TN 4 (12-09)

DI 20101.900 Exhibits

A. Exhibit I - Allowance Notice - 1619(b) Medicaid determination for aged individual

Allowance notice language

You asked us to see if you were   (1)  under our rules so that we could make your Supplemental Security Income (SSI) case active again.

We are writing to tell you that you are   (1)   under our rules. Therefore, we are making your SSI case active again. We may review your case from time-to-time to be sure you are still   (1)   under our rules.

Information About Medicaid

  (2)  

Fill-ins:

(1)

Choice 1 -

blind

 

Choice 2 -

disabled

(2)

Choice 1 -

For 1634 States (states for which SSA makes Medicaid Determinations)

 

You may still get Medicaid under special SSI rules even though your SSI checks have stopped. An agency of your state will advise you about the Medicaid program.

 

 

If you have any questions about your eligibility for Medicaid or if you need immediate medical assistance, you should get in touch with [choices under paragraph 1144(l)].

 
 

Choice 2 -

For SSI States (States that make their own Medicaid determinations based on SSI criteria)

 

You may be able to get Medicaid under special SSI rules even though your SSI checks have stopped. However, you must apply for Medicaid with [choices under paragraph 1151(6)]. Take this letter with you when you apply. The people in your state will decide if you can get Medicaid.

 
 

Choice 3

For 209(b) States (States that make their own Medicaid determinations based on more restrictive criteria)

 

You may be able to get Medicaid under special SSI rules even though your SSI checks have stopped. However, you must apply for Medicaid with [choices under paragraph 1151(6)]. Take this letter with you when you apply.

The people in your state will see when you last had Medicaid coverage. If you had Medicaid coverage when you stopped getting SSI, then your Medicaid may continue, even though your SSI checks have stopped.

 

B. Exhibit 2 - Disallowance Notice - 1619(b) Medicaid determination for aged individual

Disallowance notice language

You asked us to see if you are   (1) under our rules so that we can make your Supplemental Security Income (SSI) case active again.

We are writing to tell you that you are not   (1)   under our rules. Therefore, we cannot make your SSI case active again.

This decision is based on a review of your health problems. We have enclosed a page that gives you more details on how we made our decision.

Although we cannot make your SSI case active again, you may still qualify for Medicaid. If you have any questions about Medicaid, you should contact (name of Medicaid agency).

Fill-ins:

  1. Choice 1 - blind
    Choice 2 - disabled


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0420101900
DI 20101.900 - Exhibits - 12/08/2009
Batch run: 12/08/2009