TN 9 (05-91)

SI 01730.050 Exhibits, Assignment of Rights and Third Party Liability

A. Exhibit 1 Summary of AOR and TPL Procedures For Initial Claims (Applies only in States for which SSA makes Medicaid Eligibility Determinations)
B. Exhibit 2 Summary of TPL Procedures For Redeterminations (Applies only in States for which SSA makes Medicaid Eligibility Determinations)
C. Exhibit 3 Form SSA-169, Assignment of Rights Statement
D. Exhibit 4 Form SSA-8019, Third Party Liability Information Statement
E. Exhibit 5 Types of Insurance - (Examples)
F. Exhibit 6 List of States for Which SSA Determines and Redetermines Medicaid Eligibility (34, Including the District of Columbia)

A. Exhibit 1

Summary of AOR and TPL Procedures For Initial Claims (Applies only in States for which SSA makes Medicaid Eligibility Determinations)

 

B. Exhibit 2

C. Exhibit 3 — Form SSA-169, Assignment of Rights Statement

To view this form, go to SSA-169.

D. Exhibit 4 — Form SSA-8019, Third Party Liability Information Statement

To view this form, go to SSA-8019.

E. Exhibit 5 - Type of Insurance - (Examples)

 

  AGED-BLIND-
DISABLED ADULTS
BLIND-DISABLED MINOR CHILDREN
TYPE OF
INSURANCE
RECIPIENT SPOUSE PARENT STEP-PARENT

           INSURANCE HOLDER

EMPLOYMENT-RELATED HEALTH INSURANCE

X

X

X

X

TRICARE*

X

X

X

X

VETERAN'S
ADMINISTRATION

X

MEDICARE SUPPLEMENTAL POLICIES**

X

PRIVATELY PURCHASED
INSURANCE

X

X

X

X

 

 

 * Civilian Health and medical Plan of the Uniformed Services

** Private insurance that pays Medicare deductibles and insurance

F. Exhibit 6 - List of States for Which SSA Determines and Redetermines Medicaid Eligibility (35, Including the District of Columbia)

Alabama Mississippi
Arizona Montana
Arkansas New Jersey
California New Mexico
Colorado New York
Delaware North Carolina
District of Columbia Pennsylvania
Ohio
Florida Rhode Island
Georgia South Carolina
Indiana South Dakota
Iowa Tennessee
Kentucky Texas
Louisiana Vermont
Maine Washington
Maryland West Virginia
Massachusetts Wisconsin
Michigan Wyoming

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0501730050
SI 01730.050 - Exhibits, Assignment of Rights and Third Party Liability - 12/09/2016
Batch run: 12/13/2016
Rev:12/09/2016