These questions satisfy Medicaid eligibility requirements where the SSA-8000-BK (Application for Supplemental Security Income) is an application for Medicaid. The claimant must agree to assign their rights to third party payments for services covered under the State Medicaid plan and provide third party information.

Explain the statement to all claimants residing in States for which we make Medicaid eligibility determinations, including states with automatic assignment of rights laws.

For all claimants residing in states for which we make Medicaid eligibility determinations, complete 59(a), except in states with automatic assignment of rights laws. Consult regional instructions to determine which states have these laws.

NOTE: Although a "NO" response to (a) eliminates the need to answer (b) and (c), explain that refusal to assign their rights will not affect their entitlement to Medicare, Social Security, or eligibility to Supplemental Security Income (SSI), but will probably result in a Medicaid denial as described in SI 01730.040F.1.

When the claimant answers (a) "YES" or resides in a state with automatic assignment of rights laws, complete (b).

Consult regional instructions to determine in which States to ask question 59(c). For these states, complete question (c) when the claimant answers:

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  (a) "YES" or in automatic assignment of rights states; and

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  (b) (regardless of response).

NOTE: We send the answers to 59(a), (b), and (c) to the state via the SDX and serve as the basis for us to bill the Centers for Medicare and Medicaid Services.

If the claimant answers 59(b) "YES," complete SSA-8019 (Third Party Liability Information Statement). For more information on third party liability for Medicaid eligibility, see SI 01730.045.

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  SI 01715.020 List of State Medicaid Programs for the Aged, Blind and Disabled

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  SI 01730.040 Assignment of Rights for Medicaid Eligibility

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  SI 01730.045 Third Party Liability for Medicaid Eligibility

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  SI 01730.010 Determinations of Medicaid Eligibility

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  SI 00604.130 Filing for Medicaid Based on SSI

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  MS 08119.020, Health Expenses & Third Party Liability