SI DAL01730.008 (NM) SSA/State Agreements under Section 1634

A. Policy

The New Mexico Human Services Department (HSD) 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 or are Section 1619(b)recipients automatically have Medicaid eligibility unless:

  • They fail to meet the Assignment of Rights or Third Party Liability 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).

Individuals converted as essential persons, regardless of the State of conversion, are not eligible for Medicaid in New Mexico until they become eligible for SSI (e.g., age 65).

Please note that effective August 22, 1996, the earliest month of SSI cash payment is the month following the later of the month of filing or the date the individual becomes eligible for SSI (SI 00601.009).

B. Procedure-District Office

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

  • 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. Medicaid coverage through the SSI program will begin with the first month of SSI cash payments.

  • The SSI recipient will receive a plastic Medicaid Identification card in the mail from the New Mexico Human Services Department within 30 days after receipt of the first SSI check. Inform the recipient that the plastic Medicaid card should be retained since it is considered a permanent card. If the Medicaid card is not received timely, damaged, or lost, the SSI recipient should contact the HSD Medical Assistance Division at (505) 476-6824 or (505) 476-6810.

  • The SSI recipient should report all address changes to SSA in order to receive the Medicaid Identification card on time.

  • If the applicant has unpaid medical expenses in the 3 months prior to the month of application (date shown in the AP field) for SSI, refer the SSI applicant to the local HSD Income Support Division (ISD) office. HSD may be able to cover these unpaid expenses. Medicaid eligibility for this 3-month period requires a Medicaid application with HSD at the local ISD office, and the eligibility decision will be made by HSD.

  • HSD is responsible for determining what services are covered by Medicaid and for processing bills for services charged to Medicaid.

C. Procedure-Human Services Department

Although SSA determines Medicaid eligibility for most SSI recipients, HSD 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. HSD also makes the Medicaid determination on TOR, Assignment of Rights, TPL and Medicaid trust cases.

Medicaid cards for SSI recipients who are New Mexico residents are issued by HSD based on the payment/eligibility information given the State office by SSA on the SDX file. A plastic Medicaid Identification card is initially sent to new SSI recipients within 30 days from the time the individual is initially in C01/M01/M02 cash payment or Section 1619(b) status on the SSR. A monthly Medicaid Identification card is not issued. Medicaid eligibility information is updated to the State Medicaid eligibility file that is available to Medicaid providers to verify coverage.

If the SSI recipient is not on the SSR/SDX or the information is incomplete, see manual Medicaid certification (MMC) procedures in SI DAL01730.008E.

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; the first month of SSI eligibility is the E02 month. Since no SSI cash payments are paid for the E02 month, no Medicaid certification is made to HSD by SSA. If death occurs in the filing month, curtail development, input death termination, and refer any inquiry about medical expenses to HSD (SI 00601.010E.4.).

However, HSD automatically provides coverage for the SSI E02 month. Please note that this is an HSD agency decision and does not affect or change the SSI program policy or procedures.

E. Manual Medicaid Certification Policy

A New Mexico HSD Certification for Medicaid Eligibility, SS-RVI-317, should be routinely prepared for situations listed below when SSA makes the Medicaid determination but a correct or complete SSI record cannot be provided to HSD:

  1. Systems limitation cases;

  2. Closed period of SSI entitlement;

  3. Intervening period(s) of SSI entitlement;

  4. SSI claimant dies (See SI DAL01730.008F.4. for qualifying circumstances); or

  5. SSI claimant/reinstated recipient moves out of New Mexico 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.

F. Manual Medicaid Certification - DO Procedure

For the situations listed in SI DAL01730.008E, the DO should complete Parts I and III of the SS-RVI-317 (See Exhibit 1) and mail the original form to the State HSD office, Medical Assistance Division, P. O. Box 2348, Santa Fe, New Mexico 87504-2348.

