EXHIBIT 1
AUTHORIZATION FOR REIMBURSEMENT OF INTERIM ASSISTANCE
INITIAL CLAIM OR POSTELIGIBILITY CASE
Name ____________________________
Social Security Number ________________________________
Address________________________________________________________________
City/State/Zip Code
The term “state” means the Massachusetts Department of Transitional
Assistance.
What actions am I authorizing when I sign this authorization and I check the
“Initial Claim Only” block?
[ ] Initial Claims Only
You are authorizing the Commissioner of the Social Security Administration (SSA) to
reimburse the state for some or all of the money the state gives you. This money helps
you while SSA decides if you are eligible to receive SSI benefits. If you become eligible,
SSA pays the State from the retroactive SSI benefits due you. The reimbursement covers
the time from the first month you are eligible to receive SSI benefits through the
first month your monthly SSI benefit begins.
If the state cannot stop the last payment made to you, SSA can reimburse the state
for this additional payment amount.
What actions am I authorizing when I sign this authorization and I check the
“Posteligibility Case Only” block?
[ ] Posteligibilty Case Only
You are authorizing the Commissioner of the Social Security Administration (SSA) to
reimburse the state for some or all of the money the state gives you. This money helps
you while SSA decides if your SSI benefits can be reinstated after being terminated
or suspended. If your SSI benefits resume, SSA pays the state from the retroactive
SSI benefits due you. The reimbursement covers the time from the day of the month
the reinstatement is effective through the first month your monthly SSI benefit resumes.
If the state cannot stop the last payment made to you, SSA can reimburse the state
for this additional payment amount.
How can the state use this form when blocks for initial claims and
posteligibility cases are part of the form?
The state can use this form for one case situation at a time, either an initial claim
or a posteligibility case. If both blocks are checked the form is not valid. You and
the state must sign and date a new form with only one block checked.
What kind of state payment qualifies for reimbursement by
SSA?
SSA can reimburse a state for a payment that is paid only from state or local funds.
The state cannot be reimbursed for payments made wholly or partially from Federal
funds.
How does SSA determine how much of my SSI money to pay the
state?
SSA decides the amount of payment based on two considerations. First, SSA looks at
the amount of money claimed by the state, and second, SSA looks at the amount of your
retroactive SSI money available to pay the state. SSA can reimburse the state for
a payment made in a month only when you receive a state payment and an SSI payment
for the same month. SSA will not pay the state more money than you have for the SSI
retroactive period.
How long is this authorization effective for the state and me if I checked
the “Initial Claims Only” block?
This authorization is in effect for you and the state for twelve (12) months. The
12 months begin with the date the state notifies SSA through an electronic system
that the state has received the authorization and ends 12 months later. You and a
state representative must sign and date the authorization for the authorization to
be valid.
Exceptions apply to this rule. The state must send SSA the authorization within a
certain time frame. For a state using an electronic system, SSA must receive the authorization
information within 30 calendar days of the state matching your SSI record with your
state record. If the information is late, SSA will not accept the information sent
by the state. SSA will not pay any of your retroactive SSI benefits to the state.
SSA will send you any SSI money that may be due you, based on SSA’s regular payment
rules.
Can the authorization stay effective longer than the 12-month period? Can the
authorization end before or after the 12-month period ends?
The authorization can stay effective longer than the 12-month period, if you
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•
apply for SSI benefits before the state has the authorization form, or
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•
apply within the 12-month period the authorization is effective, or
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•
file a valid appeal of SSA’s determination on your initial claim.
The period of the authorization can end before the 12-month period ends, or end after
the 12-month period ends when any of these actions take place:
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•
SSA makes the first SSI payment on your initial claim; or
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•
SSA makes a final determination on your claim; or
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•
the state and you agree to terminate this authorization.
The authorization period will end with the day of the month any of these actions take
place.
How long is this authorization effective for the state and me if I check the
“Posteligibility Case Only” block?
This authorization is in effect for you and the state for twelve (12) months. The
12 months begin with the date the state notifies SSA through an electronic system
that the state has received the authorization and end 12 months later. You and a state
representative must sign and date the authorization for the authorization to be valid.
