
providing an oral attestation, or by mailing to SSA a completed Enrollment for Part B Immunosuppressive Drug
Coverage Form CMS-10798, which is available at https://www.cms.gov/files/document/cms-10798.pdf.

1.3.6 Medicare Part A and Part B Re-enrollment
(Rev. 6; Issued:04-26-24; Effective:04-26-24; Implementation:04-26-24)
An eligible individual who owes premiums from a past period of premium Part A or Part B
coverage is permitted to re-enroll in Medicare. Although payment of past-due premiums is not a
pre-requisite for re-enrollment, the individual is still liable for these amounts. See SSA POMS HI
01001.345 at https://secure.ssa.gov/apps10/poms.nsf/lnx/0601001345. Individuals who reenroll
can ask SSA about methods of payment and pursue options for financial relief that are described
in section 1.15.2.
1.4 Requirements for Enrolling Individuals Under Buy-in Agreements
(Rev. 6; Issued:04-26-24; Effective:04-26-24; Implementation:04-26-24)
1.4.1 General Requirements
(Rev. 7; Issued:01-16-2025; Effective01-16-2025; Implementation: 01-16-2025)
States must pay the Part A or B premiums for any individual who is both eligible to enroll in Part
B and is determined eligible for a Medicaid eligibility group in the buy-in agreement. See
sections 1843(a) and 1818(g) of the Act; 42 CFR 406.26 (a)(3) and 407.40(c)(1). A state cannot
apply a “cost-effectiveness test” to choose individuals for buy-in (i.e., restrict buy-in to those
who have incurred high medical expenses).
An individual’s enrollment under a buy-in agreement is involuntary. A beneficiary who is
eligible for a Medicaid eligibility group that is covered under their state’s buy-in agreement
cannot voluntarily terminate state buy-in coverage. See sections 1843(a) and 1818(g) of the Act;
42 CFR 406.26(a)(3) and 407.40(c)(1).
States may not pay Medicare premiums using the state buy-in process for non-citizens who are
ineligible for Medicaid benefits (e.g., individuals who qualify for health coverage funded solely
by the state).
States must follow federal requirements defining an individual’s buy-in coverage period,
including effective (start) and termination (stop) dates, even if buy-in processing is delayed.
States with buy-in agreements must exchange buy-in enrollment data with CMS on a daily basis
under 42 CFR 407.40(c)(4). See chapter 2 for information regarding state and CMS processes to
start and end buy-in.
1.4.2 Medicare Enrollment Under a State Buy-Agreement
(Rev. 7; Issued:01-16-2025; Effective01-16-2025; Implementation: 01-16-2025)
States directly enroll individuals covered under their buy-in agreement into Medicare premium
Part A and Medicare Part B at any time of the year, without regard for Medicare enrollment

periods or late enrollment penalties. See 42 CFR 406.26(a)(2) and (b)(2) and 407.40(c)(1). If an
individual covered under the buy-in agreement is already enrolled in either Medicare Part A or
Part B, the state should directly enroll the individual in buy-in and refrain from referring the
individual to SSA to apply for Medicare. See section 1.10 for more information.S
1.4.3 Limitations on State Liability for Retroactive Part B Premiums
(Rev. 6; Issued:04-26-24; Effective:04-26-24; Implementation:04-26-24)
In some instances, SSA determines full-benefit Medicaid beneficiaries16 eligible for Medicare
for a retroactive period.17 If a state learns that SSA established retroactive Medicare Part A
entitlement for a full-benefit Medicaid beneficiary, the state must review the individual’s
eligibility for Part B buy-in over the retroactive period.
Starting January 1, 2024, state liability for retroactive Medicare Part B premiums for such
individuals is limited to a period no greater than 36 months prior to the date of the Medicare
enrollment determination. See 42 CFR 407.47(f). States can request a good cause exception from
CMS for retroactive periods of less than 36 months if the state could not benefit from Medicare
(e.g., based on the state’s Medicaid recoupment policy) and limiting state liability would not
result in harm to the beneficiary. States or beneficiaries can also request a good cause exception
for retroactive periods of more than 36 months if the 36-month limit would result in harm to the
beneficiary. See section 1.13.1 for more information on limitations on retroactive Part B buy-in
liability for full-benefit Medicaid beneficiaries.
1.4.4 Medicaid Eligibility Redeterminations
(Rev. 6; Issued:04-26-24; Effective:04-26-24; Implementation:04-26-24)
Eligibility for or enrollment in Medicare constitutes “a change in circumstances” that may affect
a Medicaid beneficiary’s eligibility, either by making them eligible for an additional eligibility
group (such as a Medicare Savings Program group) or rendering them ineligible for their existing
eligibility group (such as the “adult group” described at 42 CFR 435.119).18 When a state
16 ‘‘Full-benefit’’ Medicaid coverage, in the context of individuals who are considered dually eligible, generally
refers to the package of services, beyond coverage for Medicare premiums and cost sharing, that certain individuals
are entitled to under 42 CFR 440.210 and 440.330.
17 Retroactive Medicare awards often occur when an individual under age 65 files a claim for disability benefits and
receives a favorable SSDI award multiple years after the initial application. Because individuals entitled to SSDI
benefits become entitled to premium-free Medicare Part A after 24 months, the individual becomes retroactively
entitled to Medicare Part A if the individual’s start date for SSDI benefits is older than 24 months. If an individual
already has Medicaid when they are retroactively enrolled in Medicare Part A, the state can be liable for retroactive
Part B premiums per the state buy-in agreement. Many (but not all) Medicaid beneficiaries who are retroactively
enrolled in Medicare are SSI recipients.
18 For more information, see “Medicaid and Children’s Health Insurance Program (CHIP) Renewal Requirements,”
CMS Information Bulletin, December 4, 2020, at https://www.medicaid.gov/federal-policy-
guidance/downloads/cib120420.pdf. By June 3, 2027, states must comply with new 42 CFR 435.919 (revised and
redesignated certain requirements in 42 CFR 435.916) related to promptly acting on changes in circumstances and

anticipates or receives information that a current Medicaid beneficiary is newly eligible for
Medicare, the state must promptly redetermine the individual’s eligibility as required any time a
Medicaid beneficiary experiences a change in circumstances that may impact Medicaid
eligibility. See 42 CFR 435.916(d). If the state confirms that an adult group beneficiary is
eligible for Medicare, the state may not terminate the individual’s eligibility for the group until
the state has first determined whether the individual is eligible for any other eligibility group. See
42 CFR 435.916(f)(1).
When the state has considered eligibility on all bases, the state must either move the beneficiary
to the appropriate eligibility group if Medicaid eligibility continues or provide the individual
advance notice and hearing rights in accordance with 42 CFR 435.917 and 42 CFR part 431,
subpart E prior to terminating coverage. Note: the state must provide the beneficiary advance
notice and hearing rights if the state determines the individual ineligible for the adult group due
to Medicare eligibility and only alternatively eligible for an MSP group.
Additionally, the state must maintain the beneficiary’s scope of medical assistance at least until it
has provided the appropriate notice; e.g., if a state determines an adult group beneficiary who
becomes eligible for Medicare ineligible for any other full-benefit Medicaid eligibility group or
only eligible for an MSP group, the state must continue providing adult group coverage to the
individual at least until the state has notified them of its determination and informed them of
their fair hearing rights. See 42 CFR 431.230.
If the state determines the individual eligible for a Medicaid eligibility group included in the
state’s buy-in group, the state must start paying their Part A and/or B premiums. If a state that
includes all Medicaid eligibility groups in its Part B buy-in coverage group has not completed
the eligibility redetermination for an adult group beneficiary before the first month they qualify
for Medicare, the state must enroll the individual in Part B buy-in for all months in which the
individual is enrolled in the adult group following Medicare entitlement.
1.5 Effect of Buy-in on an Individual
(Rev. 7; Issued:01-16-2025; Effective01-16-2025; Implementation: 01-16-2025)
If a Medicaid-eligible individual who is enrolled in an eligibility group included in a state’s
buy-in agreement is eligible for Medicare but not currently enrolled in it, state buy-in
enrolls the individual in Medicare, providing access to Medicare-covered items and services.
NOTE: If an individual did not enroll in premium Part A or Part B during their IEP, or
previously withdrew from the programs, Medicare entitlement will be established or re-
established effective with the first month that the individual becomes eligible for state buy-in.
scope of redeterminations based on changes in circumstances. See April 2, 2024, Streamlining the Medicaid,
Children’s Health Insurance Program, and Basic Health Program Application, Eligibility Determination, Enrollment,
and Renewal Processes Final Rule (89 FR) 22789) at https://www.federalregister.gov/documents/2024/04/02/2024-
06566/medicaid-program-streamlining-the-medicaid-childrens-health-insurance-program-and-basic-health.

If an individual is already enrolled in Medicare, state buy-in means the state will assume
payments for the beneficiary’s Medicare Part A and/or B premiums or Part B-ID premiums.
• If SSA deducts Medicare premiums from a beneficiary’s Social Security benefit
(OASDI), the deductions will stop, resulting in the beneficiary receiving a higher
monthly payment.
• If CMS directly bills the beneficiary for Medicare premiums, such billing will end.
Once buy-in coverage is effective, the beneficiary shall receive a refund from SSA for any
premiums (including any late enrollment penalties) that were deducted from the benefit amount
or for premiums directly paid by the beneficiary to CMS, for any month the beneficiary is
enrolled in state buy-in. Sometimes a state accretes a beneficiary to the state’s buy-in account in
error for months in which the individual was not eligible for a Medicaid eligibility group
included in the buy-in agreement. In these instances, the beneficiary is entitled to keep any
premium refunds received. The state must treat the individual as if they are eligible and may not
attempt to recoup these amounts from the beneficiary.19
NOTE: The refund of Medicare premiums is not countable income under supplemental security
income (SSI) methodologies. See SSA POMS SI 00815.050.B.2 at
https://secure.ssa.gov/poms.nsf/lnx/0500815050 and
SI 00815.400.A at https://secure.ssa.gov/poms.nsf/lnx/0500815400.
As a result, Medicaid agencies cannot consider the refund as income when determining
eligibility for individuals whose Medicaid eligibility is based on SSI methodologies.
1.6 Part B Buy-in Coverage Groups in the 50 States and the District of
Columbia - General
(Rev. 7; Issued:01-16-2025; Effective01-16-2025; Implementation: 01-16-2025)
Federal law allows the 50 states and the District of Columbia to select one of three Part B buy-in
19 Recovery of an “overpayment” made to beneficiaries is considered to be a retroactive termination of Medicaid
eligibility. Retroactive termination of eligibility is prohibited by regulations at 42 CFR 431.211 to 431.214, which
require states to provide at least ten days advance notice of a termination of eligibility in most situations; in a few
discrete situations, termination on the date of action is allowed. Retroactive terminations of eligibility would also
violate a beneficiary’s due process rights under the U.S. Constitution and associated case law.
States are required to provide Medicaid to eligible state residents under 42 CFR 435.403(a) and must continue to
furnish Medicaid to all eligible individuals until they are found to be ineligible pursuant to 42 CFR 435.930(b).
When a state receives information that suggests a beneficiary is not eligible for Medicaid, the state must promptly
conduct a redetermination of eligibility for that beneficiary. See 42 CFR 435.916(d)(1). This includes providing the
beneficiary with an opportunity to demonstrate that the information the state received is not accurate or that the
individual otherwise remains eligible for coverage. See 42 CFR 435.952(d). If the redetermination results in a
finding of ineligibility for the beneficiary, the state may terminate eligibility provided that the beneficiary is afforded
advance notice and hearing rights in accordance with 42 CFR part 435, subpart J and 42 CFR part 431, subpart E.

coverage groups. See section 1843 of the Act; 42 CFR 407.42.20
The buy-in coverage groups are listed below, in order of narrowest to broadest.
• Group One: Cash Assistance Recipients and Deemed Recipients of Cash Assistance
(Section 1.6.1)
• Group Two: Cash Assistance Recipients and Deemed Recipients of Cash Assistance Plus
Three Medicare Savings Program (MSP) Groups (Section 1.6.2); and
• Group Three: All Medicaid Eligibility Groups (Section 1.6.3)
As of January 1, 2024, all states and the District of Columbia, and certain territories have buy-in
agreements that include Part B buy-in for either (a) the cash assistance recipients and deemed
recipients of cash assistance plus three MSP groups or (b) all Medicaid eligibility groups.
Appendix 1.D classifies the Part B buy-in coverage groups in the 50 states, the District of
Columbia, and specified U.S. territories.
Individuals may be eligible for one or more Medicaid eligibility groups in the buy-in agreement.
NOTE: Part B buy-in coverage groups must include SSI/State Supplement Programs (SSPs)
recipients and deemed recipients of SSI/SSPs who qualify for Medicaid based on receipt (or
deemed receipt) of such cash assistance.
1.6.1 Buy-in Coverage Group One: Cash Assistance and Deemed Recipients of
Cash Assistance
(Rev. 6; Issued:04-26-24; Effective:04-26-24; Implementation:04-26-24)
This buy-in group includes only individuals who are covered under the state plan as categorically
needy and are cash assistance recipients or are deemed to be cash assistance recipients for the
purposes of the Medicaid eligibility determination. This group includes Medicaid beneficiaries
who are:21
• SSI recipients;
• State Supplement Payment (SSP) recipients; and
20 When states could first enter into buy-in agreements in July 1966, they could choose between two Part B buy-in
groups: 1) individuals receiving federally aided cash assistance; or 2) all Medicaid beneficiaries. After numerous
changes, federal law allows states to select one of the three buy-in groups outlined in this section.
21 SSA notifies Medicaid agencies of individuals who are determined eligible for SSI (and SSPs, in some cases) and
may qualify for Medicare through the SSA systems such as the State Data Exchange (SDX). See section 2.4 for
more information about SSA data sharing with states.

