Buy In Application Form – Fill Out and Use This PDF

MassHealthBuy-In

for people who are eligible for Medicare

What is MassHealth Buy-In?

MassHealth Buy-In is a program authorized by Congress for persons who are eligible for Medicare. MassHealth Buy-In allows MassHealth to pay all of the Medicare Part B premium for Massachusetts residents who are not getting other MassHealth beneits. It can also help get Medicare Part B for persons who only have Medicare Part A.

How much can I have in income and assets?

For MassHealth Buy-In, your income and assets (including bank accounts, stocks, bonds, or a second car) must be under certain limits. he chart (at the top right of this page) shows how much you can have and what you will get if your income and assets are within these limits.

If I am eligible for MassHealth Buy-In, how do I get paid?

If MassHealth Buy-In inds that you are eligible for payment of all of your Medicare Part B premium, we will tell Medicare.

If your Medicare Part B premium is deducted from your social security check, your check will be adjusted so that your Medicare premium is no longer deducted. his means that the amount of your social security check will increase based on the amount that had been deducted to pay for your Medicare Part B premium.

If you are eligible for, but not yet getting Medicare Part B, or if you are paying your Medicare Part B premium in some other way, like getting a quarterly bill from Medicare, MassHealth Buy-In will start paying this bill for you.

It will take several months to adjust your social security beneit or to pay your bill. However, you will get a refund for the amount you paid for your Medicare Part B premium back to the month you became eligible for MassHealth Buy-In. You will get this refund in the same way as you now get your social security: either through a check or direct deposit to your bank account.

When does coverage begin?

If you are eligible for MassHealth Buy-In, your coverage begins in the month we get your application. In some cases, it may begin as early as three months before your application month.

You will get a written notice that tells you about your coverage and when it starts. If you are not eligible, the notice will give you the reason(s) you are not eligible. If you think the decision is wrong, you have the right to appeal it. Information about how to appeal is on the back of the written notice.

How we use your social security number (SSN)

We use your SSN to check information you have given us. SSN iles may be matched with the iles of agencies like: the Internal Revenue Service, Social Security Administration, Systematic Alien Veriication for Entitlements (SAVE), Centers for

MHBI-2 (REV. 03/16)

*hese amounts are efective on March 1, 2016. **hese amounts are efective on January 1, 2016.

Medicare and Medicaid Services, Registry of Motor Vehicles, Department of Revenue, Department of Transitional Assistance, Department of Industrial Accidents, Division of Unemployment Assistance, Department of Veterans’ Services, Human Resource Division, Bureau of Special Investigations, and the Department of Public Health’s Bureau of Vital Statistics. Files may also be matched with social service agencies in this state and other states, and computer iles of banks and other inancial institutions, insurance companies, employers, and managed care organizations.

Estate recovery

MassHealth has the right to get back money from the estates of certain MassHealth members after they die. In general, the money that must be repaid would include Medicare premiums paid by MassHealth for a member after the member turned age 55, and at any age while the member was permanently in a long-term-care facility. Efective with Medicare premiums paid on or after January 1, 2010, MassHealth will not recover premium payments made for members who were aged 55 or older at the time the premiums were paid.

here are also some additional protections and exceptions to this estate recovery rule. If a deceased member leaves behind a spouse, or a child who is blind, permanently and totally disabled, or younger than 21, MassHealth will not require repayment while any of these persons are still living. If real property, like a home, must be sold to get money to repay MassHealth, MassHealth, in limited circumstances, may decide that the estate does not need to repay MassHealth. Also, certain income, resources, and property of American Indians and Alaska Natives may be exempt from recovery.

For more information about estate recovery, see the MassHealth regulations at 130 CMR 515.000, and Chapter 118E of the Massachusetts General Laws.

Conidentiality and Fair Treatment

MassHealth cannot discriminate against you because of race, color, sex, age, handicap, country of origin, sexual orientation, religion, or creed. MassHealth is committed to keeping conidential the personal information we have about you. All personal information that MassHealth has about any applicant or member, including medical data, health status, and the personal information you give us during your application

for and receipt of beneits is conidential. his information may not be used or released for purposes other than the administration of MassHealth without your permission, unless required by law or a court order. You can give us your written permission to use your personal health information for a speciic purpose or to share it with a speciic person or organization.

