Exhibit 2 is to be completed by the local Medicaid caseworker only at the point that
the SSI recipient is determined to be ineligible for institutional services under
Medicaid because of the transfer of resources policy.
The information used to apply the transfer of resources provision may come to the
Medicaid agency from a variety of sources, including the Social Security Administration.
The Medicaid caseworker will provide both the first month and the projected last month
of ineligibility for institutional services under Medicaid.
The Medicaid caseworker will mail Exhibit 2 to the local Social Security office.
TO: State Medicaid Agency Date: _____________ _____________________
FM: Social Security Administration
SUBJECT: Transfer of Resources - PL 100-360
This memorandum provides information on a transfer of resources for less than the
current market value on or after July 1, 1988, obtained by the Social Security Administration
during an SSI (check one):
Initial Claim Redetermination
SOCIAL SECURITY NUMBER: _______________
Information Regarding Transfer (See Attached Photocopy of Question 27 from SSI Form
SSA-8000-BK or printout of the RMEN and RGIV screens for a computer-generated SSI
Date of Transfer _______________
Description of Transferred Resource _________________________
Value of Transferred Resource $ ____________________________
Compensation (if any) Received or Expected $ ______________
Recipient or Purchaser of Resource _________________________
Relationship to Recipient/Purchaser ________________________
Co-owners (if any) of Resource at Time of Transfer _________
The current living arrangement for SSI purposes is (circle one):
A B C D
Name of Social Security Representative: _________________________
SSA Area Code and Telephone Number: _________________________
TO: Social Security Administration Date: ___________
FM: State Medicaid Agency
SUBJECT: SSI Recipient Ineligible for Medicaid Due to Transfer of Resources Provision
(PL 100-360 and PL 100-485)
The SSI recipient listed below is in a Medicaid institution.
The SSI recipient (check one)
____ was determined to be ineligible for institutional services under Medicaid
____ ceased to be eligible for institutional services under Medicaid
due solely to the transfer of resources provision.
SOCIAL SECURITY NUMBER: _______________________________________
The first month/year the SSI recipient is ineligible for institutional services under
Medicaid because of a transfer of resources is: _________________________________
The estimated last month/year the SSI recipient is ineligible for institutional services
under Medicaid because of a transfer of resources is: ____________________
Note to SSA Field Offices: Under Section 303(c) of PL 100-360, an SSI recipient who is a resident of a Medicaid-certified
skilled nursing facility or intermediate care facility is subject to the $30 payment
cap whenever Medicaid eligibility has been denied or suspended due to the transfer
of resources provision.
Medicaid Caseworker: ___________________________________________
Area Code/Telephone Number: ____________________________________