Report of State Buy-In Problem

CURRENT

Department of Health and Human Services
Centers for Medicare & Medicaid Services

SSO REPORT OF STATE BUY-IN PROBLEM
To:

Form Approved
OMB No. 0938-0035

IDENTIFICATION

Name
Medicare Claim Number

CMS
P.O. Box 11977
Baltimore, Maryland 21207-0977

Social Security Number (BOAN)

Sex

■ M ■ F
Social Security Number
(BOAN)

Welfare ID Number

From:

State and County of Residence
Claimant's Mailing Address

PART 1 Report of Problem by SSO
■ A. Part B Claim Denied
Carrier Name

■

■

B. Premium being
deducted from
beneficiary check

■

C. Being billed
for premiums

■

D. Individual received
Part B Termination
Notice

E. Other (Explain—Give Form numbers if applicable)

PART 2 SSI Status at SSO
Receiving:
Federal SSI Check
Federal Admin. State Supp.

■
■

Start Date

Stop Date

(Attach SSR & HMQ Printouts)

Signature of SSO Representative

Title

Date

PART 3 Report of Buy-In Status by Welfare Department (Check and Complete Applicable Items)
ACCORDING TO _________________________ WELFARE OFFICE, THE INDIVIDUAL IDENTIFIED ABOVE,

■

1. Has never been eligible for State buy-in.

■

2. Has been continuously eligible for State buy-in beginning (Mo., Yr.) ___________________

■

3. Has been eligible for State buy-in only for months of

_______________ through _______________ (Inclusive)

If eligibility ended because of death, give date of
death.

PART 4 Information from State's records and/or actions being taken by State

■

1. Individual is shown on State's bill as Code 41 continuing item beginning (Mo., Yr.) ___________________

■

2. Individual is shown on State's bill as other code. (Show code) _______________

■

3. State will submit (Show code) ___________________ in the monthly data exchange (Show month) ___________________

■

Accretion Effective (Mo., Yr.) ___________________

Deletion Effective (Mo., Yr.) ___________________

4. Other

■
Dept. of Public Welfare Signature

Title

CONTINUED ON REVERSE
Date

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0938-0035. The time required to complete this information collection is estimated to average 17.5 minutes per response, including
the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore,
Maryland 21244-1850.
Form CMS-1957 (11/2012)

Department of Health and Human Services
Centers for Medicare & Medicaid Services

Form Approved
OMB No. 0938-0035

PRIVACY ACT STATEMENT
Section 1320.6 of title 5 to the U.S. Code authorizes collection of this information. The
primary use of this information is to process changes to Hospital Insurance (HI)/Supplemental
Medical Insurance (SMI) premium payments by third parties (such as State agencies, or
private groups) on behalf of Medicare beneficiaries; for billing third parties; and for enrolling
individuals for SMI coverage under State buy-in agreements.
Disclosure of the information may be made to State welfare departments pursuant
to agreements with the Department of Health and Human Services for enrollment of
welfare recipients for medical insurance under section 1843 of the Social Security Act or
a congressional office from the record of an individual in response to an inquiry from the
congressional office made at the request of that individual.
Where the beneficiary's identification number is their Social Security Number, collection of
this information is authorized by Executive Order 9397. Furnishing the information on this
form including your Social Security Number, is voluntary but failure to do so may result in
disapproval of this request.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0938-0035. The time required to complete this information collection is estimated to average 17.5 minutes per response, including
the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore,
Maryland 21244-1850.
Form CMS-1957 (11/2012)