TN 28 (03-02)
NL 00804.166 Continuation of Benefits for Recipients Temporarily Institutionalized
Manual Paragraphs
INTM50. Situation Where Used:
IC and PE: The recipient is not eligible to receive continued benefits while in a
Medicaid facility (LA-D).
Exhibit Letter
We are writing to tell you that (1) not eligible to receive SSI benefits while (2)
a patient in a medical facility, e.g., hospital, nursing home. Our records show that
(3) a patient in a facility as of (4).
Fill-ins:
-
-
-
(3)
you (are/were)/(he/she) (is/was)
-
(4)
month, day, year)/(month, day, year) through (month, day, year)/(month, day, year)
on.
Payment Information
We usually reduce SSI payments for each full month that:
-
•
a claimant is a patient in a hospital or other medical facility and
-
•
Medicaid pays for or is expected to pay more than half the cost of his/her care.
We make payments for any of the first 3 full months if:
-
•
we reduce an SSI payment for any of the first 3 full months, and
-
•
patient is eligible for an SSI payment in the month before we reduce an SSI payment,
and
-
•
patient gives us proof that he/she must continue to pay his/her home expenses, and
-
•
we have proof that the patient's doctor expects him/her to stay in a medical facility
for less than 91 days.
We must receive (1) proof postmarked by the 90th day of (2) stay in the medical facility
or by the day of (3) release, if earlier.
Fill-ins:
-
-
-
Basis of Our Decision
Optional Paragraph 1
(1) not meet all of these requirements because (2) not have expenses for (3) home
which (4) must continue to pay.
Fill-ins:
-
-
-
-
Optional Paragraph 2
(1) not meet all of these requirements because we did not receive the proof about
(2) home expenses postmarked by (3).
Fill-ins:
-
-
-
Optional Paragraph 3
(1) not meet all of these requirements because (2) doctor expects (3) to stay 91days
or more.
Fill-ins:
-
-
-
Optional Paragraph 4
(1) not meet all of these requirements because we did not receive the proof postmarked
by (2) of how long (3) doctor expects (4) to stay in a medical facility.
Fill-ins:
-
-
-
-
Optional Paragraph 5
(1) not meet all of these requirements because (2) not eligible for an SSI payment
in (3)
Fill-ins:
-
-
-
Optional Paragraph 6
(1) not meet all of these requirements because (2) not have expenses for (3) home
which (4) must continue to pay. Also, we did not receive the proof postmarked by (5)
of how long (6) doctor expects (7) to stay in a medical facility.
Fill-ins:
-
-
-
-
-
-
-
Optional Paragraph 7
(1) not meet all of these requirements because we did not receive the proof about
(2) home expenses or proof postmarked by (3) of how long (4) doctor expects (5) to
stay in a medical facility.
Fill-ins:
-
-
-
-
-
Optional Paragraph 8
(1) not meet all of these requirements because we did not receive the proof postmarked
by (2) about (3) home expenses or proof of how long (4) doctor expects (5) to stay
in a medical facility.
Fill-ins:
-
-
-
-
-
Optional Paragraph 9
(1) not meet all of these requirements because (2) doctor expects (3) to stay in a
medical facility 91 days or more.
Fill-ins:
-
-
-
Optional Paragraph 10
(1) not meet all of these requirements because (2) not eligible for an SSI payment
in (3). Also, we did not receive the proof postmarked by (4) of how long (5) doctor
expects (6) to stay in a medical facility.
Fill-ins:
-
-
-
-
-
-
Optional Paragraph 11
(1) not meet all of these requirements because we did not reduce (2) SSI payment for
each of the first 3 full months (3) a patient. We can pay continued payments only
for those first 3 months.
Fill-ins:
-
-
-
INTM51. Situation Where Used:
IC and PE: The recipient is not eligible to receive continued benefits while in a
non-Medicaid facility (N02).
Exhibit Letter
We are writing to tell you that (1) not eligible to receive SSI benefits while (2)
a patient in a medical facility, e.g., hospital, nursing home. Our records show that
(3) entered a medical facility in (4).
Fill-ins:
-
-
-
-
(4)
(month, day, year)/(month, day, year) through (month, day, year)/(month, day, year)
on.
Payment Information
We usually reduce SSI for each full month that:
-
•
a claimant is a patient in a hospital or other medical facility, and
-
•
Medicaid pays for or is expected to pay more than half the cost of his/her care
We make payments for any of the first 3 full months if:
-
•
we would have stopped an SSI payment for any of these months, and
-
•
patient is eligible for an SSI payment in the month before we would have stopped an
SSI payment, and
-
•
patient is in a medical facility, and
-
•
patient gives us proof that he/she must continue to pay his/her home expenses, and
-
•
we have proof that patient's doctor expects him/her to stay in a medical facility
for less than 91 days.
We must receive (1) proof postmarked by the 90th day of (2) stay in the medical facility
or by the day of (3) release, if earlier.
Fill-ins:
-
-
-
Basis of Our Decision
Optional Paragraph 1
(1) not meet all of these requirements because (2) not have expenses for (3) home
which (4) must continue to pay.
Fill-ins:
-
-
-
-
Optional Paragraph 2
(1) not meet all of these requirements because we did not receive the proof about
(2) home expenses postmarked by (3).
Fill-ins:
-
-
-
Optional Paragraph 3
(1) not meet all of these requirements because (2) doctor expects (3) to stay 91 days
or more.
Fill-ins:
-
-
-
Optional Paragraph 4
(1) not meet all of these requirements because we did not receive the proof postmarked
by (2) of how long (3) doctor expects (4) to stay in a medical facility.
Fill-ins:
-
-
-
-
Optional Paragraph 5
(1) not meet all of these requirements because (2) not eligible for an SSI payment
in (3)
Fill-ins:
-
-
-
Optional Paragraph 6
(1) not meet all of these requirements because (2) not have expenses for (3) home
which (4) must continue to pay. Also, we did not receive the proof postmarked by (5)
of how long (6) doctor expects (7) to stay in a medical facility.
Fill-ins:
-
-
-
-
-
-
-
Optional Paragraph 7
(1) not meet all of these requirements because we did not receive the proof of how
long (2) doctor expects (3) to stay in a medical facility.
Fill-ins:
-
-
-
Optional Paragraph 8
(1) not meet all of these requirements because (2) not in a medical facility.