• 	Deemed recipients of SSI/SSP and the former Aid to Dependent Children and Families
(AFDC) Program.
1.6.1.1 Supplemental Security Income (SSI) Program Recipients
(Rev. 6; Issued:04-26-24; Effective:04-26-24; Implementation:04-26-24)
SSI is a federal cash assistance program that serves low-income individuals who are age 65 or
older or have blindness or a disability. SSI recipients typically qualify for other state and federal
programs, including Medicaid and Medicare.
1.6.1.2 Full-benefit Medicaid Eligibility for SSI Recipients
(Rev. 6; Issued:04-26-24; Effective:04-26-24; Implementation:04-26-24)
In most states, the receipt of SSI is a mandatory basis for Medicaid eligibility. See section
1902(a)(10)(A)(i)(II)(aa) of the Act; 42 CFR 435.120 (“Individuals receiving SSI group” (also
known as the “mandatory SSI group”)). As of January 1, 2024, 33 states and the District of
Columbia that cover the mandatory SSI group have an agreement with SSA under which SSA
determines eligibility for the mandatory SSI group, and the Medicaid agency automatically
enrolls in Medicaid those individuals who SSA has determined to be eligible for SSI. These
agreements are authorized under section 1634 of the Act, and states that have entered into such
agreements with SSA are commonly referred to as “1634 states.”
Nine states that cover the mandatory SSI group apply the SSI income and resource
methodologies and disability criteria in determining Medicaid eligibility but require SSI
recipients to file a Medicaid application with the state Medicaid agency to establish their
Medicaid eligibility (“SSI criteria states”).
Eight states do not cover the mandatory SSI group. Instead, these states have elected the option
to apply financial methodologies more restrictive than SSI in determining Medicaid eligibility
for individuals age 65 or older, or who have blindness or disability, subject to certain conditions.
See section 1902(f) of the Act; 42 CFR 435.121 (Individuals in states using more restrictive
requirements for Medicaid than the SSI requirements.) These states are referred to as “209(b)”
states, after the provision of the Social Security Act Amendments of 1972, Pub. L. No. 92- 603,
section 209(b), which enacted what became codified at 1902(f) of the Act.
1.6.1.3 Part B Buy-in for SSI Recipients
(Rev. 7; Issued:01-16-2025; Effective01-16-2025; Implementation: 01-16-2025)
In addition to having Medicaid, many SSI recipients are entitled to Medicare Part A and/or
enrolled in Part B. In 1634 states, once SSA has determined an individual eligible for the
mandatory SSI group and Part B, CMS will initiate, on behalf of the state, Part B buy-in for
individuals. For the purposes of Part B buy-in, CMS refers to 1634 states as SSI “auto-accrete”
states. In SSI criteria and 209(b) states, CMS does not auto-enroll SSI recipients in Part B buy-in

since they must separately apply for Medicaid. Instead, once SSA determines an individual
eligible for SSI and Part B, CMS sends an “alert” to the state to initiate Part B buy-in for the
individual if they are eligible for Medicaid. For the purposes of Part B buy-in, CMS refers to SSI
criteria and 209(b) states as “alert states.”
Appendix 1.D classifies states by whether they are an auto-accrete or alert state (including SSI
criteria and 209(b)) as of January 1, 2024. See section 2.5.1 for more information about buy-in
enrollment processes in auto-accrete and alert states.
1.6.1.4 Qualified Medicare Beneficiary Group Eligibility for SSI Recipients
(Rev. 6; Issued:04-26-24; Effective:04-26-24; Implementation:04-26-24)
In addition to qualifying for Medicaid and Part B buy-in, SSI recipients are always financially
eligible for the QMB eligibility group, which covers Medicare Parts A and B premiums and cost-
sharing. Effective October 1, 2024, CMS regulations at 42 CFR 435.909(b) require states to
automatically enroll in the QMB eligibility group most individuals determined eligible for
Medicare and the mandatory SSI group or mandatory 209(b) group (“SSI-based Medicaid”).
See section 1.6.2.6 for a description of these requirements.
1.6.1.5 State Supplement Programs (SSPs) Recipients
(Rev. 6; Issued:04-26-24; Effective:04-26-24; Implementation:04-26-24)
Most states operate their own cash assistance programs—known as optional SSPs—for people
who are 65 years old and older, or who have blindness or disability. Payments from these
programs are not counted as income under the SSI program. In many cases, these benefits
supplement the SSI benefits an individual receives.22 In other cases, individuals receive only an
SSP payment if they would otherwise meet the requirements for SSI but for having too much
income. States have the option to extend categorical Medicaid eligibility to individuals who are
not eligible for SSI, but who receive an SSP benefit.
Similar to the authority provided by section 1634 of the Act for states to enter agreements with
SSA for SSA to determine Medicaid eligibility of SSI applicants, section 1616 of the Act
authorizes states to enter agreements with SSA in which SSA determines SSP program eligibility
(“1616 agreements”). In such states, an application for SSI is also an application for SSPs. Other
states perform determinations for SSPs themselves. See SSA POMS SI 01401.001 at
https://secure.ssa.gov/apps10/poms.nsf/lnx/0501401001.
1.6.1.6 Deemed Recipients of Cash Assistance
(Rev. 7; Issued:01-16-2025; Effective01-16-2025; Implementation: 01-16-2025)
22 States in which the grant-in-aid cash benefit rate in December 1973 exceeded the SSI Federal Benefit Rate of
January 1974 are required to pay a supplement to beneficiaries to make up the difference. Individuals who continue
to receive these mandatory state supplements are mandatorily eligible for Medicaid. See 42 CFR 435.130. There are
no new applicants for this eligibility group.

Buy-in can be applicable to two categories of deemed recipients of cash assistance: deemed
SSI/SSP recipients and deemed AFDC recipients.
Over time, federal law has mandated that certain individuals who were at one point receiving
cash assistance but who lost it due to increases in Social Security benefits (OASDI) be treated,
for purposes of Medicaid eligibility, as if they continue to receive cash assistance, i.e., these
individuals are “deemed” to be receiving SSI/SSPs. Federal law and regulations make these
individuals mandatorily eligible for Medicaid.23 States must include these individuals in state
buy-in agreements.
Aid to Families with Dependent Children (AFDC) is a cash assistance program that was replaced
by Temporary Assistance for Needy Families (TANF) in 1996.24 No Medicaid state plan
eligibility groups are linked to TANF; a few Medicaid eligibility categories, however, are linked
to eligibility standards of the former AFDC program and offer eligibility to certain individuals
who are “deemed” to meet such standards, as the program existed in 1996. Deemed AFDC
recipients include individuals who receive adoption assistance, foster care, or guardianship care
under Title IV-E of the Act, in accordance with 42 CFR 435.145, and low-income families
described in section 1931(b)(1)(A) of the Act. Effective January 1, 2023, states have the option
to designate all deemed recipients of AFDC as cash assistance recipients with eligibility groups
related to SSI/SSP, or to only cover individuals who receive or are deemed to receive SSI/SSP as
cash assistance recipients in their Part B buy-in coverage group. See 42 CFR 407.42(b).
1.6.2 Buy-in Coverage Group Two: Cash Assistance Recipients and Deemed
Recipients of Cash Assistance Plus Three Medicare Savings Program Groups
(Rev. 7; Issued:01-16-2025; Effective01-16-2025; Implementation: 01-16-2025)
A second option for states to select for inclusion in their buy-in agreements is cash assistance
recipients, deemed recipients of cash assistance and the three primary Medicare Savings Program
(MSP) Medicaid eligibility groups. Preceding sections 1.6.1 through 1.6.1.3 describe the cash
assistance and deemed cash recipients who are included in buy-in agreements for states selecting
this coverage group. This section details the MSP groups that are included in this buy-in
coverage group option.
23 The following categories are deemed recipients of SSI/SSPs: certain individuals who would have been eligible for
cash assistance in 1972 but who lost it because of an increase in their OASDI benefits (42 CFR 435.134 and
435.112); certain individuals (sometimes known as “Pickle” individuals) who used to qualify for both SSDI and SSI
but who no longer qualify for SSI because their income exceeds the SSI income limit (42 CFR 435.135);certain
working individuals with disabilities who have become income-ineligible for SSI (section 1619(b) of the Act and 42
CFR 435.120(c)); certain disabled widow/ers (42 CFR 435.137 and 435.138); and certain adult children with
disabilities (section 1634(c) of the Act).
24 The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Pub. L. 104-193).

In accordance with section 1902(a)(10)(E) of the Act, MSP eligibility groups are part of states’
Medicaid programs and assist low-income individuals with their Medicare costs. The MSPs are
Medicaid eligibility groups through which Medicaid covers Medicare Part A and/or B premiums
and, for most enrollees, cost-sharing.
Starting January 1, 2023, section 402(f) of the CAA, 2021 expanded the primary MSPs to pay
some or all of the costs of the new immunosuppressive drug coverage for certain low-income
individuals who are enrolled in such drug coverage.
The MSPs include three primary Medicaid eligibility groups:
• 	Qualified Medicare Beneficiary (QMB) group
• 	Specified Low-Income Medicare Beneficiary (SLMB) group
• 	Qualifying Individual (QI) group.
Individuals may be eligible for an MSP alone (also known as “partial-benefit dually eligible
individual”) or may be simultaneously eligible for an MSP (QMB or SLMB) and a full-benefit
Medicaid eligibility group under the state plan (also known as “full-benefit dually eligible
individual”).
As noted in section 1.6, all state buy-in agreements in the 50 states and the District of Columbia
include the payment of Part B premiums for QMBs, SLMBs, and QIs.
NOTE: A fourth, and much smaller MSP eligibility group is the Qualifying Disabled Working
Individuals (QDWI) group. Eligibility for the QDWI group, as described in sections
1902(a)(10)(E)(ii) and 1905(s) of the Act and 42 CFR 435.126, is limited to individuals under
age 65 with disabilities who:
• 	are eligible to enroll in premium Part A once premium-free Part A expires following a
return to work (see section 1.3.2 for more information on premium Part A eligibility);
• 	have income that does not exceed 200 percent of the FPL;
• 	have resources that do not exceed twice the relevant SSI resource standard (i.e., for a
single individual or couple); and
• 	are otherwise ineligible for Medicaid benefits.
Individuals with disabilities who return to work may qualify for full-benefit Medicaid coverage
(e.g. mandatory coverage for working individuals under 1619(b) of the Act or optional Medicaid
buy-in eligibility groups for working individuals with disabilities described in sections
1902(a)(10)(A)(ii)(XIII), (XV), and (XVI) of the Act), which makes them ineligible for the
QDWI eligibility group. See sections 1.6.1.6 and 1.6.3 for information about Part B buy-in

coverage for working individuals with disabilities who qualify for full-benefit Medicaid
coverage.
States pay Part A premiums (but not Part B premiums) for QDWIs. States cannot include the
Part A premium payments for QDWIs in their buy-in agreements. States pay the Part A
premiums for QDWIs through the group payer process.
Sections 1.6.2.4 through 1.6.2.8 contain additional information about the QMB, SLMB, and QI
groups.
For detailed information on dually eligible individual categories, including the degree to which
individuals in each category receive assistance with Medicare Parts A and B premiums and cost-
sharing, see appendix 1.A.
For more information about the buy-in start date for these categories, see sections 1.13 and 1.14,
and appendix 1.C.
1.6.2.1 Medicare Savings Program Eligibility and Enrollment
(Rev. 7; Issued:01-16-2025; Effective01-16-2025; Implementation: 01-16-2025)
Individuals typically apply for MSPs directly at their state Medicaid agencies. States must also:
•
• Deem most individuals who receive SSI and have Medicare and full-benefit Medicaid
eligible for the QMB eligibility group as described in section 1.6.2.6; and
• Initiate an MSP application upon receipt of data from Part D Low-Income Subsidy (LIS)
program applications (‘‘LIS leads data’’) from SSA as described in section 1.6.2.3.
Income and resources criteria: Federal statutes and rules set forth the applicable income and
resource standards (“limits”) for each MSP group. See section 1902(a)(10)(E) of the Act; 42
CFR 435.123 through 126. In determining countable income and resources for MSP eligibility,
states must use income and resource methodologies no more restrictive than the methodologies
for the SSI program. See section 1905(p) of the Act; 42 CFR 435.601(b)(2). However, under
section 1902(r)(2) of the Act, states have the flexibility to adopt income and resource
methodologies less restrictive than the SSI program’s to effectively increase the QMB, SLMB
and QI income and resource limits above the federal baseline and to remove the resource test
altogether. 25
25 For more information on state flexibilities, see “Opportunities to Increase Enrollment in Medicare Savings
Programs” CMS Information Bulletin, November 1, 2021, at https://www.medicaid.gov/federal-policy-
guidance/downloads/cib11012021.pdf. See also, “Improving Participation in the Medicare Savings Programs,”
Chapter 3 in June 2020 Report to Congress on Medicaid and CHIP, Medicaid and CHIP Payment and Access
Commission (MACPAC) at https://www.macpac.gov/publication/chapter-3-improving-participation-in-the-
medicare-savings-programs/.

