CMS-1957 Supporting Statement

Supporting Statement for CMS-1957
Social Security Office (SSO) Report of State Buy-In Problem

A.

Background
This is a request for OMB reapproval of the CMS-1957, SSO Report of State Buy-In
Problems. Under Section 1843 of the Social Security Act, States may enter into an
agreement with the Department of Health and Human Services to enroll eligible
individuals in Medicare and pay their premiums. The purpose of the State Buy-in‟
program is to assure that Medicaid is the payer of last resort by permitting a State to
provide Medicare protection to certain groups of needy individuals, as part of the State‟s
total assistance plan. State Buy-in also has the effect of transferring some medical costs
for this population from the Medicaid program, which is partially State funded to the
Medicare program, which is funded by the federal government and individual premiums.
Generally, the States Buy-in for individuals who meet the eligibility requirements for
Medicare and are cash recipients or deemed cash recipients or categorically needy under
Medicaid. In some cases, States may also include individuals who are not cash assistance
recipients under the Medical Assistance Only group.

B.

Justification
1.

Need and Legal Basis

The statutory authority for the State Buy-in program is Section 1843 of the Social
Security Act, amended through 1989. Under Section 1843, a State can enter into an
agreement to provide Medicare protection to individuals who are members of a Buy-in
coverage group, as specified in the State‟s Buy-in agreement.
The Code of Federal Regulations at 42 CFR Section 407.40 provides for States to enroll
in Medicare and pay the premiums for all eligible members covered under a Buy-in
coverage group. Individuals enrolled in Medicare through the Buy-in program must be
eligible for Medicare and be an eligible member of a Buy-in coverage group.
The day to day operations of the State Buy-in program is accomplished through an
automated data exchange process. The automated data exchange process is used to
exchange Medicare and Buy-in entitlement information between the Social Security
District Offices, Medicaid State Agencies and the Centers for Medicare & Medicaid
Services (CMS). When problems arise however that cannot be resolved though the
normal data exchange process, clerical actions are required. The CMS-1957, “SSO
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Report of State Buy-In Problem” is used to report Buy-in problems cases. The CMS1957 is the only standardized form available for communications between the
aforementioned agencies for the resolution of beneficiary complaints and inquiries
regarding State Buy-in eligibility.

2.

Information Users

In most instances, the SSO becomes aware of a problem through a beneficiary complaint.
Social Security District Offices and State Medicaid Agencies submit completed CMS
1957 forms to CMS to identify and correct Buy-in problems.
A Buy-in problem usually involves one or more of the following:
1.

A request to accrete or delete an individual from a State‟s Buy-in rolls.

2.

A request to adjust the enrollment (accretion) and/or deletion (dis-enrollment)
date(s) annotated to CMS‟ Medicare record.

3.

A complaint of duplicate billing – occurs when State is paying the Medicare Part
B premiums while the premiums are being deducted from a beneficiary‟s social
security check.

4.

A complaint that an individual enrolled in the Buy-in program is also being
directly billed for the Medicare premiums.

5.

A request to refund Medicare premiums paid by the individual, while the
individual was an eligible member of a covered group.

6.

A complaint that a Medicare claim was denied due to no Medicare coverage while
the individual was an eligible member of a covered group.

7.

A complaint that an individual received a Medicare termination notice while
being an eligible member of a Buy-in coverage group.

8.

Individual is no longer eligible for Buy-in.

9.

Medicare entitlement voided due to fraud or no longer meets Medicare residency
requirement.