Certify to HSD only for the period the SSI recipient was a resident of New Mexico and received an SSI payment or was eligible for 1619(b). If the recipient resided outside of New Mexico anytime during the period of eligibility and SSA determines Medicaid eligibility in that State, call the servicing DO for the former 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-317 should be placed in the SSI folder (if available). A third copy may be placed in a central DO location to facilitate control per SI DAL01730.008F.1, step a.

In addition, take the following actions, as appropriate:

1. Systems Limitation Case

  1. Control the case so that changes in eligibility, payment status and residence (e.g., becomes N04 or moves out of New Mexico) can be reported on the SS-RVI-317, Parts I (Items 3, 5, etc.), II, and III to the State HSD office.

    Maintain control until the case is successfully established on the SSR or a new SS-RVI-317 is sent to cease eligibility in New Mexico.

  2. Once an SS-RVI-317 is issued for continuing Medicaid eligibility, HSD will continue Medicaid eligibility until one of the conditions in SI DAL01730.008G. occurs.

  3. Send a HCFA-1957 (Report of State Buy-In Problem) to the Center for Medicare and Medicaid Services (CMS) Central Office per HI 00815.088 and HI 00930.000. when the SSI recipient is entitled to Part B buy-in, but the buy-in has not been effectuated. Include a detailed explanation of the period of buy-in based on SSI payment that is not reflected on the SSR.

2. Closed Period(s) of Entitlement

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

Indicate on the SS-RVI-317 only periods of SSI payments while a resident of New Mexico for the retroactive period.

3. Intervening Period(s) of SSI Entitlement

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

Indicate on the SS-RVI-317 only periods of SSI payments while a resident of New Mexico for the retroactive period.

4. SSI Claimant Dies

  1. 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-317 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-317 since we are not making an SSI determination.

    If SSI eligibility is found, prepare an SS-RVI-317 with the additional information required in SI DAL01730.008F.4, step d.

  2. 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 for payment is found, prepare an SS-RVI-317 with the additional information required in SI DAL01730.008F.4, step d.

  3. If there is a protective statement (oral or written), but the claimant dies before SSA receives a signed SSI application, and an underpayment may be due (including IAR) someone eligible to receive the underpayment may file an SSI application (GN 00204.005). See SI DAL01730.008K, second paragraph, if these conditions do not exist.

    Complete development to determine SSI eligibility/payment (i.e., disability and all non-disability requirements). If SSI payments can be made, prepare an SS-RVI-317 with the additional information required in SI DAL01730.008F.4, step d.

  4. In preparing the SS-RVI-317 for any of the situations in SI DAL01730.008F.4, steps a.- c. above,

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

    • Provide HSD 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 received SSI payments and 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 New Mexico 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, HSD will not be aware that there were SSI payments for a period of time covering residency in New Mexico.

SSA DOs will become aware of these cases when an inquiry is received from the SSI recipient or from HSD. In these cases, prepare an SS-RVI-317 only for the period of SSI payment and residency in New Mexico. Indicate in Item 19 the date the SSI recipient moved out of New Mexico.

G. Manual Medicaid Certification - HSD Process

Upon receipt of the SS-RVI-317, the State HSD will issue an initial Medicaid Identification card. The Medicaid Identification card should be received by the SSI recipient within 30 days from the date the State receives the SS-RVI-317.

NOTE: If the Medicaid card is not received in 30 days, DOs can call the State Medicaid SSI Coordinator at (505) 476-6824 or (505) 476-6810 for status.

Once a case is manually certified in a systems limitation case for continuing Medicaid eligibility, HSD will continue to provide Medicaid coverage until:

  • A record is accreted to the SSR that matches the SSN in Item 3 of the SS-RVI-317, and HSD receives an SDX record; or

  • HSD is notified by SSA via the SS-RVI-317, Parts I (Items 3, 5, etc.), II and III, that the named SSI recipient is no longer entitled to SSI or has moved out of New Mexico; or

  • The record has been in manual certification status for 3 months. If SSI eligibility continues past the 3 months, but the record is still not accreted to the SSR, another MMC needs to be sent by the DO.