States that use section 1902(r)(2) authority to fully align their MSP income and resource
methodologies with the LIS program methodologies can determine an individual’s eligibility for
the MSPs using LIS leads data, without requesting any financial information from the
individual.26
Family of the size involved: The Social Security Act27 sets forth income limits for the MSPs
relative to the FPL “applicable to a family of the size involved.” CMS has permitted states to
apply their own reasonable definition of the phrase “family of the size involved.”28
By April 1, 2026, states must apply a definition of “family of the size involved” in determining
eligibility for the MSP groups that includes at least the individuals included in the definition of
“family size” for the Part D LIS program described in 42 CFR 423.772. To effectuate this
change, states must submit a State Plan Amendment (SPA).
See 42 CFR 435.601(e). The Part D LIS definition includes the applicant, the spouse who is
living in the same household, if any, and the number of individuals who are related to the
applicant or applicants, who are living in the same household and who are dependent on the
applicant or the applicant’s spouse for at least one half of their financial support.
COLA adjustments: States must adjust their eligibility standards to reflect the annual poverty
level guidelines established at least annually by HHS upon their publication in the Federal
Register. Additionally, states cannot count income attributable to a Social Security cost of living
adjustment (COLA) as income for MSP eligibility purposes for individuals until the month
following the month HHS publishes the new poverty level figures. See section 1905(p)(2)(D) of
the Act; 42 CFR 435.123 through 435.126.
Verification of Income and Resources:
States must verify financial eligibility for the MSPs in accordance with sections 1137 and
1902(a)(46)(A) of the Act and 42 CFR 435.940 through 435.942 and 435.380. For resources held
in financial institutions, states may either elect to accept self-attestation of resources or to use an
Asset Verification System (AVS) for the MSPs. If a state does not accept self-attestation of
resources that can be verified through AVS, the state cannot require individuals to provide proof
26 See final rule titled ‘‘Streamlining Medicaid: Medicare Savings Program Eligibility Determination and
Enrollment” published in the September 21, 2023 Federal Register (88 FR 65320, 65239) at
https://www.govinfo.gov/content/pkg/FR-2023-09-21/pdf/2023-20382.pdf (“the September 21, 2023 MSP final
rule”). States would only need to verify citizenship or immigration status obtain assignment of rights to medical
support and third-party payers as described in section 1.6.2.3.
27 See sections 1905(p)(2)(A) and (B) (the QMB group), 1902(a)(10)(E)(iii) and (iv) (the SLMB and QI groups
respectively), and 1905(s)(2) (the QDWI group) of the Act.
28 See Memorandum from Director, Center for Medicaid and State Operations, to Regional Administrator, re:
Medicaid Eligibility—Policy Governing Family Size in Determining Eligibility for Qualified Medicaid
Beneficiaries and Specified Low-Income Beneficiaries. October 2, 1997, at
https://www.medicaid.gov/sites/default/files/2019-12/medicaid-eligibilty-memo.pdf.

of such resources without first attempting to verify them through AVS.29
Distinct requirements apply to the verification of certain income and resources for all MSPs
applications (section 1.6.2.2) and to MSP applications the state receives from SSA through the
LIS leads process (section 1.6.2.3).
Screen on all bases: State Medicaid agencies must generally determine an individual’s
eligibility for all Medicaid eligibility groups for which they may qualify. For Medicare
beneficiaries, these include full-benefit Medicaid eligibility groups and the MSPs. Accordingly,
states’ eligibility system hierarchy should be programmed to reflect both MSP eligibility
determinations as well as full-benefit Medicaid eligibility groups. Note that some states may
have MSP-only applications that do not request the information necessary for categorical
Medicaid determinations. Consistent with 42 CFR 435.911(c), by April 1, 2026, states must
adhere to specific sequencing of eligibility determinations for individuals whose MSP
applications originate with SSA transmittal of LIS leads data as described in CMS regulations at
42 CFR 435.911(e)(9) and section 1.6.2.3.
1.6.2.2 Verification of Certain Income and Resources for the Medicare
Savings Programs
(Rev. 7; Issued:01-16-2025; Effective01-16-2025; Implementation: 01-16-2025)
No later than April 1, 2026, states are required to implement enrollment simplification policies
related to verification of certain income and resources that the MSPs count but LIS does not (i.e.,
interest and dividend income; non-liquid resources, and the cash value of certain whole life
insurance policies). States must also simplify verification of burial funds, which the MSPs count
differently than does LIS.
NOTE: The requirements below apply to all MSP applications, regardless of whether the
individual initiates the application by directly applying to the state Medicaid agency or the state
receives the application from SSA through the LIS leads process. Also, if CMS conducts audits
related to state MSP eligibility determinations, CMS will not identify an error if the state follows
these requirements.
Interest and dividend income and non-liquid resources: States must accept self-attestation of
the value of any: 1) dividend and interest income earned by the applicant or the applicant’s
spouse and 2) non-liquid resources owned by the applicant or the applicant’s spouse. 42 CFR
435.952(e)(1) and (e)(2). States may not request documentation of the attested value prior to
determining MSP eligibility unless the state agency has information that is not reasonably
compatible with an applicant’s attestation. In that case, the agency must seek additional
29 See “Financial Eligibility Verification requirements and Flexibilities,” CMS Informational Bulletin, November
20, 2024, at https://www.medicaid.gov/federal-policy-guidance/downloads/cib11202024.pdf.

information from the individual, which may include a reasonable explanation of the discrepancy
or documentation. See 42 CFR 435.952(c)(2).
States have the option to conduct post-enrollment verification of interest and dividend income
and/or non-liquid resources after the individual has been determined eligible for an MSP, as
described below.
Burial funds: States must allow individuals to self-attest that up to $1,500 of their resources, and
up to $1,500 of their spouse’s resources, are set aside as burial funds in a separate account
(regardless of whether they are revocable or irrevocable accounts). See 42 CFR 435.952(e)(3).
States may not request documentation of the attested amount prior to determining MSP
eligibility unless the state agency has information that is not reasonably compatible with an
applicant’s attestation. In that case, the agency must seek additional information from the
individual, which may include a reasonable explanation of the discrepancy or documentation.
See 42 CFR 435.952(c)(2).
States have the option to conduct post-enrollment verification of burial funds after the individual
has been determined eligible for an MSP, as described below.
Life insurance policies: If the total face value of all of an individual’s life insurance policies
does not exceed $1,500, the cash surrender value of the individual’s policies is not counted in
determining MSP eligibility.
If an individual attests to having a life insurance policy with a face value below $1,500, states
must accept the attested face value for purposes of making an initial eligibility determination for
MSP coverage, unless the state has information that is not reasonably compatible with the
attested information. In that case, the agency must seek additional information from the
individual, which may include a reasonable explanation of the discrepancy or documentation.
See 42 CFR 435.952(c)(2).
If an individual attests to a face value of a life insurance policy that is above $1,500, the state
may also accept their attestation of the cash surrender value of the life insurance policy. If the
agency has information about the cash surrender value of a life insurance policy that is not
reasonably compatible with the applicant’s attestation, the agency must seek additional
information from the individual, which may include a reasonable explanation of the discrepancy
or documentation. See 42 CFR 435.952(c)(2).
If the state accepted an individual’s self-attestation of the face value or cash surrender value of a
life insurance policy, the state also has the option to conduct post-enrollment verification as
described in this section below.
If the state requires documentation of the cash surrender value of a life insurance policy -- either
prior to enrollment or during post-enrollment verification -- the state must assist the individual
with obtaining this information and documentation. This requires requesting that the individual
provide the name of the insurance company and policy number and authorize the state to obtain

documentation of the cash surrender value on the individual’s behalf. The state agency may also
request, but may not require, additional information from the applicant, such as the name of an
agent.
If the individual does not provide basic information about the policy and an authorization, the
state may require that the individual provide documentation of the cash surrender value within at
least 15 calendar days. See 42 CFR 435.952(e)(4).
Post eligibility verification: States that accept an individual’s attestation for the income and
resource categories described above have the option to conduct post-enrollment verification. If
the agency requests information post-enrollment, it must allow the individual at least 90 days
from the date of the request to provide any necessary information requested and must allow the
individual to submit such documentation through the internet, by telephone, in person or through
other commonly available electronic means. 42 CFR 435.952(e)(1)(iii); (e)(2)(iii) and (e)(3)(iii)
and (e)(4)(iii); and 435.907(a).
States may not administratively recoup payments already made on behalf of individuals if post-
enrollment verification processes establish that the individual is ineligible for the MSPs. If a state
suspects that an individual committed fraud or abuse in order to obtain or maintain MSP
eligibility, the state should follow the processes described at 42 CFR part 455, subpart A of the
regulations.
1.6.2.3 Medicare Savings Programs Determinations Based on Part D Low-
Income Subsidy (LIS) Leads Data
(Rev. 7; Issued:01-16-2025; Effective01-16-2025; Implementation: 01-16-2025)
Since January 1, 2010, federal law has required SSA to transmit to states data from LIS
applications processed by SSA (“LIS leads”) and has required states to treat the data as an
application for the MSPs. See sections 1144(c)(3) and 1935(a)(4) of the Act. For additional
information about LIS leads data, see section 2.4.2.5.
States must treat the date the individual files the LIS application with SSA as the date of
application for purposes of establishing the effective date of eligibility for MSP benefits. When
calculating the 45 day timeliness standard as described under 42 CFR 435.912(c), states may
either use the date that the state receives the LIS leads data from SSA or the date of the LIS
application as the start of the calculation.30 CMS regulations at 42 CFR 435.911(e) require states
to take specific actions on MSP applications based on the receipt of LIS leads data.
30 See September 21, 2023 MSP final rule (88 FR 65320, 6532) at https://www.govinfo.gov/content/pkg/FR-2023-
09-21/pdf/2023-20382.pdf; February 18, 2010 State Medicaid Director Letter (SMDL #10–003), ‘‘Medicare
Improvements for Patients and Providers Act of 2008 (MIPPA),’’https://www.medicaid.gov/federal-
policyguidance/downloads/smd10003.pdf.

Also, if CMS conducts audits related to state MSP eligibility determinations, CMS will not
identify an error if the state follows these requirements.
No later than April 1, 2026, the states must have procedures in place to meet all of the following
requirements:
1. Treat the LIS leads data as an application for MSPs without requiring submission of
another application.
NOTE: On rare occasions, a state may receive an LIS leads file for an individual who did not
complete the entire LIS application (https://www.ssa.gov/forms/ssa-1020b-ocr-sm-inst.pdf),
because they answered “yes” on question 3, indicating they have resources that exceed the
LIS resource limit. If a state receives such a LIS leads file, it means the individual also
answered “yes” on the question 15, requesting that the state nevertheless screen them for the
MSPs. States must therefore treat the receipt of such LIS leads data as an application for
MSPs. The leads data will not contain income and resources information, so the state must
reach out to the individual to obtain missing information that is necessary for the MSP
determination (see #4).
2. Accept LIS leads data without further verification and not require additional verification
or documentation unless (1) the income or resources in the leads data are over the applicable
MSP income and resource limits data and, therefore, do not support a finding that the
individual is eligible for an MSP (see #6 below); or (2) the agency is aware of information
that is not reasonably compatible with the leads data. See 42 CFR 435.911(e)(4).
NOTE: The LIS leads data record layout
(https://www.ssa.gov/dataexchange/documents/LIS%20record.pdf) describes each LIS
income and resource data element, including whether the amount reflected incorporates
standard SSI exclusions. If the income or resource data element does not include the standard
SSI exclusions, the state must apply all applicable exclusions prior to completing the
eligibility determination. In addition, if the state’s approved Medicaid state plan disregards
certain amounts or types of income or resources under section 1902(r)(2) of the Act for the
MSP groups, the state must apply all applicable disregards prior to completing the eligibility
determination.
The LIS leads data elements for unearned income and resources (except burial funds) show
combined total amounts for the applicant and spouse if living together. Under SSI
methodologies, the income and resources of an individual and their spouse (if their spouse is
not eligible for SSI as defined in 20 CFR 416.2260(d) (“ineligible spouse”)) are countable.
As such, states should deem the combined amounts of unearned income and resources in the
LIS leads data to the applicant instead of requesting additional information unless certain
conditions exist. If the LIS leads data indicate that EITHER:
• the individual has a spouse who is eligible for SSI (an “eligible spouse”);
OR

• the state applies less restrictive methodologies than SSI under section 1902(r)(2) of
the Act for all or a portion of an applicant’s spouse’s unearned income or resources;
AND the LIS data indicate that EITHER:
• the individual would be ineligible for the QMB group but eligible for the SLMB or
QI group, in which case the state should request ownership information. If the
applicant does not provide the ownership information and the state has the
information needed to determine eligibility for the SLMB or QI groups, the state must
approve eligibility for the SLMB or QI groups;
OR
• the individual would be ineligible for an MSP, in which case the state would reach
out to the individual as required by 42 CFR 435.911(e)(8) (see #6).
3. Not request information or documentation from the individual that SSA has already
provided through the LIS leads data unless the agency has information that is not reasonably
compatible with the leads data.
4. Seek additional information that is necessary for an MSP eligibility determination but that
the LIS leads data does not contain. Prior to completing the MSP eligibility determination
states must request additional information from the individual to:
a. Obtain information for certain income and/or resources if the state has not aligned its
methodologies for them with LIS through the election of 1902(r)(2) disregards in its
Medicaid State Plan. (As compared to methodologies used by SSI, LIS does not count
in-kind support and maintenance, interest and dividend income, non-liquid resources,
and the cash value of life insurance. While SSI methodologies disregard up to $1,500
of burial funds only if they are set aside in a separate account, LIS disregards up to
$1,500 of burial funds even if they are comingled with other funds).
b. Verify the individual’s U.S. citizenship or satisfactory immigration status. In
accordance with 42 CFR 435.406(a) and section 1137(d) of the Act, the state must
request the individual complete a declaration of U.S. citizenship or satisfactory
immigration status. If the individual returns a signed declaration to the state,
requirements to verify the declaration are as follows:
• US citizens: When a Medicare beneficiary returns a declaration of U.S.
citizenship, the state is not required to undertake further steps to verify
citizenship status. See section 1903(x) of the Act and 42 CFR
435.406(a)(1)(iii). Since LIS requires Part A or Part B enrollment, the vast
majority of LIS applicants are Medicare beneficiaries. In the rare instance the
LIS data shows an individual is not a Medicare beneficiary, the state would
need to verify U.S. citizenship status.

