SI DAL01730.005 SSA/State Agreements under Section 1634 (Arkansas)

A. Policy

The Arkansas Department of Human Services (DHS) entered into an agreement under Section 1634 of the Social Security Act with the Social Security Administration (SSA) for SSA to make Medicaid eligibility determinations. Supplemental Security Income (SSI) recipients who receive an SSI cash payment, are in N24 payment status (GN 02604.405 &. GN 02604.440), or are Section 1619(b) recipients automatically have Medicaid eligibility unless:

  • They fail to meet the Assignment of Rights (AOR) provisions and Third Party Liability (TPL) requirements; or

  • The State has determined ineligibility under the Medicaid trust provision.

See SI 01730.040-SI 01730.048 for a discussion of the Medicaid eligibility limitations, including transfer of resources (TOR).

An essential person, who is the spouse of a converted individual, regardless of the State of conversion, is eligible for Medicaid in Arkansas until becoming potentially eligible for SSI (e.g., age 65).

B. Procedure-District Office

When an individual files for SSI, the SSA interviewer will provide the claimant with the following information regarding Medicaid:

  • If the claimant is found eligible for SSI payments and meets all other requirements in SI 01730.040-SI 01730.048, the claimant will also be eligible for Medicaid.

  • The SSI recipient will receive a DCO-55 client notice from DHS advising the SSI recipient of the Medicaid approval and Medicaid begin date. Within a week of approval on the Medicaid system, the recipient will receive a separate letter instructing the recipient to take the letter to either the local DHS office or Department of Finance and Administration Revenue Office to obtain a photo Medicaid Identification (ID) card. The photo Medicaid card should be retained since no monthly replacement card will be issued. If the letter to obtain the photo Medicaid ID card is not received timely, the SSI recipient should contact the Client Assistance Unit at 1-800-482-8988.

  • The SSI recipient should report all address changes to SSA in order to receive the letter for the Medicaid ID card on time and so that DHS will have an up-to-date address for mailings to recipients advising of changes in services.

  • If the claimant has unpaid medical expenses in the 3 months prior to the month of application (shown in the AP field) for SSI, refer the SSI applicant to the local DHS office. Medicaid eligibility for this 3-month period requires a Medicaid application with the county DHS office. The eligibility decision will be made by DHS (SI 01715.001C.3.).

  • DHS is responsible for determining what services are covered by Medicaid and for processing bills for services charged to Medicaid. Under the Automated Eligibility Verification and Claims Submission (AEVCS) system, Medicaid service providers have electronic equipment that reads the plastic Medicaid card and provides immediate Medicaid eligibility information.

C. Procedure-Department of Human Services

Although SSA determines Medicaid eligibility for most SSI recipients, DHS is responsible for administering the Medicaid program (e.g., the State issues Medicaid cards, determines what medical services are covered, and pays providers) and making Medicaid eligibility determinations for certain other categories. DHS also makes the Medicaid determination on TOR, AOR, TPL, and Medicaid trust cases.

Medicaid eligibility notices (DCO-55) for SSI recipients who are Arkansas residents are issued by DHS based on the eligibility information given the State DHS office by SSA on the SDX tape. The DCO-55 and the letter to obtain the photo Medicaid ID card are usually sent 10 days after the individual is in C01/M01 pay status or Section 1619(b) on the SSR. The plastic photo Medicaid ID card for new recipients will be obtained at the local DHS or Revenue Office, depending on the county. A monthly Medicaid Identification card is not issued.

Recently re-entitled SSI recipients will also receive a DCO-55, but not a new plastic Medicaid card.

If the SSI recipient is not on the SSR/SDX or the information is incomplete, see manual Medicaid certification (MMC) procedures in E. below.

D. E02 Month and Medicaid Entitlement

The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 provides that SSI payments may only begin as of the first day of the month following the later of (1) the date the application is filed or (2) the date the individual becomes eligible for such benefits (SI 00601.009). As a result of this policy, cash SSI payments are not paid for the first month of SSI eligibility (i.e., the E02 month). Since no SSI cash payments are paid for the E02 month, no Medicaid certification is made to DHS by SSA. If death occurs in the filing month, curtail development, input death termination, and refer any inquiry about medical expenses to DHS (SI 00601.010E.4.).

However, DHS has decided to provide Medicaid coverage for the SSI E02 month. If SSA becomes aware that the client did not receive coverage for the E02 month automatically, refer the client to the local DHS county office for authorization. Please note that this is a DHS agency decision and does not affect or change the SSI program policy or procedures.