Fill-ins:
-
-
(2)
you (are/were)/(he/she) (is/was)
Optional Paragraph 9
(1) not meet all of these requirements because we did not receive the proof postmarked
by (2) about (3) home expenses or proof of how long (4) doctor expects (5) to stay
in a medical facility.
Fill-ins:
-
-
-
-
-
Optional Paragraph 10
(1) not meet all of these requirements because (2) doctor expects (3) to stay 91 days
or more. Also, we did not receive the proof postmarked by (4) of how long (5) doctor
expects (6) to stay in a medical facility.
Fill-ins:
-
-
-
-
-
-
Optional Paragraph 11
(1) not meet all of these requirements because (2) not eligible for an SSI payment
in (3). Also, we did not receive the proof postmarked by (4) of how long (5) doctor
expects (6) to stay in a medical facility.
Fill-ins:
-
-
-
-
-
-
Optional Paragraph 12
(1) not meet all of these requirements because we did not stop (2) SSI payment for
all of the first 3 full months (3) a patient. We can pay continued payments only for
those first 3 months.
Fill-ins:
-
-
-
INTM52. Situation Where Used:
PE: We originally told the recipient he was not eligible to receive continued benefits
while in a Medicaid facility. Now, we find he is eligible to receive continued benefits
for the same period of time.
Exhibit Letter
We are writing to you to tell you that (1) eligible to receive SSI benefits while
(2) a patient in a medical facility, e.g., hospital, nursing home. Our records show
that (3) entered a medical facility in (4).
Fill-ins:
-
-
-
-
Payment Information
We usually reduce SSI payments for each full month that:
-
•
a patient in a hospital or other medical facility for a full month, and
-
•
Medicaid pays for or would usually pay for more than half the cost of the patient's
care.
However, this rule does not apply for any of the first 3 full months that the patient
is in a medical facility
-
•
The patient's doctor expects him/her to stay in a medical facility for less than 91
days, and
-
•
The patient has home expenses that he/she must continue to pay.
We told (1) before that we were (2) payments while (3) in a medical facility. However,
now we find that we should not have (4) payments while (5) in a medical facility for
(6).
Fill-ins:
-
-
-
-
-
-
Basis of Our Decision
Optional Paragraph 1
(1) all of these requirements because (2) had expenses for (3) home which (4) had
to continue to pay.
Fill-ins:
-
-
-
-
Optional Paragraph 2
(1) the requirements because we received the proof about (2) home expenses on time.
Fill-ins:
-
-
Optional Paragraph 3
(1) all of these requirements because (2) doctor expected (3) to stay for less than
91 days.
Fill-ins:
-
-
-
Optional Paragraph 4
(1) all of these requirements because we received the proof on time of how long (2)
doctor expected (3) to stay in a medical facility.
Fill-ins:
-
-
-
Optional Paragraph 5
(1) all of these requirements because (2) eligible for an SSI payment in (3).
Fill-ins:
-
-
-
Optional Paragraph 6
(1) all of these requirements because (2) in a medical facility.
Fill-ins:
-
-
Optional Paragraph 7
(1) all of these requirements because (2) had expenses for (3) home which (4) had
to continue to pay. Also, the proof of how long (5) doctor expected (6) to stay in
a medical facility was received on time.
Fill-ins:
-
-
-
-
-
-
Optional Paragraph 8
(1) all of these requirements because the proof about (2) home expenses was received.
Also, the proof of how long (3) doctor expected (4) to stay in a medical facility
was received on time.
Fill-ins:
-
-
-
-
Optional Paragraph 9
(1) all of these requirements because the proof about (2) home expenses was received
on time. Also, the proof of how long (3) doctor expected (4) to stay in a medical
facility was received on time.
Fill-ins:
-
-
-
-
Optional Paragraph 10
(1) all of these requirements because (2) doctor expected (3) to stay for less than
91 days. Also, the proof of how long (4) doctor expected (5) to stay in a medical
facility was received on time.
Fill-ins:
-
-
-
-
-
Optional Paragraph 11
(1) all of these requirements because (2) eligible for an SSI payment in (3). Also,
the proof of how long (4) doctor expected (5) to stay in a medical facility was received
on time.
Fill-ins:
-
-
-
-
-
Optional Paragraph 12
(1) SSI payments are meant for (2) home expenses. (3) to pay this money to the medical
facility.
Fill-ins:
-
-
-
(3)
You do not have/(He/She) does not have
INTM53. Situation Where Used:
PE: We originally told the recipient that he was not eligible to receive continued
benefits while in a non-Medicaid facility. Now, we find he is eligible to receive
continued benefits for the same period of time.
Exhibit Letter
We are writing to tell (1) that (2) eligible to receive SSI benefits while (3) a patient
in a medical facility, e.g., hospital, nursing home. Our records show that (4) entered
a medical facility in (5).
Fill-ins:
-
-
-
-
-
Payment Information
We usually stop SSI payments for each full month that:
-
•
a patient spends in a hospital or other medical facility that is run by the Federal,
State, or local government, and
-
•
if the patient has Medicaid, it does not pay for more than half the cost of his/her
care.
However, this rule does not apply for any of the first 3 full months that he/she is
a patient if:
-
•
his/her doctor expects him/her to stay in a medical facility for less than 91 days,
and
-
•
the patient has expenses for his/her home that he/she must continue to pay.
We told (1) before that we were stopping (2) payments while (3) in a medical facility.
However, now we find that we should not have stopped (4) payments while (5) in a medical
facility for (6).
Fill-ins:
-
-
-
-
-
-
(6)
(month/year) OR (month/year) and (month/year) OR (month/year) through (month/year)
Basis of Our Decision
Optional Paragraph 1
(1) all of these requirements because (2) had expenses for (3) home which (4) had
to continue to pay.
Fill-ins:
-
-
-
-
Optional Paragraph 2
(1) all of these requirements because we received the proof about (2) home expenses
on time.
Fill-ins:
-
-
Optional Paragraph 3
(1) all of these requirements because (2) doctor expected (3) to stay for less than
91 days.
Fill-ins:
-
-
-
Optional Paragraph 4
(1) all of these requirements because we received the proof how long (2) doctor expected
(3) to stay in a medical facility on time.
Fill-ins:
-
-
-
Optional Paragraph 5
(1) all of these requirements because (2) were eligible for an SSI payment in (3).