• Noncitizens: States must verify the applicant’s declaration of satisfactory
immigration status per 42 CFR 435.956 unless:
• the state has previously verified this information, and it’s included in the
individual's case record;
• the individual has not reported a change, and
• the agency has not received information indicating a potential change.
c. Obtain assignment of rights to medical support and third-party payers since the LIS
application does not contain this information. States with automatic assignment laws
do not need to obtain an executed assignment of rights and can instead inform the
individual of the terms and consequences of the state law. See 42 CFR 433.146;
https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/training-
and-handbook_256.pdf.
5. Determine the eligibility of the individual for MSP promptly and without undue delay,
consistent with timeliness standards established under 42 CFR 435.912.
6. If the income and resource information in the LIS leads data shows the individual is above
the MSP income and resource limits, the state may not complete an eligibility determination
without further steps. The state must:
a. Determine what additional information the state needs to make an MSP eligibility
determination and notify the individual, providing a minimum of 30 days to furnish
any needed information.31
b. Verify the individual’s eligibility for MSP in accordance with the agency’s
verification plan developed in accordance with 42 CFR 435.945(j).
7. In addition to and separate from any requests for additional information necessary for a
determination of MSP eligibility (and unless CMS approves otherwise), provide the
individual with information about the availability of additional Medicaid benefits on other
bases, and an opportunity to furnish such additional information as may be needed to
determine the individual’s Medicaid eligibility.32
1.6.2.4 Qualified Medicare Beneficiary Group
(Rev. 7; Issued:01-16-2025; Effective01-16-2025; Implementation: 01-16-2025)
31 The notice must tell the individual that they may be eligible for assistance with their Medicare premium and/or cost
sharing charges, but that the state needs additional information to determine such eligibility.
32 The notice must provide the scope of such benefits and responsibilities of the individual applying for such
benefits.

Under the QMB Medicaid eligibility group, states cover the Medicare Parts A and B premiums
and cost-sharing (i.e., deductibles, coinsurance, co-payments,33 and at state option, Part C
premiums) for individuals who:
• 	Meet one of the following conditions:
o 	Are entitled to Medicare Part A (including premium-free Part A and premium Part
A for certain individuals age 65 and over who need to pay a premium to enroll in
Part A);34
o 	For those without Part A, depending on the state have:
 	Part B only; or
 	Part B and conditional Part A
• 	Have income that does not exceed 100 percent of the FPL; and
• 	Have resources that do not exceed three times the maximum resource level under the SSI
program, adjusted for inflation per section 1905(p)(1) of the Act.35
Starting January 1, 2023, section 402(f) of the CAA, 2021 expanded the QMB eligibility group
to cover the premiums and cost-sharing for Part B-ID immunosuppressive drug coverage (QMB
Part B-ID) for individuals who:
• 	Are enrolled in Part B-ID and
33 Note that Medicare providers cannot charge QMBs for Medicare deductibles, coinsurance, and copays – even if
the individual agrees to pay them. See https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-
MLN/MLNMattersArticles/downloads/se1128.pdf.
34 Under section 1905(p)(1)(A) of the Act and 42 CFR 435.123, QMBs must either be entitled to premium-free Part
A, entitled to premium Part A for individuals age 65 and over, or, on or after January 1, 2023, enrolled in Part B-ID.
Individuals are not eligible for the QMB group if they are entitled to Part A based on 42 CFR 406.20(c) (Premium
Part A for individuals with disabilities who have lost SSDI and subsequently premium-free Part A after returning to
work).
35 Effective January 1, 2010, section 1905(p)(1) of the Act provides that the resource limit is three times the SSI
limit adjusted annually by increases in the Consumer Price Index. Note that the full LIS program and the QMB,
SLMB and QI groups used the same resource standard through December 31, 2023. Beginning January 1, 2024,
section 11404 of the Inflation Reduction Act of 2022 (Pub. L. 117–169) increased the income limit for the full LIS
program to income below 150 percent of the FPL and increased the resource limit to the resource limit that
previously had been applied to the partial LIS program. See 42 CFR 423.773(b)(1) and (b)(2). Note also that several
states have effectively increased income limits and/or increased or eliminated resource limits for their MSPs.

• 	Meet the QMB income and resource limits described above.
See sections 1902(a)(10)(E)(i) and 1905(p) of the Act; 42 CFR 435.123. Current minimum
federal income and asset limits for the QMB eligibility group are available at
https://www.medicaid.gov/medicaid/eligibility/seniors-medicare-and-medicaid-
enrollees/index.html. As described in section 1.6.2.1, states can modify their financial eligibility
methodologies to effectively increase the income or resource standard above the federal floor.
NOTE: The majority of individuals who qualify for QMB also qualify for a separate Medicaid
eligibility group that entitles them to the full range of services provided under the state plan, in
addition to Medicare cost-sharing assistance.36 These individuals are referred to as QMB plus.
Individuals who do not also qualify for full-benefit Medicaid are referred to as QMBSonly.
1.6.2.5 Effective Date of Qualified Medicare Beneficiary Group Coverage
(Rev. 6; Issued:04-26-24; Effective:04-26-24; Implementation:04-26-24)
Under section 1902(e)(8) of the Act, QMB enrollment is effective the month following “the
month in which the [QMB] determination first occurs.” States have flexibility in applying this
provision. States can choose to define the month in which the QMB determination first occurs
for the QMB coverage group as either: (1) the month that the applicant meets all requirements
for QMB or (2) the month in which the eligibility determination is made (if those months are
different).
For example, if an individual applies for Medicaid on January 1, and on February 15 the state
determines the individual met all of the requirements of QMB in January, the state may either
begin QMB coverage on February 1 (i.e., if state elects option one above) or March 1 (i.e., if the
state elects option two above).
For QMB-plus individuals determined eligible at application, the separate full-benefit Medicaid
coverage may be effective up to three months before the month of application, if the individual
received Medicaid covered services and would have been eligible at the time the services were
received, even though the same retroactive eligibility period does not apply to their QMB
benefits. See 42 CFR 435.915(a).
For information about the QMB effective date applicable to individuals who lack premium-free
Part A and reside in a group payer state, as required by CMS regulations at 42 CFR 406.21(c)(5),
see section 1.11.
1.6.2.6 Automatic Enrollment of SSI Recipients into the Qualified Medicare
Beneficiary Group
(Rev. 7; Issued:01-16-2025; Effective01-16-2025; Implementation: 01-16-2025)
36 In 2022, 79 percent of QMBs qualified for full-benefit Medicaid in addition to QMB (“QMB-plus”), while 21
percent of QMBs qualified for QMB alone (“QMB-only”).

Regulations at 42 CFR 435.909(b) require states take the following steps to automatically enroll
SSI recipients in the QMB group. No later than October 1, 2024:
• 	All states: Deem individuals determined eligible for the mandatory SSI or mandatory
209(b) state group (“SSI-based Medicaid”) eligible for the QMB group if they are
entitled to premium-free Part A. Start Part B buy-in coverage the first month they are
entitled to premium-free Part A and receiving SSI-based Medicaid and start QMB group
coverage the first day of the following month.
Example: if an individual is first enrolled in SSI-based Medicaid and entitled to
premium-free Part A in January 2025, the state would start paying the individual’s
Part B premiums under the buy-in agreement and deem the individual eligible for
the QMB group in January 2025. The individual’s QMB group coverage
(including Medicare cost-sharing coverage) would start February 1, 2025.
• 	Part A buy-in states: Deem individuals who have SSI-based Medicaid as eligible for the
QMB group if they lack premium-free Part A and are enrolled in Part B only. Start
Part B buy-in coverage the first month they are enrolled in Part B and receiving SSI-
based Medicaid and start QMB coverage (including Part A buy-in and Medicare cost-
sharing coverage) the first day of the following month.
Example: if an individual is first enrolled in both SSI-based Medicaid and Part B
only in January 2025, the state would start paying the individual’s Part B
premiums under the buy-in agreement and deem the individual eligible for the
QMB group in January 2025. The individual’s QMB group coverage (including
Part A buy-in and Medicare cost-sharing coverage) would start February 1, 2025
See sections 1.10 and 1.11 for more information about QMB enrollment for individuals
who lack premium-free Part A and reside in Part A buy-in states.
Option for group payer states to automatically enroll certain SSI recipients into QMB: As
described in section 1.11, individuals in group payer states who lack premium-free Part A
generally must enroll in premium Part A or conditional premium Part A at SSA during a
Medicare enrollment period prior to applying for QMB at their Medicaid agency. The regulation
at 42 CFR 435.909(b)(2) provides an exception to this requirement for individuals who:
• 	have SSI-based Medicaid;
• 	lack premium-free Part A; AND
• 	are enrolled in Part B only.
The regulation permits group payer states to deem these individuals (who have SSI-based
Medicaid, lack premium-free Part A, and are enrolled in Part B only) as eligible for the QMB
group the first month they are both enrolled in Part B and eligible for a Medicare enrollment

period. To request this option to bypass the need for premium or conditional premium Part A
enrollment at SSA, email ModernizetheMSPs@cms.hhs.gov.
Ex Parte Renewals in 1634 states: During an ex parte renewal for an individual eligible under
both the mandatory SSI and QMB groups, to renew their eligibility in both groups, states need
only verify that the individual still:
a. 	receives SSI (i.e., the state has not received data from SSA indicating a loss of SSI
status) and
b. 	is entitled to Medicare Part A (i.e., the state has not received data from SSA/CMS
indicating a loss of Part A)
1.6.2.7 Specified Low-Income Medicare Beneficiary Group
(Rev. 6; Issued:04-26-24; Effective:04-26-24; Implementation:04-26-24)
Under the SLMB Medicaid eligibility group, state Medicaid programs pay the Medicare Part B
premiums for individuals who:
• 	Are entitled to Medicare Part A (including individuals age 65 and over who are only
entitled to premium Part A);
• 	Have income that exceeds 100 percent but is less than 120 percent of the FPL; and
• 	Have resources that do not exceed three times the maximum resource level under the SSI
program, adjusted for inflation per section 1905(p)(1) of the Act.
Starting January 1, 2023, section 402(f) of the CAA, 2021 expanded the SLMB eligibility group
to cover the premiums for Part B-ID immunosuppressive drug coverage (SLMB Part B-ID) for
individuals who:
• 	Are enrolled in Part B-ID and
• 	Meet the SLMB income and resource limits described above.
See sections 1902(a)(10)(E)(iii) and 1905(p)(3)(A)(ii) of the Act; 42 CFR 435.124.
Current federal income and asset limits for SLMB are available at
https://www.medicaid.gov/medicaid/eligibility/medicaid-enrollees. As described in section
1.6.2.1, states can modify their financial eligibility methodologies and requirements above the
federal floor.
Unlike QMBs, the state is precluded from paying the Medicare Part A premiums for SLMBs.
Some individuals who qualify for SLMB also qualify for a separate Medicaid eligibility group
that entitles them to the full range of services provided under the state plan, in addition to

assistance with the Medicare Part B premium.37
SLMBs who also qualify for full-scope Medicaid are referred to as SLMB-plus and those who do
not are SLMB-only.
Coverage for an individual determined eligible under the SLMB group may be effective up to
three months before the month of application if the individual received Medicaid covered
services and would have been eligible at the time services were received. See 42 CFR
435.915(a).
1.6.2.8 Qualifying Individuals Group
(Rev. 7; Issued:01-16-2025; Effective01-16-2025; Implementation: 01-16-2025)
Under the QI Medicaid eligibility group, state Medicaid programs pay the Medicare Part B
premiums for individuals who:
• 	Are entitled to Medicare Part A (including individuals age 65 and over who are only
entitled to premium Part A);
• 	Have income that is at least 120 percent, but less than 135 percent, of the FPL;
• 	Have resources that do not exceed three times the maximum resource level under the SSI
program, adjusted for inflation per section 1905(p)(1) of the Act; and
• 	Are not otherwise eligible for another Medicaid eligibility group under the state plan.
Starting January 1, 2023, section 402(f) of the CAA, 2021 expanded the QI eligibility group to
cover the premiums for Part B-ID immunosuppressive drug coverage (QI Part B-ID) for
individuals who:
• 	Are enrolled in Part B-ID and
• 	Meet the QI income and resource limits described above.
See sections 1902(a)(10)(E)(iv) and 1905(p)(3)(A)(ii) of the Act ; 42 CFR 435.425.
Current federal income and asset limits for QIs are available at
https://www.medicaid.gov/medicaid/eligibility/seniors-medicare-and-medicaid-
enrollees/index.html. As described in section 1.6.2.1, states can modify their financial eligibility
methodologies and requirements above the federal floor.
As with SLMBs, the state is precluded from paying the Medicare Part A premiums for QIs.
37 In 2022, 26 percent of SLMBs qualified for “SLMB-plus”, while 74 percent of SLMBs qualified for SLMB-only.