E. Manual Medicaid Certification Policy

An Arkansas DHS Certification for Medicaid Eligibility, SS-RVI-304, should be routinely prepared for situations listed below when SSA makes the Medicaid eligibility determination, but a correct or complete SSI record cannot be provided to DHS:

  1. 1. 

    Systems limitation cases;

  2. 2. 

    Closed period(s) of SSI entitlement;

  3. 3. 

    Intervening period(s) of SSI entitlement;

  4. 4. 

    SSI claimant dies (see F.4. below for qualifying circumstances); or

  5. 5. 

    SSI claimant/reinstated recipient moves out of Arkansas before payment is initiated.

SSA should never certify Medicaid coverage for any month of SSI ineligibility (e.g., N04), the E02 month, the 3-month prior period, or a month of non-SSI cash payment (e.g., E01, N01) unless the non-cash month is a Section 1619(b) month or is PSY N24. For months of SSI ineligibility for a cash payment/1619(b), refer the client to the local DHS office for possible coverage under another Medicaid category administered by DHS.

F. Manual Medicaid Certification (MMC) DO Procedure

For the situations listed in E. above, the DO should complete Parts I and III of the SS-RVI-304 (See Exhibit 1) and mail the original form to the Arkansas Department of Human Services, Division of County Operations, Client Assistance Section, P. O. Box 1437, Slot S340, Little Rock, Arkansas 72203.

Certify to DHS only for the period the SSI recipient is/was a resident of Arkansas and received an SSI payment or was eligible for 1619(b), or was in PSY N24. If the recipient resided outside of Arkansas anytime during the period of eligibility and SSA determines Medicaid eligibility in that State (i.e., a 1634 State), call the servicing DO for the out-of-State residence. Have the former DO certify Medicaid to their respective State agency using their State-specific procedures.

A copy of the SS-RVI-304 should be placed in the SSI folder (if available). A third copy may be placed in a central FO location to facilitate control per 1.a. below.

In addition, take the following actions, as appropriate:

1. Systems Limitation Case

  1. a. 

    Control the case so that changes in eligibility, payment status, and residence (e.g., becomes N04 or moves out of Arkansas) can be reported on the SS-RVI-304, Parts I, (Items 3, 5, etc.) II, and III to the State DHS office.

    Maintain control until the case is successfully established on the SSR or a new SS-RVI-304 is sent to cease eligibility in Arkansas.

  2. b. 

    Once the SS-RVI-304 is received, DHS will continue eligibility for 4 months only. If Medicaid eligibility through the SSI program continues, another SS-RVI-304 needs to be sent to DHS by the servicing DO.

  3. c. 

    When the SSI recipient is entitled to Part B buy-in, but the buy-in has not been effectuated, send a HCFA-1957 (Report of State Buy-In Problem) to Center for Medicare and Medicaid (CMS) Central Office per HI 00815.088 and HI R00930.001ff. Include a detailed explanation for the period of buy-in based on SSI payment that is not reflected on the SSR.

2. Closed Period(s) of Eligibility

In closed period(s) of eligibility cases, DHS receives only one SDX transaction which indicates the record is in non-pay status. Although SSI benefits were paid for a retroactive period, DHS is not able to establish Medicaid eligibility for the closed period of SSI eligibility and payment because DHS extracts data from the SDX that only indicates the current non-pay status.

Indicate on the SS-RVI-304 all periods of SSI payment while a resident of Arkansas for the retroactive period.

3. Intervening Period(s) of Eligibility

In some cases, DHS receives an SDX transaction for cases with a “start pay-stop pay-start pay” payment history. When this occurs, DHS only extracts data from the SDX transaction that provides the Medicaid Effective Date (MEF) for the most current period of SSI eligibility/payment in Arkansas.

Indicate on the SS-RVI-304 only periods of SSI payments while a resident of Arkansas for the retroactive period.

4. SSI Claimant Dies

  1. a. 

    If a claimant dies after SSA receives the signed SSI application and death occurred after the month of filing, but before adjudication, and there is no one to receive the underpayment, but there are unpaid medical expenses alleged either on the application or by an interested party, complete development with the proper applicant (GN 00204.003) to determine SSI eligibility (i.e., disability and all non-disability requirements). If you do not have a proper applicant, complete the SS-RVI-304 listing the name and address of the “interested party” and refer the case to the State for a Medicaid determination. DO NOT indicate SSI eligibility on the SS-RVI-304 since we are not making an SSI determination.

    If SSI eligibility is found so that payment would have been due, prepare an SS-RVI-304 with the additional information required in d. below.

  2. b. 