Fill-ins:
-
-
-
Optional Paragraph 6
(1) all of these requirements because (2) in a medical facility.
Fill-ins:
-
-
Optional Paragraph 7
(1) all of these requirements because (2) had expenses for (3) home which (4) had
to continue to pay. Also, we received the proof of how long (5) doctor expected (6)
to stay in a medical facility on time.
Fill-ins:
-
-
-
-
-
-
Optional Paragraph 8
(1) all of these requirements because we received the proof about (2) home expenses
and of how long (3) doctor expected (4) to stay in a medical facility on time.
Fill-ins:
-
-
-
-
Optional Paragraph 9
(1) all of these requirements because we received the proof about (2) home expenses
and of how long (3) doctor expected (4) to stay in a medical facility on time.
Fill-ins:
-
-
-
-
Optional Paragraph 10
(1) all of these requirements because (2) doctor expected (3) to stay in a medical
facility for less than 91 days.
Fill-ins:
-
-
-
Optional Paragraph 11
(1) all of these requirements because (2) doctor expected (3) to stay for less than
91 days. Also, we received the proof of how long (4) doctor expected (5) to stay in
a medical facility on time.
Fill-ins:
-
-
-
-
-
Optional Paragraph 12
(1) all of the requirements because (2) eligible for an SSI payment in (3). Also,
we received the proof of how long (4) doctor expected (5) to stay in a medical facility
on time.
Fill-ins:
-
-
-
-
-
INTM54. Situation Where Used:
PE: We originally told the recipient that he was eligible to receive continued benefits
while in a Medicaid facility. Now we find he is not eligible to receive continued
benefits for the same period of time.
Exhibit Letter
We are writing to you to tell you that (1) not eligible to receive SSI benefits while
(2) a patient in a medical facility, e.g., hospital, nursing home. Our records show
that (3) entered a medical facility in (4).
Fill-ins:
-
-
-
-
Payment Information
-
•
(1) in a medical care facility, like a hospital or nursing home, and
-
•
(2) lived there for the full month, and
-
•
Medicaid paid for or would usually pay for more than half the cost of (3) care, and
-
•
(4) eligible for SSI payments for the first three full months (5) in the facility.
Fill-ins:
-
-
-
-
(4)
you were not/(he/she) was not
-
As a result, there is a limit of (1) on the Supplemental Security Income that (2)
due for months (3) in the facility. If (4) income, (5) due less.
Fill-ins:
-
(1)
(amount equal to the Federal payment for LA-D plus any optional State supplementary
payment, if applicable).
-
-
-
-
We told (1) before that (2) eligible for SSI payments while (3) in a medical facility.
However, now we find that (4) eligible while (5) in a medical facility for (6).
Fill-ins:
-
-
-
-
(4)
you are not/(he/she) is not
-
-
(6)
(month/year)/(month/year) and (month/year)/(month/year) through (month/year)
Basis of Our Decision
Optional Paragraph 1
(1) not meet all of these requirements because (2) did not have expenses for your
home which (3) must continue to pay.
Fill-ins:
-
-
-
Optional Paragraph 2
(1) not meet all of these requirements because we did not receive the proof about
(2) home expenses.
Fill-ins:
-
-
Optional Paragraph 3
(1) not meet all of these requirements because we did not receive the proof about
(2) home expenses postmarked by (3).
Fill-ins:
-
-
-
Optional Paragraph 4
(1) not meet all of these requirements because we did not receive the proof of how
long (2) doctor expected (3) to stay in a medical facility postmarked by (4).
Fill-ins:
-
-
-
-
Optional Paragraph 5
(1) all of these requirements because we did not receive the proof of how long (2)
doctor expected (3) to stay in a medical facility.
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
Optional Paragraph 6
(1) all of these requirements because (2) not eligible for an SSI payment in (3).
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
Optional Paragraph 7
(1) all of these requirements because (2) did not have expenses for (3) home which
(4) must continue to pay. Also, we did not receive the proof of how long (5) doctor
expected (6) stay in a medical facility postmarked by (7).
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
-
-
-
-
Optional Paragraph 8
(1) all of these requirements because the proof about (2) home expenses was not received.
Also, we did not receive the proof of how long (3) doctor expected (4) stay in a medical
facility postmarked by (5).
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
-
-
Optional Paragraph 9
(1) all of these requirements because we did not receive the proof postmarked by (2)
about (3) home expenses or of how long (4) doctor expected (5) to stay in a medical
facility.
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
-
-
Optional Paragraph 10
(1) all of these requirements because (2) not eligible for an SSI payment in (3).
Also, we did not receive the proof of how long (4) doctor expected (5) to stay in
a medical facility postmarked by (6).
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
-
-
-
INTM55. Situation Where Used:
PE: We originally told the recipient that he was eligible to receive continued benefits
while in a non-Medicaid facility. Now, we find he is not eligible to receive continued
benefits for the same period of time.
Exhibit Letter
We are writing to tell you that (1) not eligible to receive SSI benefits while (2)
a patient in a medical facility, e.g., hospital, nursing home. Our records show that
(3) a patient in a facility as of (4).
Fill-ins:
-
-
-
(3)
you (are/were)/(he/she) (is/were)
-
Payment Information
-
•
in a medical facility, run by the Federal, State or local government, and
-
•
(2) lived there for the full month, and
-
•
if (3) Medicaid, it did not pay for more than half the cost of (4) care, and
-
•
(5) eligible for SSI payments for the first three full months (6) in the facility.
Fill-ins:
-
-
-
-
-
-
We told (1) before that (2) eligible for SSI payments while (3) in a medical facility.
However, now we find that (4) eligible while (5) in the facility for (6).
Fill-ins:
-
-
-
-
(4)
you were not/(he/she) was not
-
-
(6)
(month/year)/(month/year) and (month/year)/(month/year) through (month/year)
Basis of Our Decision
Optional Paragraph 1
(1) all of these requirements because (2) did not have expenses for (3) home which
(4) must continue to pay.
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
-
Optional Paragraph 2
(1) all these requirements because we did not receive the proof about (2) home expenses
postmarked by (3).
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
Optional Paragraph 3
(1) all of these requirements because we did not receive the proof of how long (2)
doctor expected (3) to stay in a medical facility postmarked by (4).
