MassHealth Buy-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 benefits. It can also help get Medicare Part B for persons who have only 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. The chart 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 finds 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. This 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 benefit 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. For individuals, if your monthly income before taxes and deductions is below $1,313* (* These amounts are effective on March 1, 2013.) And your assets are at or below $7,080** (** These amounts are effective on January 1, 2013.) Then MassHealth Buy-In will pay all of your Medicare Part B premium For for married couples who live together, if your monthly income before taxes and deductions is below $1,765* (combined) (* These amounts are effective on March 1, 2013.) And your assets are at or below $10,620** (** These amounts are effective on January 1, 2013.) Then MassHealth Buy-In will pay all of the Medicare Part B premiums for both you and your spouse. What else do I need to know? Use of your social security number (SSN) MassHealth uses your SSN to track information in our files. Files may be matched with state and federal agencies including the Internal Revenue Service, Social Security Administration, Department of Revenue, banks, and other financial institutions. 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. Effective 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. There are also some additional protections and exceptions to this rule. If a deceased member leaves behind a spouse, or a child who is blind, permanently and totally disabled, or under age 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 515.011 and Chapter 118E of the Massachusetts General Laws. Confidential and fair treatment You have the right to confidential 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 confidential the personal information you give us during your application for and receipt of MassHealth benefits. We use the information you give us only for the administration of MassHealth. This means that we may need to share this information with our contractors and other entities. Any information we share must be kept confidential by that party. All personal information MassHealth has about any applicant or member, including medical data or health status, is confidential. This information may not be released for uses other than the administration of MassHealth without your permission or a court order. You can give us your permission in two different ways: 1) by filling out a MassHealth Eligibility Representative Designation Form; or 2) by giving us written permission to share your personal health information. Eligibility representative An eligibility representative is someone you choose to help you with some or all of the responsibilities of applying for or getting MassHealth. This person must know enough about you to take responsibility for the correctness of the statements made during the eligibility process. An eligibility representative may fill out an application or review form and other MassHealth eligibility forms, give MassHealth proof of information given on applications, review forms, and other MassHealth forms, report changes in your income, address, or other circumstances, and get copies of all MassHealth eligibility notices sent to you. An eligibility representative can be a friend, family member, relative, or other person who has a concern for your well-being and who agrees to help you. An eligibility representative is a person you choose. MassHealth will not choose an eligibility representative for you. To designate someone to be your eligibility representative, you and your eligibility representative must fill out a MassHealth Eligibility Representative Designation Form, which is included in the application packet, or you can call us to get one. An eligibility representative can also be someone who has been appointed by law to act on your behalf or on behalf of your estate. This person must fill out the applicable parts of the MassHealth Eligibility Representative Designation Form, and either you or this person must submit to MassHealth a copy of the applicable legal document stating that this person is lawfully representing you or your estate. This 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 eligibility representative, you can do this by giving us written permission. We have a form you can use to do this. You can call us to get the MassHealth Permission to Share Information Form. Reporting changes Once you are eligible, you must let us know within 10 calendar days if there are changes in the information you gave us on your application, like changes in your income or address. If you do not let us know about these changes, or give us false information, you may lose your benefits. You can let us know about any changes for MassHealth Buy-In by calling 1-888-665-9993 (TTY: 1-888-665-9997 for people who are deaf, hard of hearing, or speech disabled). Other MassHealth benefits MassHealth offers other health-care benefits that either pay for medical services directly, or pay your Medicare copayments and deductibles. You may be eligible for these benefits if your income and assets are under certain amounts, or if you are disabled and under age 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 benefits. You should also call this number if you have any questions about MassHealth Buy-In. Other benefits 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. The Executive Office of Elder Affairs also offers help with prescription drug costs through Prescription Advantage. Call Elder Affairs 