SI CHI02302.050 Field Office Verification of Title XIX Services and Expenditures for Section 1619(b)
See SI 02302.050
Section 1619(b) policy requires obtaining expenditure data for services paid by a State's title XIX program when an individual's gross earnings exceed the State's threshold amount; i.e., an individualized threshold calculation must be performed.
The appropriate agencies to contact for the title XIX expenditure data are listed below.
Contacts with local welfare agencies should be made in accordance with established office procedures.
Written requests should include the claimant's permission to release the appropriate information (e.g., SSA-8510, SSA-827).
The Exhibit provides model language for written requests.
| Department of Public Aid|
Bureau of Policy and Training
100 South Grand Avenue
East Springfield IL 62762
Local County Office of the Division of Family and Children
| SSI Coordination Unit|
Department of Social Services
P.O. Box 30037
Lansing MI 48909
| Department of Public Welfare|
444 Lafayette Road, 1st Floor
St. Paul, Minnesota 55405
| Ohio Department of Human Services|
P.O. Box 182411
Columbus OH 43218-2411
Telephone: (614) 644-8260
|HP Enterprise Services|
Attn: Enrollment Department – SSIMA
313 Blettner Blvd
Madison, WI 53784
Telephone: (608) 224-6514
Fax: (608) 221-8815
(The most efficient method is to request by fax.)
MODEL LETTER TO AGENCIES REQUESTING TITLE XIX VERIFICATION
In order for the Social Security Administration (SSA) to determine if a disabled or blind Supplemental Security Income (SSI) recipient, who is working, qualifies for continuing SSI recipient status under Section 1619(b) of the Social Security Act, we must obtain the dollar value of the cost charged to the title XIX program for services provided an individual.
Please use the enclosed form to provide the requested information to us. We have enclosed a statement signed by the individual giving permission to release this information.
If you need more information, please call ____________________, and ask for the SSA employee shown on the certification form.
CERTIFICATION BY THE STATE AGENCY MONITORING TITLE XIX SERVICES
Social Security Administration
City, State 00000
Attention: (FO Employee)
INFORMATION FROM SSA RECORDS
FULL NAME: _____________________________________
SOCIAL SECURITY NUMBER: ________________________
DATE OF BIRTH: _________________________________
CASE NUMBER: ____________________________________
TYPE OR TITLE OF SERVICE RECEIVED: _________________________________________________
NAME & ADDRESS OF PROVIDER OF SERVICE: ______________________________
STATE AGENCY CERTIFICATION
The individual shown above has used the title XIX services indicated above in the 12-month period ______ to ________:
____YES-If yes, what is the dollar value of the cost charged to the title XIX program indicated above during the 12-month period _______to ________?
____NO-If no, please explain. __________________________________________________________________________________________________________
Signature of State Agency Employee ______________________________________________
Title ___________________________Telephone Number ____________