When an SSI recipient moves from another State with intent to reside in Louisiana,
Medicaid eligibility resulting from SSI payment or Section 1619(b) is effective the
month after the month of move to Louisiana (SI 01410.030F.)
Exhibit 1
Louisiana DHH Certification for Medicaid Eligibility
TO: Louisiana Department of Health & Hospital Date: _________
______________________________ Attn: ____________________
______________________________ (Always complete for
__________________, LA _______ Emergency Certification)
I.This individual was eligible for SSI and Medicaid. SSA is unable to establish a record
or to provide complete information on the SDX. Please issue a Medicaid card for the
period of eligibility indicated below.
Reason: (check one) __Systems Limitation __Emergency
__Closed Period of Eligibility Certification
Type of Recipient: (circle one) AI AS BI BS BC DI DS DC
Name of Recipient: _____________________________________
Mailing Address _____________________________________
Including Representative _____________________________________
Payee & Zip Code: _____________________________________
Social Security Number: ______________________ Sex: ____
Date of Birth: ______________ Mo/Day/Year of SSI Application: __________
TPL Code: ______________ Transfer of Resources (yes or no): ____
First Month/Year of SSI Payment in Louisiana: ______________
If closed period of eligibility, show all months of eligibility: ______________
If the individual is not currently eligible for SSI, give reason for suspension or
termination and the effective date of non-pay: ________________________________________
Remarks:
II. SSA previously submitted a manual Medicaid certification for the above
named individual and SSN. This individual is no longer eligible for SSI effective: ______.
Reason: ___________________________________________.
III. FROM: Social Security Administration _______________________
______________________________ (CR Signature)
______________________________ (Phone #) _______________
______________________________
Emerg. Cert. Auth.-OS/MSS or above
SS-RVI-303 (12/02)
Exhibit 2
TITLE II COLA/DAC/SURVIVING SPOUSE MEDICAID EXTENSION REFERRAL LETTER
TO: Louisiana Department of Health & Hospital Date: _________
______________________________
______________________________
__________________, LA _______
(check 1. Or 2.)
_____1.The following individual was eligible for Supplemental Security Income in ______,
20__ *, but became ineligible effective with ______, 20__ * because of a title II
cost-of-living adjustment (COLA) increase paid to the eligible person or their spouse
or due to __________________.This person may now be a candidate for preservation of
Medicaid eligibility under the provision of:
(check One)
_____ Section 503 of Public Law 94-566, or
_____ Lynch v. Rank court decree.
_____2. The following individual was eligible for SSI in __________,____ but became
ineligible in _____________,_____ because of entitlement to or an increase in
(check One)
_____ DAC, or
_____ surviving spouse benefits.
Name and Address ______________________________
(Including ______________________________
Representative ______________________________
Payee) ______________________________
Parish of Residence ______________________________
Social Security Number ____________________________
Title II Claim Number ______________________________
Gross Title II Payment Prior to COLA _______________
Current Gross Title II Payment _______________
Other Current Month Income (If any) _______________
*If there is a break in entitlement between these two dates, show the months of ineligibility
and payment status code for each month: ___________________________________________________________
From: Social Security Administration ______________________________
______________________________ Area Code/Telephone
______________________________ ______________________________
Print Name of
SSA Employee
(Revised 12/02)