    If a claimant dies after SSA receives the signed SSI application and death occurred after the month of filing, but before adjudication, and there is someone eligible to receive the underpayment, complete development to determine SSI eligibility for payment (i.e., disability and all non-disability requirements). See SI 00601.010E when IAR is involved.

    If SSI eligibility is found, prepare an SS-RVI-304 with the additional information required in d. below.

  3. c. 

    If there is a protective statement (oral or written), but the claimant dies before SSA receives a signed application for SSI, and an underpayment may be due (including IAR), someone eligible to receive the underpayment may file an SSI application (GN 00204.005). See K. below, second paragraph, if these conditions do not exist.

    Complete development to determine SSI eligibility (i.e., disability and all non-disability requirements). If SSI eligibility is found, prepare an SS-RVI-304.

  4. d. 

    In preparing the SS-RVI-304 for any of the situations in a.-c. above,

    • Cross out the first and last sentence in the first paragraph of Part I;

    • Provide DHS with the name and address of the "interested party" or the person receiving the underpayment in Item 6; and

    • Annotate the Remarks section with "If alive, claimant would have been found Medicaid eligible” and the date of death.

5. SSI Claimant/Reinstated Recipient Moves Out of State Before Payment Is Made

Only one State receives an SDX file at a time. There are situations where an SSI claimant moves out of Arkansas before payments are started. Since the change of address/residency will include a new State and County Code, the SDX file will be sent to the new State of residency. Therefore, DHS will not be aware that there were SSI payments for a period of time covering residency in Arkansas.

SSA DOs will become aware of these cases when an inquiry is received from the SSI recipient or from DHS. In these cases, prepare an SS-RVI-304 only for the period of SSI payment and residency in Arkansas. Indicate in Item 18 the date the SSI recipient moved out of Arkansas.

G. Manual Medicaid Certification - DHS Process

Upon receipt of the SS-RVI-304, the State DHS will issue a letter explaining how to obtain a photo Medicaid ID card. DHS will also establish eligibility on the State Medicaid eligibility system and issue a DCO-55 client notice concerning Medicaid coverage. If a photo Medicaid ID card is needed, the SSI recipient can obtain it as instructed on the DCO-55.


If the letter to obtain the plastic photo Medicaid ID card is not received within two weeks, DOs can call the Client Assistance Unit at 1-800-482-8988 for status.

Once a systems limitation case is manually certified for continuing Medicaid eligibility, DHS will continue eligibility to Medicaid under the MMC process until:

  • DHS receives an SDX record that matches the SSN in Item 3 of the SS-RVI-304; or

  • DHS is notified by SSA via the SS-RVI-304 that the named SSI recipient is no longer entitled to SSI or has moved out of Arkansas; or

  • The record has been in manual certification status for 4 months. DHS will automatically suspend Medicaid eligibility.

If SSI eligibility continues past the 4 months, but the record is still not accreted to the SSR, another SS-RVI-304 needs to be sent by the servicing FO.

H. Emergency Need for Medicaid Card - Policy

DHS will routinely issue a DCO-55 and a letter to obtain a plastic photo Medicaid ID card to new SSI recipients within a week of the time the individual is in C01/M01 pay status and is authorized on the Arkansas Medicaid system. If the SSI recipient has been in C01/M01 SSI pay status for less than 30 days while in Arkansas but a medical emergency exists, follow the procedure in I. below to provide certification of current month Medicaid eligibility only.

A medical emergency is a situation that would endanger a person's life if medication or medical attention is not provided immediately.


A request for Medicaid certification for a retroactive period is not considered a medical emergency.

I. Emergency Need - District Office Procedure

If the emergency criteria in H. above is met, the DO should:

  1. 1. 

    Fully prepare an SS-RVI-304, Parts I and III, with the required information. All items on the SS-RVI-304 must be completed or answered ?None.? If information is omitted, there may be delays. Describe the life-threatening nature of the emergency in detail, and explain why routine procedures cannot be used in Item 18, Remarks.

  2. 2. 

    Obtain approval from an operations supervisor/MSS (or above) for use of the emergency procedure. The SSA official authorizing the appropriateness of the emergency certification should sign in Part III; and

  3. 3. 

    Inform DHS in the following manner:

    • FAX the fully completed and authorized SS-RVI-304 to the State DHS at (501) 682-8978, or

    • If the FAX machine is inoperable, mail the fully completed SS-RVI-304 to the State DHS office.

J. Emergency Need - State Procedure

  • Within 2 days of receipt of the FAX/mailed SS-RVI-304, the Client Assistance Unit will:

    • Issue an DCO-55 client notice, and

    • Establish Medicaid eligibility on the State Medicaid eligibility file for the current month only.

  • Arkansas DHS will call the servicing DO to confirm that the SS-RVI-304 was received.