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
-
Optional Paragraph 4
(1) all of these requirements because (2) eligible for an SSI payment in (3).
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
(2)
you were not/(he/she) was not
-
Optional Paragraph 5
(1) all of these requirements because (2) in a medical facility.
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
(2)
you were not/(he/she) was not
Optional Paragraph 6
(1) all of these requirements because (2) did not have expenses for (3) home which
(4) must continue to pay. Also, we did not receive the proof of how long (5) doctor
expected (6) to stay in a medical facility postmarked by (7).
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
-
-
-
-
Optional Paragraph 7
(1) all of these requirements because we did not receive the proof about (2) home
expenses or of how long (3) doctor expected (4) to stay in a medical facility postmarked
by (5).
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
-
-
Optional Paragraph 8
(1) all of these requirements because we did not receive the proof about (2) home
expenses or of how long (3) doctor expected (4) to stay in a medical facility postmarked
by (5).
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
-
-
Optional Paragraph 9
(1) all of these requirements because (2) eligible for an SSI payment in (3). Also,
we did not receive the proof of how long (4) doctor expected (5) to stay in a medical
facility postmarked by (6).
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
(2)
you were not/(he/she) was not
-
-
-
-
1622. Situation Where Used:
IC and PE: The recipient is eligible to receive continued benefits while in a Medicaid
facility.
Exhibit Letter
We are writing you to tell you that (1) eligible to receive SSI benefits while (2)
a patient in a medical facility, e.g., hospital, nursing home. Our records show that
(3) entered a medical facility in (4).
Fill-ins:
-
-
-
-
Payment Information
We usually reduce SSI payments for each full month that:
-
•
a claimant is a patient in a hospital or other medical facility and
-
•
Medicaid pays for or is expected to pay more than half the cost of his/her care.
However, this rule does not apply for any of the first 3 full months that (1) a patient
if:
-
•
(2) doctor expects (3) to stay in a medical facility for less than 91 days, and
-
•
(4) expenses for (5) home that (6) must continue to pay.
Fill-ins:
-
-
-
-
-
-
Basis of Our Decision
Optional Paragraph 1
This means that beginning (1), we (2) (3) payment because (4) in a medical facility.
Fill-ins:
-
(1)
(month/year)/(month/year) and (month/year)/(month/year) through (month/year)
-
(2)
are not reducing/did not reduce
-
-
(4)
you (are/were)/(he/she) is/were
Optional Paragraph 2
(1) SSI payments are meant for (2) home expenses. (3) to pay this money to the medical
facility.
Please tell us as soon as (4) when (5) will be leaving the medical facility, so we
can continue to pay (6) correctly.
Fill-ins:
-
-
-
(3)
You do not have/(He/She) does not have
-
-
-
1623. Situation Where Used:
IC and PE: The recipient is eligible to receive continued benefits while in a Medicaid
or non-Medicaid facility and we are sending the eligibility notice in the second or
third month of institutionalization, but prior to the Goldberg/Kelly cutoff date for
reducing/ stopping the SSI payment in the fourth month.
Exhibit Letter
Basis of Our Decision
Optional paragraph 1 to be used with either paragraph 1622 or 1625
-
•
(1) SSI payment for (2) will be (3) if (4) still in the medical facility for the full
month (5).
Fill-ins:
-
-
-
-
-
(5)
you have income/(he/she) has income
1624. Situation Where Used:
IC and PE: The recipient is eligible to receive continued benefits while in a Medicaid
or non-Medicaid facility and we are sending the eligibility notice after the Goldberg/Kelly
cutoff date for reducing/stopping the SSI payment in the fourth month.
Exhibit Letter
Basis of Our Decision
Optional paragraph 1 to be used with either paragraph 1622 or 1625
-
•
(1) (2) SSI beginning (3) if (4) still in the medical facility (5). Even though (6)
(7) money for that month, we will not reduce (8) payment of (9). This is to give (10)
time to appeal this decision.
-
•
However, (11) may have to pay back any money (12) not eligible to receive. We will
let (13) know later if (14) payment for (15) changes.
Fill-ins:
-
-
-
-
-
(5)
and have income/and has income
-
-
-
-
-
-
-
-
-
-
1625. Situation Where Used:
IC and PE: The recipient is eligible to receive continued benefits while in a non-Medicaid
facility.
Exhibit Letter
We are writing you to tell you that (1) eligible to receive SSI benefits while (2)
a patient in a medical facility, e.g., hospital, nursing home. Our records show that
(3) entered a medical facility in (4).
Fill-ins:
-
-
-
-
Payment Information
We usually reduce SSI payments for each full month that:
-
•
a claimant is a patient in a hospital or other medical facility and
-
•
Medicaid pays for or is expected to pay more than half the cost of his/her care.
However, this rule does not apply for any of the first 3 full months that (1) a patient
if:
-
•
(2) doctor expects (3) to stay in a medical facility for less than 91 days, and
-
•
(4) expenses for (5) home that (6) must continue to pay.
Fill-ins:
-
-
-
-
-
-
Basis of Our Decision
Optional Paragraph 1
This means that beginning (1), we (2) (3) payment because (4) in a medical facility.
Fill-ins:
-
(1)
(month, year)/(month/year) and (month/year)/(month/year) through (month/year)
-
(2)
are not stopping/did not stop
-
-
Please tell us as soon as (1) when (2) will be leaving the medical facility, so we
can continue to pay (3) correctly.
Fill-ins:
-
-
-
1626. Situation Where Used:
PE: The recipient was previously notified of his eligibility to continued benefits.
When using this paragraph we are notifying the recipient that his payment with be
reduced or stopped in his fourth month of institutionalization.
Basis of Our Decision
Optional Paragraph 1
We wrote (1) earlier to tell (2) that we would not (3) (4) SSI payment because (5)
a patient in a medical facility for (6).
(7) SSI payment for (8) will be reduced if (9) still in the medical facility for the
full month.
Please tell us when (10) the medical facility so we can continue to pay (11) correctly.
Fill-ins:
-
-
-
-
-
(5)
you (are/were)/(he/she) (is/was)
-
-
-
(8)
(month, year)/(month, year) and (month, year)/(month, year) through (month, year)
-
-
(10)
you leave/(he/she) leaves
-
Optional Paragraph 2
(1) SSI payment for (2) will be (3) if (4) still in the medical facility for the full
month.