Similarly, QI determinations may be retroactive for a maximum of three months prior to the
month of application, but retroactivity may not extend back to a prior calendar year. Unlike
QMB and SLMB, individuals cannot qualify for QI if they are eligible for a separate eligibility
group covered under the state plan. Thus, there is no QI-plus category.
State Medicaid programs enroll QIs only to the extent that their state Medicaid program has
available funding. The federal government makes annual allotments to states to fund the Part B
premiums. See section 1933(g) of the Act.
1.6.3 Buy-in Coverage Group Three: All Medicaid Eligibility Groups
(Rev. 7; Issued:01-16-2025; Effective01-16-2025; Implementation: 01-16-2025)
In their buy-in agreements, states can elect to pay Medicare Part B premiums for a buy-in
coverage group that includes all individuals eligible for Medicaid under the state plan. This
“catch-all” group includes the cash assistance groups and three MSP groups above, plus all other
individuals who are eligible for Medicaid, including, but not limited to, the poverty-level group
for individuals age 65 and older (sections 1902(a)(10)(A)(ii)(X); 1902(m)(1) of the Act); the
medically needy (section 1902(a)(10)(C) of the Act; 42 CFR 435.301); and institutionalized
individuals eligible under a special income level (section 1902(a)(10)(A)(ii)(V) of the Act; 42
CFR 435.236).
This buy-in coverage group also includes individuals eligible for an optional Medicaid buy-in
group for working individuals with disabilities described in sections 1902(a)(10)(A)(ii)(XVIII),
(XVI) and (XIII) of the Act provided they remain entitled to premium-free Part A. For
individuals under age 65, premium-free Part A continues at least 8 and ½ years following their
return to work including a 9-month trial work period. If the individual exhausts their entitlement
to premium-free Part A, they no longer qualify for Part B and therefore Part B buy-in coverage
(except in the rare case they enroll in premium Part A for working disabled individuals, for
which they must pay the Part A premium themselves). See section 1.3.2 for information on
Medicare coverage for individuals with disabilities under age 65 who return to work.
This buy-in coverage group does not include individuals who are eligible through section 1115
demonstrations but who do not otherwise qualify for Medicaid benefits included in the state plan.
See section 1843(h)(1)(A) of the Act.38
Generally, the effective date of coverage for Medicaid is up to three months before the month of
application if all eligibility criteria are met, with exception of the QMB group as described
above. See 42 CFR 435.915. The state is precluded from paying the Medicare Part A premiums
for SLMBs and QIs.
38 Section 1843(h)(1)(A) of the Act specifies that buy-in agreements cover “individuals who are eligible to receive
medical assistance under the plan of such State approved under title XIX.”

1.7 State Payment of Part A Premiums for Qualified Medicare Beneficiaries
(Rev. 7; Issued:01-16-2025; Effective01-16-2025; Implementation: 01-16-2025)
All states must pay the Part A premiums for QMB-eligible individuals who do not have
premium-free Part A. However, states can choose one of two methods to pay the Part A premium
for QMBs. States can expand their buy-in agreement with CMS under section 1818(g) of the Act
to include enrollment and payment of Part A premiums for QMBs who owe a premium for Part
A, or they can pay premiums through a group payer arrangement.
States that include payment of Part A premiums for QMBs in their buy-in agreements are called
‘‘Part A buy-in states.’’ As of January 1, 2025, 37 states and the District of Columbia have
chosen this option. In Part A buy-in states, individuals determined eligible for the QMB group
can enroll in premium Part A at any time of the year and without regard to late enrollment
penalties.
States that do not include Part A in their buy-in agreements and instead pay the Part A premiums
for QMBs using a group payer arrangement are known as Part A ‘‘group payer states.” As of
January 1, 2024, there are fourteen group payer states.39 The group payer arrangement allows
certain parties (for example, states) to pay Part A premiums for a class of beneficiaries. See 42
CFR 406.32(g); SSA POMS HI 01001.230 at https://secure.ssa.gov/poms.nsf/lnx/0601001230.
Group payer states can only enroll individuals in premium Part A during an applicable Medicare
enrollment period. Group payer states are also required to pay late enrollment penalties, if
applicable, for those individuals who did not enroll in Medicare Part A timely when they first
became eligible to do so (i.e., during their Medicare IEP).
See section 1.3.2 for more information about eligibility for premium Part A, section 1.6.2.4 for
more information about QMB, and sections 1.10 and 1.11 for information about enrollment in
the QMB group for individuals who need to pay a premium to enroll in Part A.
See the table in appendix 1.D, which identifies Part A buy-in states and group payer states as of
January 1, 2024.
NOTE: While states can choose to pay Part A premiums for individuals in the QMB group
through their buy-in agreements or a group payer arrangement, states must pay the Part A
premium for individuals in the smaller QDWI group through the group payer arrangement.
1.8 Conversion from Part A Group Payer to Part A Buy-in Status
(Rev. 6; Issued:04-26-24; Effective:04-26-24; Implementation:04-26-24)
39 California law requires the state to submit a SPA to become a Part A buy-in state on or after January 1, 2025. See
CA S.B. 311, amending CA Welf. & Inst. Code 14005.11 at https://legiscan.com/CA/text/SB311/2023. Upon
implementation, the number of group payer states will drop to 13.

A group payer state may elect to become a Part A buy-in state at any time. See 42 CFR
406.26(a). To effectuate this change, states must file a SPA to update their state buy-in pages in
section 3.2 of the state plan under ‘‘Coordination of Medicaid with Medicare and Other
Insurance of their state Medicaid Plan.’’ Interested states should contact the Medicare-Medicaid
Coordination Office at ModernizetheMSPs@cms.hhs.gov, which will then coordinate with the
state’s Center for Medicare and CHIP Services (CMCS) SPA Coordinator and the Division of
Premium Billing and Collections in CMS’ Office of Financial Management (see contact
information in chapter 6).
Enrollments under a new buy-in agreement can begin no earlier than the third month after the
month in which the agreement is executed (i.e., formal notification is signed by the state and
accepted by CMS). See 42 CFR 406.26(b).
1.9 Federal Financial Participation (FFP) for Medicare Costs
(Rev. 6; Issued:04-26-24; Effective:04-26-24; Implementation:04-26-24)
States can receive FFP for individuals who are cash assistance recipients and deemed recipients
of cash assistance and individuals who eligible for the relevant MSPs. See 42 CFR 431.625.
Specifically, states can seek FFP for the state payment of:
• Medicare Part B premiums, deductibles, coinsurance, and copays for cash assistance
recipients (SSI/SSPs) and deemed recipients of cash assistance;
• Part A or B premiums, deductibles, coinsurance, and copays for QMBs; and
• Part B premiums for SLMBs and QIs.
The state’s regular FMAP rate applies to these expenditures, except the Part B premiums for QIs,
which the federal government fully funds through annual allotments made to states. See section
1933(g) of the Act.
For eligible individuals who are enrolled in any other category of Medicaid, FFP is not available
for the state payment of Part B premiums. However, paying the premiums for these individuals
under buy-in helps states maximize federal funding for health care services.
First, states cannot obtain FFP for state Medicaid expenditures that could have been paid for
under Medicare Part B if the individual had been enrolled in Part B. See 1903(b)(1) of the Act;
42 CFR 431.625(d)(3). In addition, under CMS policy, states cannot require Medicaid applicants
and beneficiaries to apply for Medicare as a condition of eligibility unless the state pays any
Medicare cost-sharing or premiums the individual incurs.40 If the state does not pay the Part B
40 See final rule titled ‘‘Medicare Program: Implementing Certain Provisions of the Consolidated Appropriations
Act, 2021 and Other Revisions to Medicare Enrollment and Eligibility Rules” published in the November 3, 2022
Federal Register (88 FR 66454, 66468) at https://www.govinfo.gov/content/pkg/FR-2022-11-03/pdf/2022-
23407.pdf.

premiums for a Medicaid beneficiary and the individual does not enroll in Part B, CMS does not
consider Medicare Part B to be a liable third party under 42 CFR part 433, subpart D and,
therefore, the state must cover the items and services in accordance with its state Medicaid
plan.41
State agencies report gross expenditures (total computable) and apply the applicable FMAP on
the Quarterly Expenditure Report for Medical Assistance Payments (Form CMS-64).42
States should direct any questions about Form CMS-64 to the analyst within the CMCS Financial
Management Group (FMG), Division of Financial Operations (DFO) for their state.
1.10 Streamlined Enrollment Under a Buy-in Agreement
(Rev. 6; Issued:04-26-24; Effective:04-26-24; Implementation:04-26-24)
Buy-in agreements permit states to enroll eligible individuals covered under the agreement in
Medicare Part A or B, with the state paying their premiums, at any time of the year (without
regard to enrollment periods). CMS does not bill states for any applicable late enrollment
penalties due to late enrollment. See sections 1843 and 1818(g) of the Act.
States must directly enroll a Medicaid beneficiary included in the state’s Part B buy-in coverage
group if SSA has determined the individual eligible for Medicare (i.e., the individual is entitled
to Part A and/or enrolled in Part B).
For example, if a member of a Part B buy-in coverage group is entitled to premium-free Part A
but is not enrolled in Part B, the state should directly enroll the individual in Part B buy-in
without referring them to the SSA FO to file for Part B.
Similarly, if a QMB-eligible individual is already enrolled in Part B, a Part A buy-in state should
directly enroll that individual in QMB and Part A buy-in (without requiring the individual to first
file for Part A at the SSA FO). For additional information about enrolling QMB-eligible
individuals without premium-free Part A in the QMB group, see section 1.11.
1.11 Qualified Medicare Beneficiary Enrollment for Individuals Who Need to
Pay a Premium to Enroll in Part A
(Rev. 6; Issued:04-26-24; Effective:04-26-24; Implementation:04-26-24)
As described in section 1.7, all states must pay the Part A premium for individuals who are
enrolled in the QMB eligibility group. Part A buy-in states cover the Part A premiums for QMBs
41 See Coordination of Benefits and Third Party Liability (COB/TPL) in Medicaid handbook, chapter 1, section D.1
at https://www.medicaid.gov/sites/default/files/2020-08/COB-TPL-Handbook.pdf.
42 The expenditures for allowable Medicare Part A premiums are claimed on line 17.A of the Form CMS-64.9 or
CMS-64.9P (whichever applies). The expenditures for allowable Medicare Part B premiums are claimed on line
17.B of the Form CMS-64.9 or CMS-64.9P.

under their buy-in agreements. Group payer states do not include Part A premium payments for
QMBs in their buy-in agreement and instead use the group payer arrangement to pay Part A
premiums for QMBs.
As described in section 1.6.2.4, to qualify for the QMB group under section 1905(p)(1) of the
Act, an individual must be entitled to Part A (see definition of “entitlement to Part A” in section
1.1). Further, section 1905(a) of the Act specifies that payments of Medicare cost-sharing for
QMBs (including Part A premiums) are ‘‘medical assistance’’ for purposes of FFP, if made in
the month following the month in which the individual becomes a QMB.
Because a literal read of the law would produce a result that essentially nullifies the impact of the
QMB benefit and buy-in statutory provisions, CMS has a long-standing policy under which
states can receive FFP for paying an individual’s Part A premium the first month of entitlement,
thereby triggering both Part A entitlement and QMB coverage.
For individuals who reside in Part A buy-in states, the process for enrolling in QMB is more
streamlined as compared to individuals who reside in group payer states.
Part A buy-in states: Part A buy-in states can determine an individual eligible for the QMB
group if they are enrolled in Part B only and not yet entitled to Part A. Enrollment in Part B is
sufficient to meet the requirement that the individual be entitled to Part A for the purposes of the
state’s QMB eligibility determination.
Individuals can enroll in Part A at any time of the year without regard for Medicare enrollment
periods or late enrollment penalties if the state pays their Part A premium under its buy-in
agreement.43
Group payer states: Group payer states can approve eligibility for individuals under the QMB
group after SSA has enrolled them in premium Part A or conditional premium Part A (the
‘‘conditional enrollment process”). The conditional enrollment process enables low-income
individuals to apply at SSA for premium Part A on the condition that they will only be enrolled
in Part A if the state determines they are eligible for the QMB group.
If an individual conditionally files for Part A, then applies for the QMB group with their state
Medicaid program, the individual can effectively become simultaneously enrolled in Part A and
the QMB group if the individual meets all other QMB eligibility requirements.
The conditional enrollment acts as a placeholder in SSA’s system. Premium Part A entitlement is
only effective with the individual’s enrollment in QMB. The Medicare Part A start date will
43 Note that if a Part A buy-in state resident lacks both Parts A and Part B, the state cannot determine the individual
eligible for QMB and enroll them in Part A buy-in until SSA enrolls them in premium Part A or conditional
premium Part A. Such individuals can conditionally enroll in premium Part A at any time of the year (without regard
for Medicare enrollment periods or late enrollment penalties, if applicable). See SSA POMS HI 00801.140 at
https://secure.ssa.gov/apps10/poms.nsf/lnx/0600801140.

