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.

State

Contact

Illinois

Department of Public Aid
Bureau of Policy and Training
100 South Grand Avenue
East Springfield IL 62762

Indiana

Local County Office of the Division of Family and Children

Michigan

SSI Coordination Unit
Department of Social Services
P.O. Box 30037
Lansing MI 48909

Minnesota

Department of Public Welfare
Systems Division
444 Lafayette Road, 1st Floor
St. Paul, Minnesota 55405

Ohio

Ohio Department of Human Services
MTA/History Unit
P.O. Box 182411
Columbus OH 43218-2411

Telephone: (614) 644-8260

Wisconsin

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.)

EXHIBIT

   

MODEL LETTER TO AGENCIES REQUESTING TITLE XIX VERIFICATION

    

Dear:

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.

Sincerely,

                             District Manager

Enclosures

    

CERTIFICATION BY THE STATE AGENCY MONITORING TITLE XIX SERVICES

Social Security Administration

Street Address

City, State 00000

Attention: (FO Employee)

INFORMATION FROM SSA RECORDS

FULL NAME: _____________________________________

SOCIAL SECURITY NUMBER: ________________________

DATE OF BIRTH: _________________________________

ADDRESS: ____________________________

______________________________________

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. _________________________________________________________________________________________