Fill-ins:
-
-
-
-
Optional Paragraph 3
(1) SSI payment for (2) will be stopped if (3) still in the medical facility for the
full month and (4) income.
Fill-ins:
-
-
-
-
1627. Situation Where Used:
IC and PE: The recipient is not eligible to receive continued benefits while in a
Medicaid facility.
Optional Paragraph 15 is only used in a manual denial notice.
Exhibit Letter
We are writing you to tell you that (1) not eligible to receive SSI benefits while
(2) a patient in a medical facility, e.g., hospital, nursing home. Our records show
that (3) entered a medical facility in (4).
Fill-ins:
-
-
-
-
Payment Information
We usually reduce SSI payments for each full month that:
-
•
a claimant is a patient in a hospital or other medical facility and
-
•
Medicaid pays for or is expected to pay more than half the cost of his/her care.
(1) could be eligible for continued payments for any of the first 3 full months that
(2) a patient if:
-
•
we would have reduced (3) payment for any of these months, and
-
•
(4) eligible for an SSI payment in the month before we would have reduced (5) SSI
payment, and
-
•
(6) us proof that (7) home expenses that (8) to continue to pay, and
-
•
we have proof that (9) doctor expects (10) to stay in a medical facility for less
than 91 days.
We must receive the proofs by the 10th of the month after the month (11) admitted to the medical facility.
Fill-ins:
-
-
-
-
-
-
-
-
-
-
-
Basis of Our Decision
Optional Paragraph 1
(1) all of these requirements because (2) not have expenses for (3) home which (4)
must continue to pay.
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
-
Optional Paragraph 2
(1) all of these requirements because we did not receive the proof about (2) home
expenses postmarked by (3).
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
Optional Paragraph 3
(1) all of these requirements because (2) doctor expects (3) to stay 91 days or more.
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
Optional Paragraph 4
(1) all of these requirements because we did not receive the proof of how long (2)
doctor expects (3) to stay in a medical facility by (4), and we could not find a good
reason why it was received late
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
-
Optional Paragraph 5
(1) all of these requirements because the proof of how long (2) doctor expects (3)
to stay in a medical facility was not prepared and dated by (4).
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
-
Optional Paragraph 6
(1) all of these requirements because the proof of how long (2) doctor expects (3)
to stay in a medical facility was not received.
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
Optional Paragraph 7
(1) all of these requirements because (2) eligible for an SSI payment in (3).
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
(2)
you were not/(he/she) was not
-
Optional Paragraph 8
(1) all of these requirements because (2) expenses for (3) home which you must continue
to pay. Also, we did not receive the proof of how long (4) doctor expects (5) to stay
in a medical facility by (6), and we could not find a good reason why it was received
late.
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
(2)
you do not have/(he/she) does not have
-
-
-
-
Optional Paragraph 9
(1) all of these requirements because we did not receive the proof about (2) home
expenses or of how long (3) doctor expects (4) to stay in a medical facility by (5),
and we could not find a good reason why it was received late.
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
-
-
Optional Paragraph 10
(1) all of these requirements because we did not receive the proof about (2) home
expenses or of how long (3) doctor expects (4) to stay in a medical facility by (5)
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
-
-
Optional Paragraph 11
(1) all of these requirements because (2) doctor expects (3) to stay 91 days or more.
Also, we did not receive the proof of how long (4) doctor expects (5) to stay in a
medical facility by (6), and we could not find a good reason why it was received late.
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
-
-
-
Optional Paragraph 12
(1) all of these requirements because we did not receive the proof of how long (2)
doctor expects (3) to stay in a medical facility or of how long (4) doctor expects
(5) to stay in a medical facility by (6), and we could not find a good reason why
it was received late.
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
-
-
-
Optional Paragraph 13
(1) all of these requirements because (2) eligible for an SSI payment in (3). Also,
we did not receive the proof of how long (4) doctor expects (5) to stay in a medical
facility by (6), and we could not find a good reason why it was received late
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
(2)
you were not/(he/she) was not
-
-
-
-
Optional Paragraph 14
(1) all of these requirements because we did not reduce (2) SSI payment for all of
the first 3 full months (3) a patient. We can pay continued payments only for the
first 3 months.
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
1628. Situation Where Used:
IC and PE: The recipient is not eligible to receive continued benefits while in a
non-Medicaid facility.
Fill-in 24, choices 49, 50 and 51 [THESE CHOICES DO NOT APPEAR IN THIS SECTION] are only used in a manual denial notice.
Exhibit Letter
We are writing you to tell you that (1) not eligible to receive SSI benefits while
(2) a patient in a medical facility, e.g., hospital, nursing home. Our records show
that (3) in this facility for (4).
Fill-ins:
-
-
-
(3)
you will be/(he/she) will be
-
(4)
for the full month of (month/year)/for each full month through (month/year)/for each
full month on (month, year)
Payment Information
We usually reduce SSI payments for each full month that:
-
•
a claimant is a patient in a hospital or other medical facility that is run by the
Federal, State, or local government, or an institution run by the Federal, State,
or local government, including some hospitals, nursing homes, other care facilities
or prisons, and
-
•
if the claimant had Medicaid, it does not pay for more than half the cost of his/her
care.
(1) could be eligible for continued payments for any of the first 3 full months that
(2) a patient if:
-
•
we would have stopped (3) SSI payment for any of these months, and
-
•
(4) eligible for an SSI payment in the month before we would have stopped (5) SSI
payment, and
-
•
(6) in a medical facility, and
-
•
(7) us proof that (8) home expenses that (9) to continue to pay, and
-
•
we have proof that (10) doctor expects (11) to stay in a medical facility for less
than 91 days.
We must receive the proofs by the 10th of the month after the month (12) admitted
to the medical facility.
Fill-ins:
-
-
-
-
-
-
-
-
-
-
-
-
Basis of Our Decision
Optional Paragraph 1
(1) all of these requirements because (2) expenses for (3) home which (4) must continue
to pay.
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
(2)
you do not have/(he/she) does not have
-
-
Optional Paragraph 2
(1) all of these requirements because we did not receive the proof about (2) home
expenses by (3).
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
Optional Paragraph 3
(1) all of these requirements because (2) doctor expects (3) to stay 91 days or more.