H. Emergency Need for Medicaid Card - Policy

An initial plastic Medicaid card is sent to new SSI recipients within 30 days of the day the individual is in C01/M01/M02 cash payment status or Section 1619(b) status in New Mexico. Re-entitled SSI recipients will not receive a new Medicaid card; their eligibility will simply be updated on the Medicaid eligibility system.

There are, however, situations when routine procedures will not provide a Medicaid card in time for the SSI recipient to obtain emergency medical attention. Therefore, if:

  • The SSI recipient has been in C01/M01/M02 cash payment status for less than 30 days in New Mexico; and

  • A medical emergency exists that would endanger a person's life if medication or medical attention is not provided immediately; and

  • The medical provider is refusing to provide services without a Medicaid card or proof of Medicaid eligibility, then follow the procedure in SI DAL01730.008I to provide emergency certification of Medicaid eligibility for the current month only .

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

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

I. Emergency Need - District Office Procedure

If the criteria in SI DAL01730.008H is met, the DO should take all of the following actions in sequence:

  1. Fully prepare an SS-RVI-317, Parts I and III, with the required information. All items on the SS-RVI-317 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 19, Remarks.

  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. Inform HSD in the following manner:

    • Fax the fully completed and authorized SS-RVI-317 to the State Medical Assistance Division at (505) 476-7204; or

    • If the fax is inoperable, call the State Medicaid SSI Coordinator in the State Medical Assistance Division at 505) 476-6824 or (505) 476-6810 to provide complete information from the SS-RVI-317.

      On the same day as the telephone call, mail the original copy of the completed SS-RVI-317 to the State HSD office. The SS-RVI-317 is the folder documentation required by the New Mexico Human Services Department. Place a copy in the SSI folder, if available.

      NOTE: A telephone call to HSD is appropriate only in an emergency situation.

      For all cases, provide the State HSD office with the reason for the medical emergency and any special instructions needed for recipient contact in the Remarks section.

J. Emergency Need - State Procedure

  • If the SS-RVI-317 was faxed or called in to the State Medical Assistance Division, the State office will authorize Medicaid eligibility/coverage within one day on the State system for providers to verify eligibility. HSD State office will use any special contact instructions provided by the DO to contact the recipient.

  • If the information on the SS-RVI-317 was called in, the State Medical Assistance Division will expect to receive a copy of the SS-RVI-317 from the servicing SSA DO within 7 workdays.

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, an underpayment would be due, and a parent/spouse or IAR State can be eligible for an underpayment, pursue an application and complete development for payment of the underpayment and Medicaid eligibility (GN 00204.005). See SI DAL01730.008E. for manual Medicaid certification instructions.

If an oral inquiry/protective writing does not exists 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 local HSD-ISD office. The 3-month period of retroactivity for coverage ends with the date an application for Medicaid is filed with HSD on behalf of the deceased individual, not with the date of death.

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

When an SSI recipient in C01, M01 or M02 with cash payments, Section 1619(b), or protected payment status contacts the SSA office alleging nonreceipt of the initial plastic Medicaid card or that Medicaid coverage is not on HSD records, use the following procedures:

  1. 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 “32” for New Mexico residents. If protected payments are being paid using 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).

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

  2. SSI Recipient in C01/M01/M02—First Payment Generated or Address Changed to New Mexico Less than 30 Days Ago

    Inform the SSI recipient that SSA has notified HSD of his/her SSI eligibility for cash payments, but enough time has not elapsed for HSD to issue the plastic Medicaid card. Explain that he/she should contact HSD if he/she does not receive the Medicaid card within 30 days after receiving the first SSI payment in New Mexico. If the recipient alleges a current medical emergency, follow procedures in SI DAL01730.008H. and SI DAL01730.008I.