reflect the QMB start date that the state reports to CMS. If the state does not determine the
individual eligible for QMB, SSA will not establish premium Part A entitlement.
When processing the conditional Part A enrollment, SSA will refer the individual to the
appropriate state Medicaid office to apply for the QMB group and may give the individual a
screen shot of the application to bring to the state as proof of the conditional enrollment. The
state can also query SSA’s State Verification and Exchange System (SVES) to verify the
conditional Part A enrollment. See SSA POMS HI 00801.140 at
https://secure.ssa.gov/apps10/poms.nsf/lnx/0600801140 for more information about the
conditional enrollment process.
Although the conditional enrollment process provides a way for individuals to enroll in the QMB
eligibility group without paying their own Part A premiums upfront, it requires individuals to
complete a two-step process to enroll in QMB, which can be difficult to complete.
Group payer states can elect to bypass the conditional enrollment process for individuals who
have SSI-based Medicaid, are enrolled in Part B only, and are eligible for a Medicare enrollment
period, as described in 42 CFR 435.909(b)(2). For more information about this option, see
section 1.6.2.6.
Individuals in group payer states who do not enroll in premium Part A or conditional premium
Part A during their IEP can only file for premium Part A during the annual GEP (January 1
through March 31) or an applicable SEP.
No later than April 1, 2026, 42 CFR 406.21(c)(5) requires states to start QMB coverage as early
as the month Part A entitlement begins (i.e., month after enrollment) for individuals who enroll
in premium Part A or conditional premium Part A during a Medicare enrollment period. QMB
coverage for such individuals starts the month premium Part A entitlement begins (if the state
determines the individual has met the eligibility requirements for the QMB group in the same
month that Part A enrollment occurs), or a month later than the month of Part A entitlement (if
the individual is determined eligible for the QMB group the month Part A entitlement begins or
later).
1.12 Policy Regarding Which Entity Initiates Buy-in
(Rev. 6; Issued:04-26-24; Effective:04-26-24; Implementation:04-26-24)
Depending upon the circumstances, CMS or the state will generally initiate buy-in enrollment
(“accretion”). This section describes which entity initiates the accretion.
NOTE: In certain circumstances, however, SSA should take steps to initiate Part B buy-in
through the Public Welfare Accretion process for Medicaid beneficiaries who file a Medicare
application and who are in an eligibility group that is included in the state buy-in agreement.
This most commonly occurs when a full-benefit Medicaid beneficiary newly qualifies for
Medicare and applies for Medicare Part B before SSA has established Medicare entitlement and

before the state or territory has established Part B buy-in. See SSA POMS HI 00815.030 at
https://secure.ssa.gov/poms.nsf/lnx/0600815030. The Public Welfare accretion process allows
SSA field offices to establish Medicare Part B through state buy-in, making the state responsible
for paying the Medicare Part B premiums, instead of the individual.
For more information about PW accretions, see section 2.8; SSA POMS HI 00815.030 at
https://secure.ssa.gov/poms.nsf/lnx/0600815030.
1.12.1 Part B Buy-in for Cash-Related Recipients (SSI/SSPs)
(Rev. 6; Issued:04-26-24; Effective:04-26-24; Implementation:04-26-24)
SSA regularly communicates with states regarding who is entitled to SSI and/or federally
administered SSPs through SSA data systems, such as the State Data Exchange (SDX). See
section 2.4.2 for a list of SSA systems for states. In addition, SSA sends information to CMS
about SSI/SSPs recipients who qualify for Medicare which, in turn, assists states in enrolling
cash recipients in Part B buy-in. See section 2.5.1.1 for more information.
The state is responsible for accreting individuals the state has found eligible for Medicaid in the
SSI criteria category to the state’s buy-in rolls.
In auto-accrete states and states with 1616 agreements, CMS automatically initiates state
payment of Part B premiums for individuals (“auto-accretes” them into Part B buy-in) only after
SSA notifies CMS that the individual is entitled to SSI and eligible for Medicare. In states with
1616 agreements, CMS will auto-accrete individuals who receive SSI only, or SSI in
combination with SSPs, or SSPs-only.
NOTE: Although CMS generally initiates auto-accretions for these individuals, the state is
responsible for taking action to ensure all eligible individuals are enrolled in Part B buy-in.
In alert states (SSI criteria and 209(b) states), CMS sends states “SSI alert notification” records
for SSI individuals who are also eligible for Medicare. Alert states are responsible for accreting
SSI/SSP recipients the state has found eligible for Medicaid to the state’s buy-in rolls.
States must always initiate:
• Part A or B buy-in for QMBs;
• Part A buy-in for QDWIs;
• Part B buy-in for deemed recipients of cash assistance;
• Part B buy-in for SLMB and QI; and
• Part B buy-in for other full-benefit Medicaid recipients.

1.13 Definition of Part B Buy-in Coverage Period
(Rev. 6; Issued:04-26-24; Effective:04-26-24; Implementation:04-26-24)
1.13.1 Beginning of Part B Buy-in Coverage
(Rev. 6; Issued:04-26-24; Effective:04-26-24; Implementation:04-26-24)
For an individual enrolled in the “required eligibility groups” (i.e., cash assistance recipients or
deemed recipients of cash assistance) or the three MSPs, Part B buy-in begins the later of:
• 	The first month in which the individual meets the requirements both for eligibility in the
buy-in group (i.e., the effective date of the individual’s full-benefit Medicaid or MSP
coverage) and eligibility for Medicare Part B; or
• 	The first month in which the individual meets the requirements both for eligibility in the
buy-in group (i.e., the effective date of the individual’s full-benefit Medicaid or MSP
coverage) and eligibility in the buy-in group (i.e., the effective date of the individual’s
full-benefit Medicaid or MSP coverage) and eligibility for Medicare Part B; or
• 	The effective date of the buy-in agreement or modification that includes the buy-in group
to which the individual belongs (defined as the third month after the document’s
execution).
See 42 CFR 407.47(b) and (c).
For an individual enrolled in one of the “other Medicaid eligibility groups” (when the buy-in
coverage group includes all Medicaid eligibility groups), Part B buy-in begins the later of:
• 	The second month after the individual meets the requirements both for eligibility in the
buy-in group (i.e., the effective date of the individual’s Medicaid coverage) and
eligibility for Medicare Part B; or
• 	The effective date of the buy-in agreement or modification that includes the buy-in group
to which the individual belongs (defined as the third month after the document’s
execution).
See 42 CFR 407.47(d).
As described in sections 1.6.2.4 and 1.6.2.7, many individuals who qualify for the QMB
eligibility group and some individuals who qualify for the SLMB eligibility group also
separately qualify for a full-benefit Medicaid eligibility group (i.e., QMB-plus, and SLMB-plus).
While an individual’s separate Medicaid eligibility or SLMB eligibility can be retroactive up to 3
months before the application, QMB eligibility is effective no earlier than the month following
the month of the determination of such eligibility. See 42 CFR 435.915 and sections 1902(e)(8)
and 1905(a) of the Act. Therefore, if a state determines that an individual is eligible for the QMB

eligibility group and a separate Medicaid eligibility group, the Part B buy-in coverage period
may start based on the non-QMB Medicaid eligibility group under which the individual is
determined eligible before the coverage period corresponding to the QMB eligibility group
begins.
To illustrate, for a QMB-plus individual, the start of Part B buy-in coverage is often earlier than
the QMB effective date.
For example, if a Medicare-eligible individual—
• Applies for Medicaid on January 1 of a particular calendar year;
• Is determined in January to be eligible under the eligibility group described in section
1902(a)(10)(A)(ii)(X) of the Act (relating to individuals who have incomes up to the FPL and are
either 65 years old or older or with disabilities, which is considered an ‘‘other Medicaid
eligibility group’’) retroactive to October 1 of the previous calendar year;
• Is determined in January to meet all eligibility requirements for the QMB eligibility group; and
• The individual’s state has elected to include all Medicaid beneficiaries eligible for Medicare in
its Part B buy-in agreement, then, in this example, Part B buy-in starts on November 1 of the
previous calendar year (i.e., the buy-in start date for ‘‘other Medicaid eligibility groups,’’ which
is the second month the individual is eligible for the Medicaid eligibility group and Medicare).
Part A buy-in will begin February 1 of the current year.44
NOTE: In some instances, SSA determines Medicaid beneficiaries eligible for premium-free
Part A for a retroactive period.45 The individual is also retroactively eligible to enroll in Part B
over this period. If a state learns that SSA established retroactive Medicare Part A entitlement for
a member of a buy-in coverage group, the state must review the individual’s eligibility for Part B
buy-in over the retroactive period.
Beginning January 1, 2024, state liability for retroactive Medicare Part B premiums for full-
benefit Medicaid beneficiaries under a buy-in agreement is limited to a period no greater than 36
44 While the individual’s QMB eligibility under the state plan will not become effective until February of the
particular calendar year, Part B buy-in starts on November 1 of the previous calendar year, because the individual
was eligible in a Medicaid eligibility group that was included in the state’s buy-in coverage group effective in
October of the previous calendar year (that is, the buy-in start date for ‘‘other Medicaid eligibility groups,’’ which is
the second month the individual is eligible for a buy-in coverage group and Medicare).
45 This generally occurs when an individual under age 65 who files a claim for disability benefits at SSA receives a
favorable Social Security Disability Insurance (SSDI) award multiple years after the initial application, and SSA
determines the individual eligible for SSDI benefits at or up to 12 months prior to the point of application.
Individuals entitled to SSDI become entitled to premium-free Medicare Part A after 24 months of entitlement to
SSDI, but in certain cases, an individual’s start date for SSDI benefits is retroactive more than 24 months. In that
case, the determination of SSDI eligibility for a retroactive period for the individual means that the individual’s
premium-free Part A entitlement is retroactive as well.

months prior to the date of the Medicare enrollment determination, as discussed in section 1.4.3.
See 42 CFR 407.47(f)(1).
States can request a good cause exception for retroactive periods of less than 36 months if the
state could not benefit from Medicare (e.g., based on the state’s Medicaid recoupment policy)
AND limiting state liability would not result in harm to the beneficiary. The state or beneficiaries
can also request a good cause exception for retroactive periods of more than 36 months if a 36-
month limit would result in harm to the beneficiary.
In evaluating the good cause exception request, CMS’ primary consideration would be whether
the beneficiary has unpaid medical bills and needs Medicare coverage during the retroactive
period for unpaid medical bills.46
States can email DPBCStateBuy-in@cms.hhs.gov to request a good cause exception. Individuals
can seek an exception by contacting 1-800-MEDICARE.
1.13.2 End of Part B Buy-in Coverage
(Rev. 6; Issued:04-26-24; Effective:04-26-24; Implementation:04-26-24)
Part B buy-in coverage ends with the earliest of the events specified below:
• Loss of membership in the buy-in group – The last day of the month in which the
individual is enrolled in one or more Medicaid categories under the buy-in group.
• Death – Coverage ends on the last day of the month in which the individual dies.
• Loss of enrollment in Medicare Part A – If an individual is under age 65 and is no
longer enrolled in Medicare Part A (i.e., no longer qualifies for SSA disability benefits),
Part B buy-in ends on the last day of the last month for which the individual is enrolled in
Part A.
• Termination or modification of the buy-in agreement – If the state’s buy-in agreement
is terminated or modified to restrict coverage to a narrower buy-in group, coverage for an
individual ends on the last day of the last month for which the agreement is in effect or
covers the broader group.
CMS may modify the effective date of the deletion requested by the state based on CMS system
processing rules that limit the retroactivity of Part B deletions to two months prior to the
“processing month.” See 42 CFR 407.48(c)(2). To learn more about CMS processing limits
46 See the Medicare Eligibility and Enrollment final rule (88 FR 66454, 66487) at
https://www.govinfo.gov/content/pkg/FR-2022-11-03/pdf/2022-23407.pdf.