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
Optional Paragraph 4
(1) all of these requirements because we did not receive the proof of how long (2)
doctor expects (3) to stay in a medical facility by (4), and we could not find a good
reason why it was received late.
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
-
Optional Paragraph 5
(1) all of these requirements because the proof of how long (2) doctor expects (3)
to stay in a medical facility was not prepared and dated by (4).
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
-
Optional Paragraph 6
(1) all of these requirements because we did not receive the proof of how long (2)
doctor expects (3) to stay in a medical facility by (4).
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
-
Optional Paragraph 7
(1) all of these requirements because (2) eligible for an SSI payment in (3).
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
(2)
you were not/(he/she) was not
-
Optional Paragraph 8
(1) all of these requirements because (2) in a medical facility.
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
(2)
you are not/(he/she) is not
Optional Paragraph 9
(1) all of these requirements because (2) in a medical facility.
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
(2)
you were not/(he/she) was not
Optional Paragraph 10
(1) all of these requirements because (2) have expenses for (3) home which (4) must
continue to pay. Also, the proof of how long (5) doctor expects (6) to stay in a medical
facility was not received by (7), and we could not find a good reason why it was received
late.
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
(2)
you do not/(he/she) does not
-
-
-
-
-
Optional Paragraph 11
(1) all of these requirements because we did not receive postmarked by (2) the proof
about (3) home expenses or of how long (4) doctor expects (5) to stay in a medical
facility, and we could not find a good reason why it was received late.
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
-
-
Optional Paragraph 12
(1) all of these requirements because we did not receive postmarked by (2) the proof
about (3) home expenses or of how long (4) doctor expects (5) to stay in a medical
facility, and we could not find a good reason why it was received late.
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
-
-
Optional Paragraph 13
(1) all of these requirements because (2) doctor expects (3) to stay 91 days or more.
Also, we did not receive postmarked by (4) the proof of how long (5) doctor expects
(6) to stay in a medical facility, and we could not find a good reason why it was
received late.
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
-
-
-
1630. Situation Where Used:
PE: We originally told the recipient that he was not eligible to receive continued
benefits while in a non-Medicaid facility. Now, we find he is eligible to receive
continued benefits for the same period of time.
Exhibit Letter
We are writing you to tell you that (1) eligible to receive SSI benefits while (2)
a patient in a medical facility, e.g., hospital, nursing home. Our records show that
(3) entered this facility on (4).
Fill-ins:
-
-
-
-
Payment Information
We usually reduce SSI payments for each full month that:
-
•
a claimant is a patient in a hospital or other medical facility and that is run by
the Federal, State, or local government, and
-
•
if the claimant has Medicaid, it does not pay for more than half the cost of his/her
care.
(1) could be eligible for continued payments for any of the first 3 full months that
(2) a patient if:
-
•
(3) doctor expects (4) to stay in a medical facility for less than 91 days, and
-
•
(5) expenses for (6) home that (7) must continue to pay.
We told (8) before that we were stopping (9) payment while (10) in a medical facility.
However, now we find that we should not have stopped (11) payments while (12) in a
medical facility for (13).
Fill-ins:
-
-
-
-
-
-
-
-
-
-
-
-
-
(13)
(month, year)/(month, year and month, year)/(month, year) through (month, year)
Basis of Our Decision
Optional Paragraph 1
(1) all of these requirements because (2) had expenses for (3) home which (4) had
to continue to pay.
Fill-ins:
-
-
-
-
Optional Paragraph 2
(1) all of these requirements because we received the proof about (2) home expenses
(3).
Fill-ins:
-
-
-
Optional Paragraph 3
(1) all of these requirements because (2) doctor expected (3) to stay for less than
91 days.
Fill-ins:
-
-
-
Optional Paragraph 4
(1) all of these requirements because we did not receive the proof of how long (2)
doctor expected (3) to stay in a medical facility by (4), but we found a good reason
why it was received late.
Fill-ins:
-
-
-
-
Optional Paragraph 5
(1) all of these requirements because the proof of how long (2) doctor expected (3)
to stay in a medical facility was prepared and dated by (4).
Fill-ins:
-
-
-
-
Optional Paragraph 6
(1) all of these requirements because we received the proof of how long (2) doctor
expected (3) to stay in a medical facility by (4).
Fill-ins:
-
-
-
-
Optional Paragraph 7
(1) all of these requirements because (2) were eligible for an SSI payment in (3).
Fill-ins:
-
-
-
Optional Paragraph 8
(1) all of these requirements because (2) in a medical facility.
Fill-ins:
-
-
1631. Situation Where Used:
PE: We originally told the recipient that he was eligible to receive continued benefits
while in a Medicaid facility. Now, we find he is not eligible to receive continued
benefits for the same period of time.
Exhibit Letter
We are writing you to tell you that (1) not eligible to receive SSI benefits while
(2) a patient in a medical facility, e.g., hospital, nursing home. Our records show
that (3) entered this facility on (4).
Fill-ins:
-
-
-
-
Payment Information
We understand that
-
•
(1) in a medical care facility, like a hospital or nursing home, and
-
•
(2) lived there for the full month, and
-
•
Medicaid paid for or would usually pay for more than half the cost of (3) care, and
-
•
(4) eligible for SSI payments for the first three full months (5) in the facility.
As a result, there is a limit of (6) on the Supplemental Security Income (7) due for
months (8) in the facility. If (9) income, (10) due less.
We told (11) before that (12) eligible for SSI payments while (13) in a medical facility.
However, now we find that (14) eligible while (15) in a medical facility for (16).
Fill-ins:
-
-
-
-
(4)
you were not/(he/she) was not
-
-
-
-
-
-
-
-
-
-
(14)
you were not/(he/she) was not
-
-
(16)
(month, year)/(month/year) and (month/year)/(month, year) through (month/year)
Basis of Our Decision
Optional Paragraph 1
(1) all of these requirements because (2) did not have expenses for (3) home which
(4) must continue to pay.
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
-
Optional Paragraph 2
(1) all of these requirements because the proof about (2) home expenses was not received
by (3).
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
Optional Paragraph 3
(1) all of these requirements because (2) doctor expected you to stay 91 days or more.
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
Optional Paragraph 4
(1) all of these requirements because we did not receive the proof of how long (2)
doctor expected (3) to stay in a medical facility by (4), and we could not find a
good reason why it was received late.