  3. SSI Recipient's Eligibility is Established on the SSR for 30 Days or More

    • If the data is correct, but there has been a change of address or change in payment status within the past 2 weeks, inform the recipient that the change has been reported to HSD and that a Medicaid card should be received and Medicaid coverage established on HSD records in about 2 weeks.

      NOTE: See SI DAL01730.008R, if the change of address was from another State.

    • If the data is correct and no change of address or payment status data has been transmitted within the past 2 weeks, refer the recipient to the State toll free number 1-888-997-2583. State employees at the 1-888 number can query to determine the recipient's status on the State's computer system and take corrective action.

  4. Need for a Replacement Plastic Card

    At times, the plastic Medicaid card can be lost or damaged. Refer the SSI recipient to the State toll-free number 1-888-997-2583 to request a replacement.

M. Medicaid To “Ping-Pong” Cases - Policy

There are SSI cases that are PSY C01 the first month, PSY E01 the second, C01 the third, E01 the fourth, etc. This “ping-ponging” starts when the following scenario occurs:

  • The SSI recipient receives title II benefits and is entitled to Medicare;

  • A COLA (or change in title II benefit) and State buy-in of the SMI premium cause the rounded title II benefit to equal the SSI FBR;

  • The SSI PSY changes to E01 and the State Medicaid agency stops paying the SMI premium;

  • Once the State stops paying the SMI premium, the title II benefit is recomputed which results in the SSI payment status changing to C01 with an SSI payment of $1.00; then

  • State buy-in again applies, and the cycle repeats.

To correct the situation for these limited number of cases, HSD can provide coverage to these “ping-pong” cases under the State optional Medicaid extension provisions WHEN THE SSI RECIPIENT CHOOSES such coverage.

N. “Ping-Pong” Cases - DO Procedures.

DOs should follow these procedures for any SSI recipient concerned about loss of Medicaid due to the “pong-pong” effect:

  1. Explain the reason for the “ping-ponging” effect (See SI DAL01730.008M) to the SSI recipient and the two choices available.

    If the SSI recipient chooses to continue with the current SSI “ping-pong” cycle of payment, explain that an SSI payment will be received approximately every other month and Medicaid coverage will be provided for the same month. Medicaid coverage will not be provided and the Part B Medicare premium will not be paid by the State in the month an SSI payment is not made; or

    If the SSI recipient chooses to be covered under the New Mexico optional Medicaid extension provision, the SSI recipient will be provided with Medicaid coverage each month, and will remain in E01 unless another factor of eligibility results in ineligibility. No SSI payment will be due and continuing eligibility reviews will be conducted by HSD rather than by SSA. Medicare buy-in will be continuous.

    NOTE: It may be possible that eligibility for some assistance programs may be tied to receipt of an SSI payment. It will be the responsibility of the SSI recipient to explore this possibility and to make the choice.

  2. Let the SSI recipient decide whether to continue with the SSI “ping-pong” cycle of payment or to be covered under the New Mexico optional Medicaid extension provision.

  3. If the SSI recipient chooses to continue with the current SSI situation, take no further action.

  4. If the SSI recipient chooses to be covered under the NM optional Medicaid extension provision, then complete Exhibit 2, “C01/E01-Medicaid Extension Referral” form.

  5. Send a copy of the referral form for control purposes to:

    HSD, Medical Assistance Division
    Buy-In Coordinator, P. O. Box 2348
    Santa Fe, New Mexico 87504-2348

  6. Mail the original of the referral form to the local HSD office.

O. “Ping-Pong” Cases - State Procedures

Upon receipt of the referral form, the local HSD Medical Assistance caseworker will:

  1. Initiate action to convert the case from a Federal SSI case to a State Medicaid case. The Medical Assistance caseworker can only convert the SSI case to a State case when the PSY is E01. (NOTE: Because the cycle between PSY E01 and C01 is very short, it is important that the case be referred to the State promptly.)