intended to prevent excessive hardship for beneficiaries, see section 2.6.1.3.
If a beneficiary enrolled in a Medicaid eligibility category included in the state’s buy-in group
experiences a change in circumstance that may impact eligibility, the state must conduct a
redetermination based on the change in circumstance. See 42 CFR 435.916(f). See section 1.4.4
for information about state requirements for Medicaid redeterminations and buy-in coverage
when an individual enrolled in state buy-in experiences a change in circumstances. For more
information about the end of state buy-in, see SSA POMS HI 00815.021 at
https://secure.ssa.gov/poms.nsf/lnx/0600815021.
1.14 Definition of Part A Buy-in Coverage Period
(Rev. 6; Issued:04-26-24; Effective:04-26-24; Implementation:04-26-24)
1.14.1 Beginning of Part A Buy-in Coverage
(Rev. 6; Issued:04-26-24; Effective:04-26-24; Implementation:04-26-24)
Part A buy-in begins the later of:
• The effective date of the buy-in agreement or modification that covers QMBs (defined as
the third month after the document’s execution); or
• The month the individual is enrolled in premium Part A and QMB.
See 42 CFR 406.26(b).
See sections 1.10 and 1.11 for information about QMB enrollment for individuals who must pay
a premium to enroll in Part A.
1.14.2 End of Part A Buy-in Coverage
(Rev. 7; Issued:01-16-2025; Effective01-16-2025; Implementation: 01-16-2025)
Part A buy-in coverage ends with the earliest of the events specified below:
• Loss of QMB status – The last day of the month in which the individual is enrolled in
the QMB group.
• Death – Coverage ends on the last day of the month in which the individual dies.
• Enrollment in premium-free Part A – If an individual enrolls in premium-free Part A,
Part A buy-in coverage ends on the last day of the last month the individual is enrolled in
premium Part A, at which point the beneficiary will be entitled to premium-free Part A.
• Termination of the Part A buy-in agreement – If the state terminates its Part A buy-in

agreement (i.e., removes the payment of Part A premiums for QMB from the buy-in
agreement), coverage through the buy-in agreement will end. However, payment of the
Part A premiums for QMB individuals must continue under the group payer arrangement.
CMS may modify the effective date of the deletion requested by the state based on the CMS
regulation limits the Part A deletion date to the month CMS receives the deletion. See 42 CFR
406.26(c). CMS terminates (deletes) Part A buy-in coverage effective at the end of the month in
which the state's deletion request is received (up until the last business day of the month), even if
the individual lost eligibility in an earlier month. To learn more about CMS processing of Part A
deletion requests for individuals who lose QMB status, see section 2.6.1.4.

1.15 Implications for Beneficiaries When State Buy-in Coverage Ends
(Rev. 7; Issued:01-16-2025; Effective01-16-2025; Implementation: 01-16-2025)
When a state stops paying the Part A or Part B premium for an individual, Medicare enrollment
continues without interruption, with the beneficiary assuming responsibility for paying the
premiums. See 42 CFR 406.26(d) and 407.50(a).
• Premiums paid under a state buy-in agreement: The beneficiary is deemed to have
enrolled during the IEP and is liable for the standard base premium amount even if they
had been paying a late enrollment penalty prior to enrollment in buy-in.
• Premiums paid under state group payer arrangement: The beneficiary becomes liable for
the premium amount the state paid (i.e., the Medicare Part A premium may be subject to
a late enrollment penalty if the state had been paying one).
If the beneficiary receives Social Security (OASDI), RRB or OPM benefits, the respective
issuing entity deducts the Part B premium amount from their monthly benefit payment. If the
beneficiary does not receive Social Security, RRB or OPM benefits, CMS will directly bill them
for Medicare Part A and/or B premiums.47
For more information about the implications when buy-in ends, see SSA POMS HI 00815.021 at
https://secure.ssa.gov/poms.nsf/lnx/0600815021.
For information about beneficiary options for financial relief from retroactive Part B premium
when buy-in ends, see section 1.15.2.
1.15.1 Voluntary Withdrawal (Termination) From Medicare
(Rev. 6; Issued:04-26-24; Effective:04-26-24; Implementation:04-26-24)
Once the state ends buy-in coverage (or state payment of Part A premiums for QMBs in group
payer states), SSA will mail the beneficiary a notice of state buy-in termination (“buy-out
notice”).
The buy-out notice describes the option to withdraw from Medicare Part A and/or Part B. If the
beneficiary files Form CMS-1763 (Request For Termination of Premium Part A, Part B or Part B
Immunosuppressive Drug Coverage)48 within 30 days of the buy-out notice date, Part A and/or
47 Part B premiums are billed quarterly, whereas Part A alone and Part A and Part B combined are billed monthly. A
grace period for premium payment extends until the end of the third month of unpaid premiums; after 90 days the
direct billing notice will include a termination date of coverage. See SSA POMS HI 01001.030 at
https://secure.ssa.gov/poms.nsf/lnx/0601001030.
48 Form CMS-1763 is available at https://www.cms.gov/medicare/cms-forms/cms-forms/downloads/cms1763.pdf.

Part B will generally terminate the month buy-in has ended.
NOTE: The notice may be dated after buy-in has already terminated.
• 	If the beneficiary files Form CMS-1763 during the six months following the loss of buy-
in, Medicare coverage ends at the end of the month in which the beneficiary filed the
notice.
• 	If a beneficiary waits more than six months after buy-in coverage ends to file Form CMS-
1763, Medicare coverage ends at the end of the month after the month in which the
beneficiary notifies SSA or CMS that they wish to withdraw.
1.15.2 SSA Options for Financial Relief from Retroactive Premium Billing
(Rev. 7; Issued:01-16-2025; Effective01-16-2025; Implementation: 01-16-2025)
SSA may initially deduct from OASDI benefit payments premium amounts of up to three months
(current month plus two retroactive months) when Part B buy-in coverage ends.49
Beneficiaries can pursue either or both of the options below to obtain financial relief from
retroactive Part B (or Part A) premium billing.
• 	Premium Waiver - Beneficiaries who believe they cannot afford to pay the retroactive
premiums can request a premium waiver by submitting a Request for Waiver of
Overpayment Recovery, available at https://www.ssa.gov/forms/ssa-632-bk.pdf to their
local SSA office. If SSA grants the waiver request and has already deducted retroactive
Medicare premiums from the beneficiary’s benefit payment or the individual has made
the direct premium payment to CMS, SSA will refund the waived amount to the
beneficiary. See SSA POMS HI 00830.015 at
https://secure.ssa.gov/apps10/poms.nsf/lnx/0600830015 for more information about
retroactive premium waivers.
• 	Installment Payments for Retroactive Premiums - Beneficiaries may request an
installment plan for retroactive premiums from their local SSA office or by contacting
SSA’s national 800 number (1-800-772-1213 or TTY 1-800-325-0778). To qualify,
individuals must attest they cannot afford to pay the retroactive premiums in one lump
sum. Installment payments must be at least $15 per month. If SSA approves an
installment plan and has already deducted retroactive Medicare premiums from the
beneficiary’s benefit payment or the individual has made the direct premium payment to
CMS, SSA will refund to the beneficiary the retroactive premiums less the installment
payments owed. For more information about installment payments, see SSA POMS HI
49 See section 2.6.1.3, SSA POMS HI 00815.042 at http://policynet.ba.ssa.gov/poms.nsf/lnx/0600815042, SSA
POMS HI 01005.001 at https://secure.ssa.gov/apps10/poms.nsf/lnx/0601005001, and SSA POMS HI 01005.015 at
https://secure.ssa.gov/apps10/poms.nsf/lnx/0601005015.

00805.180 at https://secure.ssa.gov/poms.nsf/lnx/0600805180 and SSA POMS HI
00830.060 at https://secure.ssa.gov/apps10/poms.nsf/lnx/0600830060.

Appendix 1.A Dual Eligibility Categories and Assistance with Medicare Part A and Part B Costs
(Rev. 7; Issued:01-16-2025; Effective01-16-2025; Implementation: 01-16-2025)
Category 	Monthly
Income*
Resources* 	Covers
Part A
premium
(when
applicable)
Covers
Part B
premium
Covers
Part B-
ID
premium
Covers
Parts A
and B
cost-
sharing
Covers
Part B-
ID cost
sharing
Full-
benefit
Medicaid
coverage**
QMB-
only
FPL ≤ 100% 	<3 times the SSI
resource limit,
adjusted for
inflation*
X 	X 	X***
QMB-
plus**
FPL ≤
100%
<3 times the SSI
resource limit,
adjusted for
inflation*
X 	X 	X*** 	X
QMB-
Part B-
ID
FPL ≤
100%
<3 times the SSI
resource limit,
adjusted for
inflation*
X 	X
SLMB-
only
>
100% FPL <
120%
<3 times the SSI
resource limit,
adjusted for
inflation*
X
SLMB-
plus**
> 100% FPL
< 120%
<3 times the SSI
resource limit,
adjusted for
inflation*
X 	Depends
on state
plan*****
X
SLMB-
Part B-
ID
> 100% FPL
< 120%
<3 times the SSI
resource limit,
adjusted for
inflation*
X

Category 	Monthly
Income*
Resources* 	Covers
Part A
premium
(when
applicable)
Covers
Part B
premium
Covers
Part B-
ID
premium
Covers
Parts A
and B
cost-
sharing
Covers
Part B-
ID cost
sharing
Full-
benefit
Medicaid
coverage**
QI 	≥ 120% FPL
< 135%
<3 times the SSI
resource limit,
adjusted for
inflation*
X
QI-Part
B-ID
≥ 120% FPL
< 135%
<3 times the SSI
resource limit,
adjusted for
inflation*
X
QDWI 	≤200%
FPL
<2 times the SSI
resource limit
X
Full-
benefit
Medicaid
**
Determined by
state
Determined by
state
Depends on
state Buy-in
Agreement****
Depends on
state
plan*****
X
* CMS releases the income and resource limits for all states and the District of Columbia annually. Higher income limits apply for Alaska and Hawaii. The resource limit
calculation for QMBs, SLMBs, and QIs is three times the SSI resource limit, adjusted for inflation per section 1905(p)(1) of the Act. In determining countable income and
resources for MSP eligibility, states must use income and resource methodologies no more restrictive than SSI’s. However, under the authority of section 1902(r)(2) of the Act,
states have the flexibility to adopt more liberal income and resource methodologies than used by SSI to effectively increase the QMB, SLMB and QI income and/or resource
limits above the federal limits. Some states have used section 1902(r)(2) authority to effectively eliminate any resource criteria for the MSP groups.
** “Full-benefit” Medicaid coverage, in the context of individuals who are considered dually eligible, generally refers to coverage for a range of items and services, beyond
coverage for Medicare premiums and cost-sharing, that certain individuals are entitled to under 42 CFR 440.210 and 440.330. Individuals who are QMB-plus/SLMB-plus
receive full-benefit Medicaid in addition to Medicare cost-sharing and premiums coverage. Individuals who receive full-benefit Medicaid only are entitled to Medicare Part A
and/or enrolled in Part B, and qualify for full-benefit Medicaid benefits, but not the QMB or SLMB eligibility groups.S
*** While individuals enrolled in QMB-only and QMB-plus do not pay Medicare deductibles, coinsurance, or copays, they may have a small Medicaid copay for services that
Medicare and Medicaid cover.

**** States pay the Part B premiums if they include all Medicaid categories in their Part B buy-in coverage group.
***** Beneficiary pays no more than the Medicaid copay amount (if applicable) for state plan services covered by both Medicare and Medicaid if the provider participates in
Medicaid. Also, all Medicare providers (regardless of Medicaid participation) must accept the Medicare-allowed amount (“Medicare assignment”) as payment in full for Part B
services furnished to dual eligible beneficiaries.

Appendix 1.B Dual Eligibility Category Descriptions
(Rev. 7; Issued:01-16-2025; Effective01-16-2025; Implementation: 01-16-2025)
Qualified Medicare Beneficiaries (QMBs) without other Medicaid (QMB-Only – also
known as QMB “partial-benefit”) are enrolled in Medicare Part A (or if uninsured for Part A,
have filed for premium Part A on a conditional basis), have income up to 100 percent of the
federal poverty level (FPL) and resources that do not exceed three times the limit for
supplementary security income (SSI) eligibility with adjustments for inflation, and are not
otherwise eligible for full-benefit Medicaid coverage. Medicaid pays their Medicare Part A
premiums, if any, and Medicare Part B premiums. Medicare providers may not bill QMBs for
Medicare Parts A and B cost-sharing amounts, including deductibles, coinsurance, and copays.50
Providers can bill Medicaid programs for these amounts, but states have the option to reduce or
eliminate the state’s Medicare cost-sharing payments by adopting policies that limit payment to
the lesser of (a) the Medicare cost-sharing amount, or (b) the difference between the Medicare
payment and the Medicaid rate for the service.
Individuals in the limited Part B-ID benefit may also qualify for the QMB eligibility group with
coverage limited to the Part B-ID premium and/or cost-sharing, a status known as QMB-Part B-
ID.
QMBs with full-benefit Medicaid (QMB-Plus – also known as QMB “full-benefit”) meet the
QMB-related eligibility requirements described above and the eligibility requirements for a
separate categorical Medicaid eligibility group covered under the state plan. In addition to the
coverage for Medicare premiums and cost-sharing described above, QMB-plus individuals
receive the full range of Medicaid benefits applicable to the separate eligibility group for which
they qualify. Medicaid pays their Medicare Part A premiums, if any, and Medicare Part B
premiums. Medicare providers may not bill QMBs for Medicare Parts A and B cost-sharing
amounts, including deductibles, coinsurance, and copays.51 Providers can bill Medicaid
programs for these amounts, but states have the option to reduce or eliminate the state’s
Medicare cost-sharing payments by adopting policies that limit payment to the lesser of (a) the
Medicare cost- sharing amount, or (b) the difference between the Medicare payment and the
Medicaid rate for the service. QMBs with full-benefit Medicaid pay no more than the Medicaid
copay (if applicable) for services covered in the state plan (i.e., services furnished by a Medicaid
provider and that Medicaid covers, but Medicare does not). These individuals pay Medicare cost-
sharing for Medicare-covered care not included in the state plan unless the state chooses to pay
these costs.
Specified Low-Income Medicare Beneficiaries (SLMBs) without other Medicaid (SLMB-
50 However, states may charge QMBs a nominal Medicaid copay for services that Medicare and Medicaid cover in
accordance with section 1916(a) of the Act.
51 However, states may charge QMBs a nominal Medicaid copay for services that Medicare and Medicaid cover in
accordance with section 1916(a) of the Act.

Only – also known as SLMB “partial-benefit”) are enrolled in Part A and have income
between 100 and 120 percent of the FPL, and resources that do not exceed three times the limit
for supplementary security income (SSI) eligibility with adjustments for inflation. Medicaid pays
only the Medicare Part B premiums for this group.
Individuals enrolled in the limited Part B-ID benefit are also eligible for the SLMB-Only group,
if they meet the SLMB income and resource requirements described in the preceding paragraph.
For these individuals, Medicaid pays the Part B-ID premium.
SLMBs with full-benefit Medicaid (SLMB-Plus – also known as SLMB “full-benefit”) meet
the SLMB-related eligibility requirements described above, and the eligibility requirements for a
separate categorical Medicaid eligibility group covered under the state plan. In addition to
coverage for Medicare Part B premiums, these individuals receive full-benefit Medicaid
coverage (i.e., the package of benefits provided to the separate Medicaid eligibility group for
which they qualify). For Medicaid-covered services (i.e., services furnished by a Medicaid
provider and that either: (1) Medicare and Medicaid, or (2) Medicaid, but not Medicare, cover), a
SLMB-Plus beneficiary pays no more than a nominal Medicaid copay (if applicable).52
Qualifying Individuals (QIs) are enrolled in Part A and have income of at least 120 but less
than 135 percent of the FPL, resources that do not exceed three times the limit for SSI eligibility
with adjustments for inflation and are not eligible for any other eligibility group under the state
plan. QIs receive coverage for their Medicare Part B premiums, to the extent their state Medicaid
programs have available slots. The federal government makes annual allotments to states to fund
the Part B premiums.
Individuals enrolled in the limited Part B-ID benefit are also eligible for the QI group, if they
meet the QI requirements described in the preceding paragraph. For these individuals, Medicaid
pays the Part B-ID premium.
Qualified Disabled and Working Individuals (QDWIs – also known as QDWI “partial-
benefit”) became eligible for premium-free Part A by virtue of qualifying for Social Security
Disability Insurance (SSDI) benefits, but lost those benefits, and subsequently premium-free
Medicare Part A, after returning to work. QDWIs have income that does not exceed 200 percent
of the FPL, resources that do not exceed two times the SSI resource standard and are not
otherwise eligible for Medicaid. Medicaid pays the Medicare Part A premiums only.
Full-benefit Medicaid: These individuals are entitled to Medicare Part A and/or enrolled in Part
B, and qualify for full Medicaid benefits, but not the QMB or SLMB groups. Individuals in this
category are sometimes referred to as “other full duals.” Full-benefit Medicaid coverage refers to
the package of services, beyond coverage for Medicare premiums and cost-sharing, that certain
individuals are entitled to under 42 CFR 440.210 and 440.330. For Medicaid-covered services
(i.e., services furnished by a Medicaid provider and that either: (1) Medicare and Medicaid, or
52 States may apply cost-sharing, such as copayments, deductibles, and/or premiums, to certain Medicaid
beneficiaries in accordance with 42 CFR 447.52 to 447.56.

(2) Medicaid, but not Medicare, cover), a full-benefit Medicaid beneficiary pays no more than
the Medicaid coinsurance53 (if applicable). For Medicare-only covered services (i.e., services
covered by Medicare, but not Medicaid), these individuals pay the Medicare cost-sharing unless
the state chooses to cover Medicare cost-sharing for all Medicare- covered services for this
eligibility group.
53 States may apply Medicaid cost-sharing, such as copayments, deductibles, and/or premiums, to certain Medicaid
beneficiaries in accordance with 42 CFR 447.52 through 447.56.

Appendix 1.C Medicaid Effective Dates and Buy-in Start and Stop
Dates
(Rev. 6; Issued:04-26-24; Effective:04-26-24; Implementation:04-26-24)
Cash
assistance
(SSI/SSPs)
and
Deemed
Recipients
of Cash
Assistance
Eligibility
Groups
QMB
Eligibility
Group
SLMB
Eligibility
Group
QI
Eligibility
Group
Other
Full-
Benefit
Medicaid
Eligibility
Groups
Medicaid eligibility effective
up to 3 months before the
month of application.
42 CFR 435.915(a)  	 	 	
Medicaid eligibility effective
the month after the month of
the QMB eligibility
determination.
Section 1902(e)(8) of the Act

Part B Buy-in coverage starts
the month an individual
qualifies for Medicare and is
eligible for a Medicaid group
in the buy-in agreement.*, **
42 CFR 407.47(a)-(c)
 	 	 	
Part B Buy-in coverage starts
the second month after an
individual qualifies for
Medicare and is eligible for a
Medicaid group in the buy-in
agreement.*, **
42 CFR 407.47(d)

Part A buy-in coverage starts
the month QMB coverage
starts.*
42 CFR 406.26(b) 
In group
payer states
only:

As early as
the month
after actual/
conditional
Part A
application
occurred
during the
GEP or an
applicable
SEP.
Part B buy-in disenrollment
due to loss of eligibility for
any Medicaid group in buy-in
agreement effective the month
after Medicaid coverage
ends. ***
42 CFR 407.48(c)
 	 	 	 	
Part A buy-in disenrollment
based on loss of QMB
eligibility is effective the
month after QMB ends.****
42 CFR 406.26 (c)(2)

*This date applies if a buy-in agreement is already in effect; currently, all states include MSPs in their Part B buy-in
agreements. Thirty-six states and the District of Columbia have Part A buy-in agreements.
** Note: Starting January 1, 2024, if a full-benefit Medicaid beneficiary is retroactively enrolled in Medicare, state
liability for retroactive Part B premiums for such individuals is limited to a period no greater than 36 months prior to
the date of the Medicare enrollment determination. See 42 CFR 407.47(f); section 1.4.3.
*** CMS may modify the effective date of the Part B deletion requested by the state. CMS limits the retroactivity of
Part B deletions to two months prior to the “processing month.” See section 2.6.1.3.
**** CMS may modify the effective date of the Part A deletion requested by the state. CMS limits the Part A
deletion date to the month CMS processes the deletion. See section 2.6.1.4.

Appendix 1.D Policies Related to Buy-in in the 50 States, the District of
Columbia, and Specified U.S. Territories
(Rev. 7; Issued:01-16-2025; Effective01-16-2025; Implementation: 01-16-2025)
State/Territory54 SSI Status
Accrete or
Alert
Part A
Buy-in
Part A
Group
Payer
55
Part B
Buy-in
coverage
group56
Alabama Accrete X All Medicaid
groups
Alaska Alert (SSI-criteria) X All Medicaid
groups
Arizona Accrete X All Medicaid
groups
Arkansas Accrete X All Medicaid
groups
California Accrete X All Medicaid
groups
Colorado Accrete X All Medicaid
groups
Commonwealth of
Northern Mariana Islands N/A N/A N/A All Medicaid
groups
Connecticut Alert (209b) X Cash
assistance/MSPs
Delaware Accrete X All Medicaid
groups
District of Columbia Accrete X All Medicaid
groups
Florida Accrete X All Medicaid
groups
Georgia Accrete X All Medicaid
groups
Guam Alert N/A N/A All Medicaid
groups
Hawaii Alert (209b) X All Medicaid
groups
Idaho Alert (SSI-criteria) X Cash
assistance/MSPs
54 Policies in this table are current as of January 1, 2024. As of this date, the 50 states, the District of Columbia, and specified
U.S. territories (the Commonwealth of Northern Mariana Islands, Guam, the U.S. Virgin Islands) have entered into buy-in
agreements with CMS.
55 States can choose to pay Part A premiums for QMBs through their buy-in agreements or a group payer arrangement. Federal
law requires states to pay the Part A premiums for QDWIs through the group payer arrangement.
56 As of January 1, 2024, the 50 states and the District of Columbia have chosen 1 of 2 Part B buy-in coverage groups: (1) Cash
Assistance Recipients and Deemed Cash Assistance Recipients Plus Three MSPs (“Cash Assistance/MSPs”) or (2) All Medicaid
eligibility groups ("All Medicaid Groups”). The Commonwealth of Northern Mariana Islands, Guam, the U.S. Virgin Islands do
not cover the MSPs but cover all Medicaid groups.

State/Territory54 	SSI Status
Accrete or
Alert
Part A
Buy-in
Part A
Group
Payer
55
Part B
Buy-in
coverage
group56
Illinois 	Alert (209b) 	X 	Cash
assistance/MSPs
Indiana 	Accrete 	X 	All Medicaid
groups
Iowa 	Accrete 	X 	All Medicaid
groups
Kansas 	Alert (SSI-criteria) 	X 	All Medicaid
groups
Kentucky 	Accrete 	X 	Cash
assistance/MSPs
Louisiana 	Accrete 	X 	Cash
assistance/MSPs
Maine 	Accrete 	X 	Cash
assistance/MSPs
Maryland 	Accrete57 	X 	All Medicaid
groups
Massachusetts 	Accrete 	X 	Cash
assistance/MSPs
Michigan 	Accrete 	X 	All Medicaid
groups
Minnesota 	Alert (209b) 	X 	Cash
assistance/MSPs
Mississippi 	Accrete 	X 	All Medicaid
groups
Missouri 	Alert (209b) 	X 	Cash
assistance/MSPs
Montana 	Accrete 	X 	Cash
assistance/MSPs
Nebraska 	Alert (SSI-criteria) 	X 	Cash
assistance/MSPs
Nevada 	Alert (SSI-criteria) 	X 	All Medicaid
groups
New Hampshire 	Alert (209b) 	X 	Cash
assistance/MSPs
New Jersey 	Accrete 	X 	All Medicaid
groups
New Mexico 	Accrete 	X 	All Medicaid
groups
New York 	Accrete 	X 	Cash
assistance/MSPs
North Carolina 	Accrete 	X 	All Medicaid
groups
North Dakota 	Alert (209b) 	X 	Cash
assistance/MSPs
57 Although Maryland has a 1634 agreement, CMS does not auto-accrete SSI recipients who are Medicare-eligible in
Part B buy-in. Instead, Maryland initiates Part B buy-in enrollment for Medicare-eligible SSI recipients.

State/Territory54 	SSI Status
Accrete or
Alert
Part A
Buy-in
Part A
Group
Payer
55
Part B
Buy-in
coverage
group56
Ohio 	Accrete 	X 	All Medicaid
groups
Oklahoma 	Alert (SSI-criteria) 	X 	Cash
assistance/MSPs
Oregon 	Alert (SSI-criteria) 	X 	All Medicaid
groups
Pennsylvania 	Accrete 	X 	Cash
assistance/MSPs
Rhode Island 	Accrete 	X 	Cash
assistance/MSPs
South Carolina 	Accrete 	X 	All Medicaid
groups
South Dakota 	Accrete 	X 	Cash
assistance/MSPs
Tennessee 	Accrete 	X 	Cash
assistance/MSPs
Texas 	Accrete 	X 	Cash
assistance/MSPs
Utah 	Alert (SSI-criteria) 	X 	All Medicaid
groups
Vermont 	Accrete 	X 	Cash
assistance/MSPs
Virginia 	Alert (209b) 	X 	All Medicaid
groups
U.S. Virgin Islands 	N/A 	N/A 	N/A 	All Medicaid
groups
Washington 	Accrete 	X 	All Medicaid
groups
West Virginia 	Accrete 	X 	Cash
assistance/MSPs
Wisconsin 	Accrete 	X 	Cash
assistance/MSPs
Wyoming 	Accrete 	X 	All Medicaid
groups

Transmittals Issued for this Chapter
Rev # 	Issue Date 	Subject 	Impl Date 	CR#
R7SPMP 	01/16/2025 	Updates to several sections in Chapter 1 of the State
Payment of Medicare Premiums Manual.
01/16/2025 	N/A
R6SPMP 	04/26/2024 	Revisions to Manual for the State Payment of
Medicare Premiums
04/26/2024 	N/A
R5SPMP 	02/09/2024 	Revisions to the Manual for the State Payment of
Medicare Premiums
02/09/2024 	N/A
R4SPMP 	08/21/2020 	New State Payment of Medicare Premiums,
(SPMP)
09/08/2020 	N/A

100-24 State Payment of Medicare Premiums: Chapter 1 - Program Overview and Policy

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