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
-
Optional Paragraph 5
(1) all of these requirements because the proof of how long (2) doctor expected (3)
to stay in a medical facility was not prepared and dated by (4).
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
-
Optional Paragraph 6
(1) all of these requirements because we did not receive the proof of how long (2)
doctor expected (3) to stay in a medical facility by (4).
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
-
Optional Paragraph 7
(1) all of these requirements because (2) eligible for an SSI payment in (3).
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
(2)
you were not/(he/she) was not
-
Optional Paragraph 8
(1) all of these requirements because (2) did not have expenses for (3) home which
(4) must continue to pay. Also, we did not receive the proof of how long (5) doctor
expected (6) to stay in a medical facility by (7), and we could not find a good reason
why it was received late.
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
-
-
-
-
Optional Paragraph 9
(1) all of these requirements because we did not receive the proof about (2) home
expenses or of how long (3) doctor expected (4) to stay in a medical facility by (5),
and we could not find a good reason why it was received late.
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
-
-
Optional Paragraph 10
(1) all of these requirements because we did not receive postmarked by (2) the proof
about (3) home expenses or of how long (4) doctor expected (5) to stay in a medical
facility by (6), and we could not find a good reason why it was received late.
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
-
-
-
Optional Paragraph 11
(1) all of these requirements because (2) doctor expected (3) to stay 91 days or more.
Also, we did not receive the proof of how long (4) doctor expected (5) to stay in
a medical facility by (6), and we could not find a good reason why it was received
late.
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
-
-
-
Optional Paragraph 12
(1) all of these requirements because the proof of how long (2) doctor expected (3)
to stay in a medical facility was not prepared and dated by (4). Also, we did not
receive the proof of how long (5) doctor expected (6) to stay in a medical facility
by (7), and we could not find a good reason why it was received late.
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
-
-
-
-
Optional Paragraph 13
(1) all of these requirements because (2) eligible for an SSI payment in (3). Also,
we did not receive the proof of how long (4) doctor expected (5) to stay in a medical
facility by (6), and we could not find a good reason why it was received late.
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
(2)
you were not/(he/she) was not
-
-
-
-
1632. Situation Where Used:
PE: We originally told the recipient that he was eligible to receive continued benefits
while in a non-Medicaid facility. Now, we find he is not eligible to receive continued
benefits for the same period of time.
Exhibit Letter
We are writing you to tell you that (1) not eligible to receive SSI benefits while
(2) a patient in a medical facility, e.g., hospital, nursing home. Our records show
that (3) entered this facility on (4).
Fill-ins:
-
-
-
-
Payment Information
We understand that
-
•
(1) in a medical facility, run by the Federal, State, or local government, and
-
•
(2) lived there at least 1 full month, and
-
•
If (3) Medicaid, it did not pay for more than half the cost of (4) care, and
-
•
(5) eligible for SSI payments for the first three full months (6) in the facility.
We told (7) before that (8) eligible for SSI payments while (9) in a medical facility.
However, now we find that (10) eligible while (11) in a medical facility for (12).
Fill-ins:
-
-
-
-
-
(5)
you were not/(he/she) was not
-
-
-
-
-
(10)
you were not/(he/she) was not
-
-
(12)
(month/year)/(month/year) and (month/year)/(month/year) through (month/year)
Basis of Our Decision
Optional Paragraph 1
(1) all of these requirements because (2) did not have expenses for (3) home which
(4) must continue to pay.
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
-
Optional Paragraph 2
(1) all of these requirements because the proof about (2) home expenses was not received
by (3).
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
Optional Paragraph 3
(1) all of these requirements because we did not receive the proof of how long (2)
doctor expected (3) to stay in a medical facility by (4), and we could not find a
good reason why it was received late.
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
-
Optional Paragraph 4
(1) all of these requirements because the proof of how long (2) doctor expected (3)
to stay in a medical facility was not prepared and dated by (4).
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
-
Optional Paragraph 5
(1) all of these requirements because we did not receive the proof of how long (2)
doctor expected (3) to stay in a medical facility by (4).
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
-
Optional Paragraph 6
(1) all of these requirements because (2) were not eligible for an SSI payment in
(3).
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
-
-
Optional Paragraph 7
(1) all of these requirements because (2) in a medical facility.
Fill-ins:
-
(1)
You do not meet/(He/She) does not meet
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(2)
you were not/(he/she) was not
Optional Paragraph 8
(1) all of these requirements because (2) did not have expenses for (3) home which
(4) must continue to pay. Also, we did not receive the proof of how long (5) doctor
expected (6) to stay in a medical facility by (7), and we could not find a good reason
why it was received late.
Fill-ins:
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(1)
You do not meet/(He/She) does not meet
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-
Optional Paragraph 9
(1) all of these requirements because the proof about (2) home expenses was not received.
Also, we did not receive the proof of how long (3) doctor expected (4) to stay in
a medical facility by (5), and we could not find a good reason why it was received
late.
Fill-ins:
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(1)
You do not meet/(He/She) does not meet
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-
-
-
Optional Paragraph 10
(1) all of these requirements because we did not receive postmarked by (2) the proof
about (3) home expenses or of how long (4) doctor expected (5) to stay in a medical
facility, and we could not find a good reason why it was received late.
Fill-ins:
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(1)
You do not meet/(He/She) does not meet
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Optional Paragraph 11
(1) all of these requirements because (2) doctor expected (3) to stay 91 days or more.
Also, we did not receive the proof of how long (4) doctor expected (5) to stay in
a medical facility by (6), and we could not find a good reason why it was received
late.
Fill-ins:
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(1)
You do not meet/(He/She) does not meet
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-
Optional Paragraph 12
(1) all of these requirements because the proof of how long (2) doctor expected (3)
to stay in a medical facility was not prepared and dated by (4). Also, we did not
receive the proof of how long (5) doctor expected (6) to stay in a medical facility
by (7), and we could not find a good reason why it was received late.
Fill-ins:
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(1)
You do not meet/(He/She) does not meet
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1633. Situation Where Used:
IC and PE: Both members of an eligible couple were entitled to continued benefits
while in a Medicaid facility for the same period of time. Use this paragraph for retroactive
situation where the couple has remained an eligible couple.
Exhibit Letter
We are writing you to tell you that you and your spouse were eligible to receive SSI
benefits while you were patients in a medical facility, e.g., hospital, nursing home.