  2. Initiate action to continue Medicare buy-in.

  3. Notify the SSI recipient that Medicaid entitlement and Medicare buy-in are now the responsibility of HSD.

P. Medical Expenses Prior to Filing For SSI

If the applicant has unpaid medical expenses in the 3 months prior to the month of application for SSI, refer the applicant to the local HSD office.

Medicaid eligibility for this 3-month prior period requires a Medicaid application with HSD, and the eligibility decision will be made by HSD.

Q. Referrals to HSD for Non-SSI Recipients

As discussed in SI DAL01730.008A, SSA makes Medicaid eligibility determinations for most SSI recipients. Only HSD makes Medicaid ineligibility determinations for SSI claimants/recipients.

HSD makes both eligibility and ineligibility determinations for Medicaid in other State programs. Some of these State Medicaid programs are listed in SI 01715.005 and SI 01715.015 (Special Group of Former SSI Recipients).

1. Title II COLA

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

The 503 leads (Pickle) file identifies SSI recipients who will no longer receive an SSI payment once the title II COLA is received. No separate Medicaid application is needed. HSD automatically accretes this group to the Medicaid eligibility file. Each case is reviewed within 12 months of accretion.

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 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 HSD 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 HSD, a referral may be made to the local HSD office using Exhibit 3. Photocopy Exhibit 3 as needed. Completion of Exhibit 3 is self-explanatory.

2. Disabled Adult Children and Widower(er)s

Also included in SI 01715.015 are disabled adult children (DAC) and widow(er)s who lose SSI. DACs are automatically accreted to the Medicaid eligibility file. Widow(er)s must apply with HSD.

Although HSD 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 HSD, refer these inquirers to the State HSD office using Exhibit 3.

3. Children's Medical Services (CMS)

A State program not listed in SI 01715.015 is the Children's Medical Services (CMS) program. CMS is a State program, administered by the New Mexico Department of Health, that provides services for the prevention, diagnosis and treatment of handicapping conditions for children in New Mexico. Interested parties can call (505) 827-2548 or write to the New Mexico Dept. of Health, Children's Medical Services, 1190 St. Francis Dr., Santa Fe, NM 87504.

4. Working Disabled Individuals (WDI) Program

HSD implemented the Working Disabled Individuals (WDI) program in January 2001. Recipients will have Medicaid co-payments to pay depending on the amount of annual earned income. The WDI program provides Medicaid to two categories of individuals:

  1. Individuals who lose SSI eligibility due to initial receipt of Social Security Disability. The title II beneficiary can qualify for Medicaid until the beneficiary becomes eligible for Medicare, at which point they must return to work in order to retain eligibility for Medicaid.

  2. Individuals who are disabled and are working. If an individual is receiving Social Security or SSI Disability benefits, the individual meets the disability criteria.

To qualify under the WDI Medicaid program an individual must:

  • Meet SSA criteria for disability (DDS via a referral from HSD will make this determination if the individual is not currently receiving SSA/SSI disability benefits); and

  • Have a recent attachment to the workforce (i.e., quarterly earnings meet the SSA definition of a QC, or lost SSI due to receipt of title II disability payments); and

  • Be 18 years of age or older; and

  • Have countable resources less than $10,000 for an individual or $15,000 for a couple; and

  • Have monthly total countable earned income (after exclusions) not to exceed 250% of poverty level; and

  • Have total countable unearned income of less than $1,090 a month.

Refer individuals to the local HSD office and have them ask for the Medicaid Category 043-Working Disabled Individuals.

