State Medicare Buy-In Problem Form

EWs must first ensure Buy-In problems are resolved after correcting discrepancies of the client’s data and the client has accurate eligibility in MEDS and CalSAWS. If necessary, submit an SCD 1296.

The EW must review the problem and their efforts to correct it with their supervisor, before completing an online fillable State Medicare Buy-In Form.

The online fillable State Medicare Buy-In Problem Form is used to correct Buy-In problems after the EW’s corrective actions are unsuccessful.

Situations Requiring the Use of the State Medicare Buy-In Problem Form

The State Medicare Buy-In Problem Form must be used by the EW to report specific Buy-In problems including, but not limited to, the following situations:

When an individual is inadvertently dropped (deleted) from Medicare Buy-In.
To advise DHCS a recipient is entitled to Buy-In when activity (accretion) has not been confirmed 2 months after the Medical approval date.
To change the MBI/HIC number on the MC record if pending or active (accreted) status is shown on the MEDS INQB screen.

EW Action

Before submitting an online fillable State Medicare Buy-In Problem Form to the Medicare Premium Payment (Buy-In) Program, EWs must first:

Review the Buy-In information on the INQB screen.
- Evaluate the [STATUS] fields, and
- Evaluate the effective date of Part A/B [EFF-DATE], and the last Bendex change date [LAST-BENDEX-CHG].
Review the Medicare code [MEDICARE] on the INQM screen.
Make corrections through the CalSAWS/MEDS on-line processes.
Obtain the EW Supervisor approval to send an online fillable State Medicare Buy-In Problem Form if repeated attempts to correct the problem have failed.

Completing the State Medicare Buy-In Problem Form

For the Medicare Premium Payment (Buy-In) Program to successfully resolve a problem case, adequate details are needed on the State Medicare Buy-In Problem Form. The following information must be thoroughly completed:

Section A: County or Agency Representative Information (EW’s contact information including the EW’s email address).
Section B: Beneficiary or Client Information.
Section C: Problem Reference by selecting an appropriate Buy-In Problem Quick Reference from drop-down menu and describe a specific detailed problem and the change being requested under Remarks section (200 character limit.) If necessary, the EW may attach verifications, documents or files.

EWs will receive a reply via email from the Buy-In Unit within 24 to 48 business hours after submitting an online State Medicare Buy-In Problem form. If no response received within 48 hours, EWs should contact the Buy-In Unit by a secured email or phone.

Contacting Medicare Buy In Unit

The EW may contact DHCS to report Buy-In problems either by:

Completing the State Medicare Buy-In Problem Form on the TPL web page.
Sending a Secure e-mail to buyin@dhcs.ca.gov
Calling Buy-In Unit at (916) 750-3563

EW Follow-Up

After sending an online fillable State Medicare Buy-In Problem Form to notify DHCS to resume Buy-In, the EW must: