Medicare Premium Payment (Buy-In) Program
The Medicare Premium Payment Program, or Medicare Buy-In, allows Medi-Cal to pay Medicare Part A and/or Part B premiums for Medi-Cal members and others who qualify for Medi-Cal under special program, allowing Medi-Cal to defer medical costs to Medicare where appropriate.
The Medicare Premium Payment and the Medicare Part D State Contribution Payment programs help to ensure that Medi-Cal is the payer of last resort.
What is Medicare?
Medicare is a federal health insurance program for the aged (persons age 65 or older), certain younger individuals with disabilities, and individuals with End Stage Renal Disease (ESRD). Medicare coverage through the state buy-in program may consists of of the following:
Part A - Hospital insurance (HI)
Part B - Supplementary Medical insurance (SMI)
Part C - Prescription drug coverage (contribution payment)
Members cannot have Part A Medicare coverage without Part B Medicare coverage. Members must have Part A and/or Part B coverage to be eligible for Part D.
Medicare Part B Buy-In Agreement
The State of California participates in a buy-in agreement with the Centers for Medicare and Medicaid Services (CMS), whereby Medi-Cal automatically pays Medicare Part B premiums for all Medi-Cal members who have Medicare Part B entitlement as reported by Social Security Administration (SSA).
Social Security Act, Section 1843
Medicare Part D State Contribution Payments
Prescription drug coverage costs shifted from Medicaid to Medicare beginning January 2006 as a result of the 2003 Medicare Prescription Drug, Improvement and Modernization Act (MMA), creating the Medicare Part D prescription drug program. The state is required to pay a Part D premium payment for eligible for Medi-Cal members entitled to Part A or Part B coverage.
Medicare Prescription Drug, Improvement and Modernization Act 2003
State Buy-In Manual - Part A and Part B Transaction Codes
The buy-in transaction codes provide a concise, definitive means of communication between the CMS and the State of California. Most transaction codes require no further action on the part of the State; however, there are instances where additional action by the State is appropriate. For description of any of the transaction codes, see the PDF attachments below.
Part A Buy-In/Group Payer Transaction Codes (PDF)Part B Buy-In/Group Payer Transaction Codes (PDF)
State Medicare Buy-in Program Problem Report (online fillable form)
Please use the form below to report a Medicare buy-in problem to the Buy-In Unit at DHCS. The use of this form is strictly intended for state, county and federal agencies. This form is not intended for general public use. Members with a buy-in problem should contact their county eligibility worker for assistance.
TPLRD Home Page