Authorized Representative

An authorized representative is someone you choose to help you get health care coverage through programs ofered by MassHealth and the Massachusetts Health Connector. You can do this by illing out the Authorized Representative Designation Form (ARD) or a similar designation form. An authorized representative may ill out your application or eligibility review forms, give proof of information given on these eligibility forms, report changes in your income, address, or other circumstances, get copies of all MassHealth or Health Connector eligibility or enrollment notices sent to you, and act on your behalf in all other matters with MassHealth or the Health Connector.

An authorized representative can be a friend, family member, relative, or other person or organization of your choosing who agrees to help you. It is up to you to choose an authorized representative, if you want one. MassHealth or the Health Connector will not choose an authorized representative for you.

You must designate in writing on the Authorized Representative Designation Form or a similar designation document or authorization document the person or organization you want to be your authorized representative. In most cases, your authorized representative must also ill out this form or a similar designation document or authorization document. his form is included in the application packet, or you can call us or visit www.mass.gov/masshealth to get one. Please see the instructions on the form for more details.

An authorized representative can also be someone who is acting responsibly on your behalf if you cannot designate an authorized representative in writing because of a mental or physical condition, or has been appointed by law to act on your behalf or on behalf of your estate. his person must ill out the applicable parts of the Authorized Representative Designation Form or provide a similar designation document. If this person has been appointed by law to represent you, either you or this person must also submit to MassHealth or the Health Connector a copy of the applicable legal document stating that this person is lawfully representing you or your estate. his person may be a legal guardian, conservator, holder of power of attorney, or health care proxy, or if the applicant or member has died, the estate’s administrator or executor.

Permission to Share Information

If you want us to share your personal health information, including sending copies of your eligibility notices, with someone who is not your authorized representative, you can do this by giving us written permission. We have forms you can use to do this. You can call us or visit www.mass.gov/ masshealth to get a copy of the appropriate form.

Reporting Changes

If there are any changes in your income, assets, address, health insurance, immigration status, or disability status, you must tell us within 10 calendar days of the changes or as soon

as possible. If you do not tell us about these changes, you may lose your beneits. You can tell us about any changes by calling 1-888-665-9993 (TTY: 1-888-665-9997 for people who are deaf, hard of hearing, or speech disabled.

Other MassHealth beneits

MassHealth ofers other health care beneits that either pay for medical services directly, or pay your Medicare copayments and deductibles. You may be eligible for these beneits if your income and assets are under certain amounts, or if you are disabled and younger than 65. Call a MassHealth Enrollment Center at 1-888-665-9993 (TTY: 1-888-665-9997 for people who are deaf, hard of hearing, or speech disabled) to learn about these beneits. You should also call this number if you have any questions about MassHealth Buy-In.

Other beneits

Medicare recipients can get help with prescription drug costs through Medicare. To get more information, call Medicare at 1-800-MEDICARE (1-800-633-4227) (TTY: 1-877-486-2048 for people who are deaf, hard of hearing, or speech disabled), or visit www.medicare.gov.

he Executive Oice of Elder Afairs also ofers help with prescription drug costs through Prescription Advantage. Call Elder Afairs toll free at 1-800-AGE-INFO (1-800-243-4636) (TTY: 1-877-610-0241 for people who are deaf, hard of hearing, or speech disabled) to learn more about these beneits.

How do I apply for MassHealth Buy-In?

1.To apply for MassHealth Buy-In, ill out the attached application. Include information about your spouse too, if he or she lives with you.

2.Sign the illed-out application, include proof of your income (except for social security income), and

send it to: MassHealth Enrollment Center Central Processing Unit

P.O. Box 290794 Charlestown, MA 02129-0214

or fax it to: 1-857-323-8300

3.When we get the application, we will review it for completeness. If we need more information, we will write to you or call. Once we get all information, we will decide if you are eligible. We will also decide if your spouse is eligible.

4.A voter registration form is included with your application. (You do not need to register to vote to get MassHealth Buy-In.)

5.If you want someone to act on your behalf as your authorized representative, use the enclosed Authorized Representative Designation Form to tell us.

(CUT ON THE DOTTED LINE)

Commonwealth of Massachusetts

EOHHS

www.mass.gov/masshealth

for people who are eligible for Medicare

Who is applying? you

you and your spouse