K. Individual Dies Before Filing for SSI

If an individual did not file an SSI application with SSA before death, but an oral inquiry/protective writing exists, and an underpayment would be due a parent/spouse or IAR State, then pursue an application and complete development for payment of the underpayment and Medicaid eligibility (GN 00204.005). See E. above for manual Medicaid certification instructions.

If an oral inquiry/protective writing does not exist or one exists but no underpayment would be due (e.g., death in the E02 month), or no one is eligible for an underpayment (if one were to exist), immediately refer an interested party inquiring about Medicaid coverage for the decedent's unpaid medical expenses to the county DHS office. The 3-month period of retroactivity for Medicaid coverage ends with the date an application for Medicaid is filed with DHS on behalf of the deceased individual, not with the date of death.

L. Nonreceipt of Letter to Obtain Medicaid Card or Medicaid Coverage Not on State Records

When an SSI recipient in C01, M01, M02 with cash payments, Section 1619(b), N24, or protected payment status contacts the SSA office alleging (1) non-receipt of the initial letter to obtain the plastic Medicaid ID card in 30 days of receipt of the first SSI check and no manual Medicaid certification is required per E. above; or (2) that Medicaid coverage is not on DHS records, then:

Verify that the correct address, zip code and State/County code are on the SSR. The State/County code in the ADDR and CMPH segments of the SSR should start with ?04? for Arkansas residents. If protected payments are being paid using the G-K systems procedures, the SCR field in the DUPR segment should have 5 zeros (SM 01305.640 and MSS 98N084, dated 04/23/98).

  1. 1. 

    If the address date on the SSR is incorrect, transmit the correct information to the SSR. This information will be sent to DHS via the SDX. Also, take action to complete whatever additional development (e.g., LA) is required by SSI.

  2. 2. 

    If the SSR is correct, refer the recipient to the Client Assistance Unit at 1-800-482-8988 or (501) 682-8233.

M. Medicaid Card - Change or Replace Needed

DHS issues the DCO-55 client notice and the letter to obtain the plastic Medicaid ID card from the local DHS or Revenue Office at initial entitlement in Arkansas. The plastic Medicaid ID card should be retained by the recipient and used when medical services are provided. The AEVCS system for SSI recipients is updated from information on the SDX. However, no new Medicaid card is automatically issued as long as the State Medicaid number remains the same, even if the SSI recipient's name changes or SSI eligibility is lost for a short period of time.

If the plastic Medicaid card is lost or identifying information on the card changes:

  • Review the SSR to see if identifying information changes are needed and transmit any necessary changes; then

  • Refer the SSI recipient to the Client Assistance Unit at 1-800-482-8988 who will handle the inquiry.

N. Medical Expenses Prior to Filing for SSI

If the SSI applicant has unpaid medical expenses in the 3 months prior to the date of application for SSI, refer the applicant to the county DHS office. Medicaid eligibility for this 3-month prior period requires a Medicaid application with DHS, and the eligibility decision will be made by DHS.

O. Referrals to DHS for non-SSI Recipients

As discussed in A. above, SSA makes Medicaid eligibility determinations for most SSI recipients. Only DHS makes Medicaid ineligibility determinations for SSI claimants/recipients.

DHS makes both eligibility and ineligibility determinations in all other Medicaid categories. Some of these Medicaid categories are listed in SI 01715.005 (Medicaid Groups) and SI 01715.015 (Special Groups of Former SSI Recipients). The information below provides specifics for some of these programs in Arkansas.

1. Title II COLA

Included in the list in SI 01715.015 are SSI recipients who would continue to receive SSI payments but for a title II COLA (Section 503 of P.L. 94-566 and Lynch v. Rank court case). Annually, at COLA time, Arkansas DHS receives two tapes identifying this protected group:

  1. a. 

    The 503 leads (Pickle) file identifies SSI recipients who will no longer receive an SSI payment once the title II COLA is received. DHS automatically converts these cases to a non-SSI category. No separate Medicaid application with DHS is required for conversion.

  2. b. 

    The Lynch v. Rank file identifies individuals who would have been identified at COLA time except that they were ineligible for SSI (e.g., N04, M01/M02 with $0 payment) when the Lynch file was run, but could be eligible now except for the title II COLA increase. The Lynch v. Rank file provides information for the current year plus the two preceding years. The file is usually transmitted to States in mid-December. A Medicaid application must be filed with DHS by individuals in this category.

If an individual meets this Medicaid extension provision (i.e., would have been eligible for SSI except for the COLA increase) and alleges after the beginning of the new year that there has been no contact from DHS, refer the individual to the State DHS office using Exhibit 2. Photocopy Exhibit 2 as needed. Completion of Exhibit 2 is self-explanatory.