Our records show that you and your spouse entered this facility on (1).
Fill-ins:
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Payment Information
We usually reduce SSI payments for each full month that:
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•
you and your spouse live in a hospital or other medical facility for a full month,
and
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•
Medicaid pays for or would usually pay for more than half the cost of care for both
of you.
However, this rule does not apply to either of you for any of the first 3 full months
that you and your spouse are patients if:
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•
your doctors expect you and your spouse to stay in a medical facility for less than
91 days, and
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•
you and your spouse have expenses for your home that you must continue to pay.
Your SSI payments are meant for your home expenses. You and your spouse do not have
to pay this money to the medical facility.
This means that for (1) we did not reduce your payment and your spouse's payment because
you were both in a medical facility.
Fill-ins:
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(1)
(month, day, year)/(month/year) and (month/year)/(month/year) through (month/year)
1634. Situation Where Used:
IC and PE: Both members of an eligible couple were eligible to receive continued benefits
while in a non-Medicaid facility for the same period of time. Use this paragraph for
retroactive situations where the couple has remained an eligible couple.
Exhibit Letter
We are writing you to tell you that you and your spouse are eligible to receive SSI
benefits while you are patients in a medical facility, e.g., hospital, nursing home.
Our records show that you and your spouse entered this facility on (1).
Fill-ins:
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Payment Information
We usually reduce SSI payments for each full month that:
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•
you and your spouse live in a for a full month in a hospital or other medical facility
that is run by the Federal, State, or local government, and
-
•
if you and your spouse have Medicaid, it does not pay for more than half the cost
of care.
However, this rule does not apply to either of you for any of the first 3 full months
that you and your spouse are patients if:
-
•
your doctors expect you and your spouse to stay in a medical facility for less than
91 days, and
-
•
you and your spouse have expenses for your home that you must continue to pay.
This means that for (1) we did not reduce your payment and your spouse's payment because
you were both in a medical facility.
Fill-ins:
-
(1)
(month, day, year)/(month/year) and (month/year)/(month/year) through (month/year)
1629. Situation Where Used:
PE: We originally told the recipient he was not eligible to receive continued benefits
while in a Medicaid facility. Now, we find he is eligible to receive continued benefits
for the same period of time.
Exhibit Letter
We are writing you to tell you that (1) eligible to receive SSI benefits while (2)
a patient in a medical facility, e.g., hospital, nursing home. Our records show that
(3) entered this facility on (4).
Fill-ins:
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-
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Payment Information
We usually reduce SSI payments for each full month that:
-
•
a claimant is a patient in a hospital or other medical facility for a full month,
and
-
•
Medicaid pays for or would usually pay for more than half the cost of his/her care.
However, this rule does not apply for any of the first 3 full months that (1) a patient
if:
-
•
(2) doctor expects (3) to stay in a medical facility for less than 91 days, and
-
•
(4) expenses for (5) home that (6) must continue to pay.
We told (7) before that we were (8)(9) payment while (10) in a medical facility. However,
now we find that we should not have (11) (12) payments while (13) in a medical facility
for (14).
(15) SSI payments are meant for (16) home expenses. (17) to pay this money to the
medical facility.
Fill-ins:
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(14)
(month/year)/(month/year) and (month/year) (month/year) through (month/year)
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(17)
You do not have/(He/She) does not have
Basis of Our Decision
Optional Paragraph 1
(1) all of these requirements because (2) had expenses for (3) home which (4) must
continue to pay.
Fill-ins:
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-
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-
Optional Paragraph 2
(1) all of these requirements because we received the proof about (2) home expenses
by (3).
Fill-ins:
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-
-
Optional Paragraph 3
(1) all of these requirements because (2) doctor expected (3) to stay for less than
91 days.
Fill-ins:
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-
-
Optional Paragraph 4
(1) all of these requirements because we did not receive the proof of how long (2)
doctor expected (3) to stay in a medical facility by (4), but we found a good reason
why it was received late.
Fill-ins:
-
-
-
-
Optional Paragraph 5
(1) all of these requirements because the proof of how long (2) doctor expected (3)
to stay in a medical facility was prepared and dated by (4).
Fill-ins:
-
-
-
-
Optional Paragraph 6
(1) all of these requirements because we received the proof of how long (2) doctor
expected (3) to stay in a medical facility by (4).
Fill-ins:
-
-
-
-
Optional Paragraph 7
(1) all of these requirements because (2) eligible for an SSI payment in (3).
Fill-ins:
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-
-
Optional Paragraph 8
(1) all of these requirements because (2) in a medical facility.
Fill-ins:
-
-
Optional Paragraph 9
(1) all of these requirements because (2) had expenses for (3) home which (4) had
to continue to pay. Also, we did not receive the proof of how long (5) doctor expected
(6) to stay in a medical facility by (7), but we found a good reason why it was received
late.
Fill-ins:
-
-
-
-
-
-
-
Optional Paragraph 10
(1) all of these requirements because we received the proof about (2) home expenses.
Also, the proof of how long (3) doctor expected (4) to stay in a medical facility
was not received by (5), but we found a good reason why it was received late.
Fill-ins:
-
-
-
-
-
Optional Paragraph 11
(1) all of these requirements because we received the proof about (2) home expenses
on time. Also, we did not receive the proof of how long (3) doctor expected (4) to
stay in a medical facility by (5), but we found a good reason why it was received
late.
Fill-ins:
-
-
-
-
-
Optional Paragraph 12
(1) all of these requirements because (2) doctor expected (3) to stay for less than
91 days. Also, we did not receive the proof of how long (4) doctor expected (5) to
stay in a medical facility by (6), but we found a good reason why it was received
late.
Fill-ins:
-
-
-
-
-
-
Optional Paragraph 13
(1) all of these requirements because the proof about (2) home expenses was prepared
and dated by (3). Also, we did not receive the proof of how long (4) doctor expected
(5) to stay in a medical facility by (6), but we found a good reason why it was received
late.
Fill-ins:
-
-
-
-
-
-
Optional Paragraph 14
(1) all of these requirements because (2) eligible for an SSI payment in (3). Also,
we did not receive the proof of how long (4) doctor expected (5) to stay in a medical
facility by (6), but we found a good reason why it was received late.
Fill-ins:
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