10.
Individual moved out of the country.
The CMS-1957 is used in the resolution of beneficiary complaints regarding the State
Buy-in Program. The instructions for completing the CMS-1957 are posted on SSA
PolicyNet: HI 00815.088, Servicing DO/BO Processing of CMS-1957. The SSO
completes Part 1 and Part 2 of the form and forwards the form to the State Medicaid
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Agency for additional information, if necessary. The form is returned to the SSO for
final review of the State data. The SSO forwards the form to CMS when the Third Party
billing file and related records need correction.
The CMS-1957 is designed as a cover letter to accumulate information necessary in
resolving Buy-in problem cases. The CMS-1957 is described below:
Identifying information is provided at the top portion of the form. This includes a “To”
and “From” block; Beneficiary level-identification block including: Name; Medicare
Claim Number, Social Security Number, Welfare ID Number, State and County of
Residence, Sex, Date of Birth, and Claimant‟s Mailing address. The SSO may need to
contact the State Medicaid Agency in order to complete the identification block.
Part 1, “Report of Problem by SSO” and Part 2, “SSI Status at SSO” (if applicable) are
completed by the Social Security District Office. This section describes the problem
and/or situation.
Part 3, “Report of Buy-In Status by Welfare Department” and Part 4, “Information from
the State‟s records and/or actions being taken by State” are completed by the State
Medicaid Agency. These sections are used for verifying Buy-in eligibility. After
verifying the Buy in status, the form is signed by the authorized State Medicaid Agency
personnel; the form is dated and returned to the appropriate SSO and then the form is sent
to CMS for resolution.
Beneficiary problems and concerns related to the State Buy-in program cannot be
officially documented without the use of CMS-1957 form. This form facilitates the
coordination of efforts between the SSDOs, State Medicaid Agencies and CMS in the
resolution of State Buy-in problems.
3.

Improved Information Technology
The form CMS-1957 is completed once for each Medicare record. In an effort to
improve the use of the form through advance technology and electronic
submissions, the form is now available in a PDF fill-able format with” save as”
and „e-signature‟ features. The form CMS-1957 now lends itself to submission to
CMS through electronic mail exchange.

4.

Duplication
There is no duplication of work when resolving a State Buy-in problem. Each
problem is unique to a Medicare record. The information provided on the CMS1957 is also unique to each individual.
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5.

Small Businesses
This form is not completed by small business, but rather State and Federal
Agencies.

6.

Less Frequent Collection
This form is completed as needed when a beneficiary experiences a problem
related to the State Buy-in problem.

7.

Special Circumstances
There are no special circumstances.

8.

Federal Register/Outside Consultation
The 60-day Federal Register notice published on____________________.

9.

Payment/Gift To Respondents
There are no payments/gifts to respondents.

10.

Confidentiality
While there are no assurances of confidentiality provided, the information is used
only within the Medicare program.

11.

Sensitive Questions
There are no questions of a sensitive nature associated with this form.

12.

Burden Estimate (Hours & Wages)
There are approximately 3,802 forms completed and submitted to CMS for
resolution annually. It is assumed that each form represents a beneficiary making
a complaint. Therefore, 3,802 beneficiaries provided information to their local
SSO District Office.
The SSO completes Part 1 and Part 2 of the form by compiling and documenting
information provided by the beneficiary. The average interview and completion
time for the CMS-1957 is 20 minutes.
The form may be forwarded to the State Medicaid Agency for verification of the
Buy-in status and returned to the SSO. The two sections completed by the State
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Medicaid Agencies are merely check boxes. Contacts in the State Medicaid
Agencies estimate that this part of the form can be completed in 15 minutes.
The burden is computed as follows:
SSO Beneficiary Interview:
3,802 beneficiary interviews multiplied by 20 minutes (1/3 hr)
= 1,266.07 hours
State Medicaid Agency:
CMS only records the total count of forms received. A breakdown by
Agency is not available.
Total burden = (Not applicable) hours
SSO Beneficiary Interview:
Based on the standard hourly rate of $18.45 GS-7, step 5 multiplied by
1, 266.07 hours
= $23,358.99
13.

Capital Costs
$23,358.99

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14.

Annual Cost to Federal Government
Printing Costs:
No printing costs currently incurred.
Processing Costs:
Not Applicable – CMS does not record SSA‟s processing costs related to the
CMS 1957 form.
Social Security District Office Service complaints on the CMS-1957. Cost is
computed as follows: GS-7, step 5, hourly rate of $18.45 multiplied by 1,266.07
hours = 23,358.99
Total Federal Cost is $23,358.99

15.

Program Changes
The number of respondents decreased since the last time this information
collection was submitted for OMB approval. We have adjusted the burden
accordingly.

16.

Publication and Tabulation Data
This information is not published or tabulated.

17.

Display of Expiration Date
No expiration date currently exists on the form and we are seeking approval to not
display an expiration date on the form. Neither the form nor the information
requested changes from renewal to renewal. The requirement to include an
expiration date, would necessitate the destruction of “in stock” forms with old
dates. This would represent an increased cost to the Government for reprinting
new forms.

18.

Certification
There are no exceptions to the certification statement.

C.

Collections of Information Employing Statistical
Methods
This section does not apply because statistical methods were not used in
developing this collection.
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