SI BOS02003.004 New Hampshire Interim Assistance Reimbursement Agreement
See SI 02003.001
On November 3, 1977 the New Hampshire Department of Health and Welfare, now the Department of Health and Human Services (DHHS) entered into an Interim Assistance Reimbursement (IAR) Agreement with the Social Security Administration (SSA). This agreement was updated and renewed with DHHS on March 8, 2001, and modified to incorporate a revised authorization form on March 23, 2002. The IAR Agreement covers SSI initial claims only.
1. Initial Period Covered
The IAR Agreement with the DHHS provides for reimbursement to DHHS for General Assistance provided to the SSI recipient, by the New Hampshire Municipalities, for initial claims situations. The reimbursement covers the General Assistance (GA) paid for the interim period while the SSI application is pending. The interim period is described in SI 02003.001.
2. Protective filing
The IAR authorization serves as a protective filing for an initial SSI claim. The date that the Municipality receives a signed IAR authorization establishes a 60-day protective filing period for SSI eligibility. If an individual does not file an SSI application within the 60-day protective filing period, the IAR authorization does not serve as protective filing for SSI purposes.
3. Life of the Authorization
For initial SSI claims the IAR authorization is binding on the State of New Hampshire and an individual only if the Municipality notifies SSA within thirty (30) calendar days of the date that the individual signed the authorization. In such cases, the signed authorization remains in effect for one calendar year beginning with the date SSA receives it. In the instance that SSA is not notified timely, or the authorization has expired, SSA will release a retroactive SSI payment to the individual and the State of New Hampshire will be responsible for pursuing recovery of IAR from the individual without assistance from SSA. If an individual applies for SSI within the one calendar year period covered by the IAR authorization, or files a timely request for an administrative review within the time permitted by SSA regulations, or has already applied for SSI before the Municipality received an authorization, the period for the life of the authorization will be extended beyond the one year period, until such time as:
SSA releases the initial SSI payment; or
SSA makes a final determination (including a determination on appeal) and no timely request for review is filed; or
The Municipality and the individual agree to terminate the authorization.
The Municipality providing the GA must obtain a new authorization for each SSI application a GA recipient files. Each authorization is effective for one SSI application (i.e, A State may recoup GA only for the IA period pertaining to the SSI application that applies to that authorization. If that application is finally denied, and a subsequent application is filed and approved, the State cannot recoup for IAR unless a new authorization was obtained for the subsequent SSI application.)
When an IAR authorization is received, input the Grant Reimbursement (GR) code for DHHS to the SSR.
GR Code: 30060
Issue A-OTP's and mail correspondence to:NH DHHS
Office of Finance/Billing
A/O (Claimant's Name)
129 Pleasant Street
Concord NH 03301-3857
FAX manually prepared SSA-L8125s and SSA-L8125-F6s to:
The New Hampshire IAR Authorization Form, effective April 2002, is provided in Exhibit 1.
NH Department of Health & Human Services Form 151 7/89
SSI Interim Assistance Rev: 3/02
AUTHORIZATION FOR REIMBURSEMENT OF INTERIM ASSISTANCE
Applicant's Name – Please Print Social Security Number
I request that General or Interim Assistance be provided to me during the period in which my SSI application is pending.
If I am found eligible to receive Supplemental Security Income (SSI) benefits, I understand that I am authorizing the Commissioner of the Social Security Administration (SSA) to send to the State of New Hampshire, Department of Health & Human Services (DHHS):
My first retroactive payment of SSI benefits, or
An amount equal to the amount of reimbursable public assistance the Municipality provided me, if law restricts the manner in which my SSI money can be released to me.
The New Hampshire DHHS may:
Deduct from my first retroactive SSI payment the sum of all Municipality assistance benefits made to, or on behalf of, me by the Municipality in situations when law does not restrict the manner in which my SSI money can be released to me, or
Have SSA send an amount equal to the amount of reimbursable public assistance the Municipality provided to me, if law restricts the manner in which my SSI money can be released to me,
for the months beginning with:
and ending with, and including:
the month my SSI payment begins, or
the following month if the Municipality cannot promptly stop making its last public assistance payment to me.
(Assistance financed wholly or in part by federal funds cannot be included.)
I authorize the Municipality to release to the New Hampshire DHHS and/or SSA any records pertaining to my receipt of Interim Assistance.
The State of New Hampshire, DHHS is required to:
pay me the balance due from the retroactive SSI payment within 10 working days of the receipt of my SSI payment, and
give me written notice explaining:
How much SSA repaid DHHS for Interim Assistance the Municipality gave to me;
The balance, if any due me, unless the Social Security Act requires SSA to pay me such balance. (In such an event, SSA will notify me of the manner in which the balance will be paid to me.); and
That I will have an opportunity for an Administrative Hearing with the DHHS if I disagree with its actions regarding repayment of Interim Assistance to the Municipality or any action it took regarding this authorization.
I understand that this authorization is only binding on the Municipality and me if the Municipality notifies SSA of it within 30 calendar days of the date I signed it. Also, this form must be signed and dated by both a Municipality representative and me to be a valid agreement that authorizes the State to receive IAR from my SSI payments. I understand this authorization is effective for one year from the date the Municipality receives the signed form from me. However, if I have already applied for SSI before the Municipality received this authorization, or if I apply for SSI within one calendar year of the date described above, or I file a timely request for an administrative review within the time permitted under SSA regulations, this authorization will remain in effect, even if beyond the one calendar year period, until such time as:
SSA makes the initial SSI payment on my initial claim; or
SSA makes a final determination on my claim; or
The Municipality and I both agree to terminate this authorization.
This form serves as a signed statement of my intention to claim SSI benefits if I have not filed an SSI application as of the date that this authorization is received by the Municipality. My eligibility for SSI benefits may begin as early as the date I sign this form if I file an application at a Social Security office for SSI benefits within 60 days after that date. This form also serves as a notice from SSA that I have 60 days from the date the State receives this form to file for SSI benefits. However, if I do not file an application for SSI benefits at a Social Security office within 60 days after that date, then I understand that I cancel my intention to claim SSI benefits and this authorization no longer protects my filing date for SSI.
Applicant's Signature Date
Municipality's Representative's Signature Date