TN 9 (05-91)

SI 01730.050 Exhibits, Assignment of Rights and Third Party Liability

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

 

G-SI_01730.050A

 View PDF Version

B. Exhibit 2

G-SI_01730.050B

 View PDF Version

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
RECIPIENTSPOUSEPARENTSTEP-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)

AlabamaMississippi
ArizonaMontana
Arkansas