Exceptions apply to this rule. The state must send SSA the authorization within a
certain time frame. For a state using an electronic system, SSA must receive the authorization
information within 30 calendar days of the state matching your SSI record with your
state record. If the information is late, SSA will not accept the information sent
by the state. SSA will not pay any of your retroactive SSI benefits to the state.
SSA will send you any SSI money that may be due you, based on SSA’s regular payment
rules.
Can the authorization stay effective longer than the 12-month period? Can the
authorization end before or after the 12-month period ends?
The authorization can stay in effect longer than the 12-month period if you file a
valid appeal. You must file your appeal within the time frame SSA requires.
The period of the authorization can end before the 12-month period ends, or can end
after the 12-month period ends when any of these actions take place:
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•
SSA makes the first SSI payment on your posteligibility case after a period of suspension
or termination; or
-
•
SSA makes a final determination on your appeal; or
-
•
the state and you agree to terminate this authorization.
The authorization period will end with the day of the month any of these actions take
place.
Can SSA use this authorization form to protect my filing date for SSI
benefits?
SSA can use this form to protect your filing date if you checked the “Initial Claims
Only” block. When you sign this form, you are saying that you have the intention of
filing for SSI benefits if you have not already applied for benefits.
You have sixty (60) days from the date the state receives this form to file for SSI
benefits. Your eligibility to receive SSI benefits can be as early as the date you
sign this authorization if you file within the 60-day time period. If you file for
SSI benefits after the 60-day time period, this form will not protect your filing
date. Your filing date will be later than the date you sign this form.
How do I appeal a state’s decision if I do not agree with the
decision?
You can disagree with a decision the state made during the reimbursement process.
You will receive a state notice telling you how to appeal the decision. You cannot
appeal to SSA if you disagree with any state decision.
Within 10 working days after the state receives the reimbursement money from SSA,
the state must send you a notice. The notice will tell you three things: (1) the amount
of the payments the state paid you; (2) that SSA will send you a letter explaining
how SSA will pay the remaining SSI money (if any) due you, and (3) about your right
to a hearing with the state, including how to request the hearing.
What Happens if SSA mistakenly sends the payment to
me?
I understand that if I am found eligible to receive SSI payments, and by mistake the
payment is sent to me, when it should have been sent to DTA, then DTA can demand that
I pay to it the amount of money that SSA determines is due DTA. If I do not pay this
amount, I understand DTA can seek to collect this amount from me through a court action
or other legal remedy. The Commissioner of the SSA will not be a party to, or responsible
for, participating in DTA’s efforts to recover any IAR due it, under these circumstances.
_____________________________ Date__________________
Signature of Individual Receiving Interim Assistance
___________________________ Date______________ GR Code______
Signature of State Representative
EXHIBIT 2
SSA Field Office Intervention Needed
When the SSI System receives the electronic reimbursement request from the State Agency,
and cannot automatically compute the reimbursement amount, the system sets an I9 diary
on the SSR.
The I9 diary indicates FO Intervention is required. I9 diaries are listed in ChiNet.
The I9 diary may be posted to the SSR in 3 to 25 business days from the start of the
eIAR process.
How do I resolve the I9 diary?
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1.
Review the SSR to determine any months that require a manual SSI payment computation.
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2.
Select Special Payments Menu (UPSP) in Direct SSR Update (UMEN).
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4.
On UPOT, select option 3=Interim Assistance Reimbursement. Do NOT input a payment date
range on UPOT. The system takes care of this for you.
The System pre-fills the One Time Payment screens (UPOA) with State Agency’s
information and (UPOP) with information from the SSR.
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5.
Review the UPOP screen for accuracy. Input any corrections to the SSI Federal and
State amounts due and paid for the months in the IAR period. Complete the “Prorate
Day” column where proration is required.
The System determines the amount of reimbursement, alerts the CR that a 2-PIN approval
is required and displays the Simulated SSR.
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6.
Confirm that the Simulated SSR is accurate, obtain the 2-PIN approval, and send data
to the SSR.
The System pays the State Agency and resolves the rest of the underpayment according
to the priority of payment rules.