Exhibit 2 can also be used to refer inquiries from individuals who may be eligible under the “Pickle provision.”

2. Disabled Adult Children and Widow(er)s

Also included in SI 01715.015 are disabled adult children (DAC) and widow(er)s who lose SSI because of title II benefits.

Although DHS is notified via the SDX when these SSI recipients lose SSI, there are times when SSA receives inquiries from the former SSI recipients. To ensure that these former SSI recipients are timely identified by DHS, refer these inquirers to the State DHS office using Exhibit 2.

3. Arkansas Medically Needy Program

The Arkansas Medically Needy program is intended to provide Medicaid coverage to individuals who do not qualify for SSI or AFDC, but who have insufficient income or resources to meet the cost of medical services.

There are two eligibility categories:

  1. a. 

    Exceptional Medically Needy are individuals or families whose adjusted income is within the State's Medically Needy income standard.

  2. b. 

    Spend-down Medically Needy are individuals or families whose income is more than the State's Medically Needy income levels, but have medical expenses greater than the excess income over the limit.

4. Children's Medical Services

In addition to Medicaid, medical assistance is available to children under 18 years of age with special physical health care needs who can benefit from surgical or medical intervention for diagnosis and treatment of certain diseases or defects.

P. Medicaid Coverage in the Month of Move

When an SSI recipient moves from another State with intent to reside in Arkansas, Medicaid eligibility resulting from SSI payment or Section 1619(b) is effective the month after the month of move to Arkansas (SI 01410.030F.).

Arkansas DHS Certification for Medicaid Eligibility Exhibit 1

TO:Arkansas Department of Human Services                  Date:___________________

Division of County Operations

P. O. Box 1437, Slot S340                                            Attn: Client Asst. Unit

Little Rock, Arkansas 72203


I.This individual is 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.

1. Reason: (check one) __ Systems Limitation      __ Medical Emergency

   __ Closed/Intervening Period                                 Certification

          of Eligibility or Death

2. Type of Recipient:(circle one) AI AS BI BS DI DS DC

3. Social Security Number: ________________     4. DOB: _____________

5. Name of Recipient: _______________________________________________

6. Mailing Address     ________________________________________

Including Repre.    ________________________________________

Payee & Zip Code:   ________________________________________

7. State/County Code: _________    8. Living Arrangement Code: ________

County of Residence: ________________________

9. Mo/Day/Year of SSI Application: _____________    10. Sex: __________

11. First Month/Year of SSI in Arkansas: _______________________

12. Title II/Medicare Claim #: _____________     13. DOD: _____________

14. TPL Code: _______    15. Transf. RE? ______   16. Medicaid Trust? ____

17. Enter an "E" only for months of SSI payments while in Arkansas:





















































18. Remarks: ______________________________________________


II. SSA previously submitted a manual Medicaid certification for the individual and SSN. This individual is no longer eligible for SSI effective: _______. Reason: ____________________________


III.Social Security Administration         ______________________________________

    ______________________________                    (CR Print Name)

    ______________________________                    Phone #: _____________________

    ______________________________         ______________________________________

                                                                      (Emerg. Cert. Auth.-OS/MSS or above)

SS-RVI-304 (12/02)

Exhibit 2


To:Arkansas Department of Human Services                        Date:__________

Division of County Operations

Attn: Jack Tiner

P. O. Box 1437, Slot S333

Little Rock, Arkansas 72203

(check 1. or 2.)

1.The following individual was last eligible for Supplemental Security Income (SSI) in ________, 20___, but became ineligible for payment effective with ____________, 20____* because of a title II cost-of-living adjustment (COLA) increase paid to the eligible person or their spouse. The person may now be a candidate for preservation of Medicaid eligibility under the provision of:

(check one)

_____ Section 503 (Pickle) of Public Law 94-566, or

_____ Lynch v. Rank court decree.

2.The following individual was eligible for SSI in __________, 20___, but became ineligible in __________, 20___ because of entitlement to or an increase in:

(check one) _______ DAC or ________ widow(er) benefits.

Name and Address    _______________________________________

(Including                 _______________________________________

Representative           _______________________________________

Payee)                      _______________________________________

County of Residence      ____________________________________

Social Security Number      __________________________________

Title II Claim Number      ___________________________________

Gross Title II Payment Prior to COLA      ______________________

                                                               (if applicable)

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

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SI DAL01730.005 - SSA/State Agreements under Section 1634 (Arkansas) - 05/30/2024
Batch run: 05/30/2024