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 benefits. How do I apply for MassHealth Buy-In? 1. To apply for MassHealth Buy-In, fill out the attached application. Include information about your spouse too, if he or she lives with you. 2. Sign and send the filled-out application, with proof of your income (except for social security income), to MassHealth Enrollment Center Central Processing Unit P.O. Box 290794 Charlestown, MA 02129-0214 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. Information about voter registration 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 eligibility representative, use the enclosed MassHealth Eligibility Representative Designation Form to tell us. MHBI-2 (Rev. 03/13) Page 1 begins. MassHealth Commonwealth of Massachusetts EOHHS www.mass.gov/masshealth MassHealth Buy-In Application for people who are eligible for Medicare This is an application for payment of your Medicare Part B premium. It can also help you get Medicare Part B if you are getting only Medicare Part A. If you want to apply for other MassHealth benefits, 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) for a different application. Please print clearly and fill out all sections. General Information Who is applying? __ you __ you and your spouse If you and your spouse live together, you must also give us information about your spouse even if he or she is not applying for benefits. You Last name First name MI Street address __ own __ rent City State Zip Mailing address (if different from above) City State Zip Date of birth Gender __ M __ F Preferred written language Telephone number Social security number Medicare claim number Your Spouse Last name First name MI Date of birth Gender __ M __ F Preferred written language Social security number Medicare claim number Income Fill out this section for you and your spouse. List the gross monthly income (before taxes and other deductions, such as the Medicare Part B premium). Send proof of your income, like a copy of two recent paystubs or copies of pension check stubs. (You do not have to send proof of social security income.) Your gross monthly income from social security before taxes and deductions Your spouse’s gross monthly income from social security before taxes and deductions Your gross monthly income from pensions before taxes and deductions Your spouse’s gross monthly income from pensions before taxes and deductions Your gross monthly income from Veterans' benefits before taxes and deductions Your spouse’s gross monthly income from Veterans' benefits before taxes and deductions Your gross monthly income from annuities or trusts before taxes and deductions Your spouse’s gross monthly income from annuities or trusts before taxes and deductions Your gross monthly income from dividends and/or interest before taxes and deductions Your spouse’s gross monthly income from dividends and/or interest before taxes and deductions Your gross monthly income from a job (before deductions) Your spouse’s gross monthly income from a job (before deductions) Your gross monthly income from rental income (after expenses) Your spouse’s gross monthly income from rental income (after expenses) Your gross monthly income from other sources (please specify) Your spouse’s gross monthly income from other sources (please specify) Page 2 begins. Assets Fill out this section for you and your spouse. List the value of all assets you and/or your spouse own. Do not list your primary home or car. Your savings accounts Your spouse's savings accounts Your and your spouse's savings accounts Your checking accounts Your spouse's checking accounts Your and your spouse's checking accounts Your second car Your spouse's second car Your and your spouse's second car Your certificates of deposits Your spouse's certificates of deposits Your and your spouse's certificates of deposits Your stocks Your spouse's stocks Your and your spouse's stocks Your bonds Your spouse's bonds Your and your spouse's bonds Your mutual funds Your spouse's mutual funds Your and your spouse's mutual funds Your other assets (please specify) Your spouse's other assets (please specify) Your and your spouse's other assets (please specify) Total value of all assets listed in this application for you Total value of all assets listed in this application for your spouse Total value of all assets listed in this application for you and your spouse Signature Please read the following carefully. Then sign and date the bottom of this page. Both you and your spouse must sign if your spouse lives with you. I give permission to MassHealth to get any records or data to prove any information given on this application. I understand that I must tell MassHealth of any changes in information I gave on this application. I further certify under the penalty of perjury that the information on this application is correct and complete to the best of my knowledge. If you are acting on behalf of someone in filling out this application, the enclosed MassHealth Eligibility Representative Designation Form must also be filled out and sent back with this application. Your signature on this application as an eligibility representative certifies that the information on this application is correct and complete to the best of your knowledge. If you think MassHealth’s decision about whether you are eligible is wrong, you have the right to appeal. If you are denied benefits, you will get information on how to appeal. Signature of applicant or eligibility representative Date Signature of applicant’s spouse or eligibility representative Date Once you have filled out and signed this form, send it to MassHealth Enrollment Center Central Processing Unit P.O. Box 290794 Charlestown, MA 02129-0214 MHBI-1 (Rev. 01/13) Document ends.