R. Medicaid Coverage in the Month of Move

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

Exhibit 1

New Mexico HSD Certification for Medicaid Eligibility

TO:  New Mexico Human Services Department         Date:___________________

       Medical Assistance Division

       P. O. Box 2348                                               Attn: SSI Coordinator

       Santa Fe, New Mexico 87504-2348

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     __ Emergency     __ Closed/Intervening Period ___ Certification of Eligibility or Death

2. Type of Recipient (circle one):   Aged(01)     Blind(03)       Disabled(04)

3. Social Security Number: _______________    4. DOB: _______________

5. Name of Recipient: ___________________________

6. Mailing Address __________________________

Including Representative ______________________

Payee & Zip Code:         ______________________

7. State/County Code: _______________       8. Living Arrangement Code: ________________

9. First Month/Year of SSI Paymentin New Mexico: ____________________

10. Title II/Medicare Claim #:   _________________      11. Sex: ________

12. Mo/Day/Year of SSI Application:   _____    13. DOD: ____    Underpayment paid?   Yes or No

14. TPL Code:    ____    15. Transfer RE?   _______      16. Medicaid Trust? ___________

17. If closed/intervening period of eligibility or death, show all months of SSI eligibility: _________________

18. If the individual is not currently eligible for SSI, give reason for suspension or termination and the effective date of non-pay: _____________________________________________________

19. Remarks: ________________________________________________________________

II. SSA previously submitted a manual Medicaid certification for the above named individual and SSN. This individual is no longer eligible for SSI effective __________. Reason: ____________________________________________________.

III.   Social Security Administration                ____________________________

        ___________________________                 (CR Print Name)

        ___________________________            Phone #: ____________________

                                                         ________________________________________
                                                    (Emergency Certification Authority - O/S or above)

SS-RVI-317 (06/2002)

Exhibit 2

C01/E01 Medicaid Extension Referral

To:  New Mexico Human Services Department        Date: ____________

       __________________________________        Attn:   Medical Assistance Worker

       __________________________________

cc:  NM HSD Buy-In Coordinator, Medical Assistance Division,

      P. O. Box 2348, Santa Fe, New Mexico 87504-2348

Because of title II income, entitlement to Medicare, and the Supplemental Security Income (SSI) Federal benefit rate, the SSI recipient identified below receives an SSI payment and Medicaid one month, but does not receive an SSI payment and Medicaid the next month. With the loss of Medicaid comes the loss of buy-in for Medicare. The situation repeats itself resulting in alternating months of eligibility for SSI payments.

The SSI recipient identified below has elected to forgo the receipt of an SSI payment and to be covered under the New Mexico Human Services Department optional Medicaid extension provision cited in the NM Medical Assistance Program Manual 402.6.

We believe the following individual qualifies for coverage under the State optional Medicaid extension provision.

Name:   _________________________________      SSN:  __________________________

Add:      _________________________________      DOB: __________________________

             _________________________________      Phone: _________________________

Gross title II income: $ _______________       Current E01 Effective Date: _____________

Please take appropriate action to accrete the individual to the State program.

If you have any questions, please call __________ at (AC & Phone) ________________.

From:    Social Security Administration

             ________________________

             ________________________

(Revised 06/2002)

Exhibit 3

TITLE II COLA/DAC/WIDOW(ER) MEDICAID EXTENSION REFERRAL LETTER

To:  New Mexico Human Services Department                   Date:__________

     Medical Assistance Division

     P. O. Box 2348

     Santa Fe, New Mexico 87504-2348

(check 1. or 2.)

_____1.       The following individual was eligible for Supplemental Security Income (SSI) in ______, but became ineligible effective with __________ because of a title II cost-of-living adjustment (COLA) increase paid to the eligible person or his/her spouse or due to ___________. This person may now be a candidate for preservation of Medicaid eligibility under the provision of:
(check one)

_____ Section 503 of Public Law 94-566, or

_____ Lynch v. Rank court decree.

_____2.      The following individual was eligible for SSI in ______,____ but became ineligible in ______,_____ 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 06/2002


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0501730008DAL
SI DAL01730.008 - (NM) SSA/State Agreements under Section 1634 - 11/28/2016
Batch run: 11/28/2016
Rev:11/28/2016