TN 28 (03-02)

NL 00804.166 Continuation of Benefits for Recipients Temporarily Institutionalized

Manual Paragraphs

INTM50. Situation Where Used:

IC and PE: The recipient is not eligible to receive continued benefits while in a Medicaid facility (LA-D).

Exhibit Letter

We are writing to tell you that (1) not eligible to receive SSI benefits while (2) a patient in a medical facility, e.g., hospital, nursing home. Our records show that (3) a patient in a facility as of (4).

Fill-ins:

1. (1) 

   you are/ Name is

2. (2) 

   you are/(he/she) is

3. (3) 

   you (are/were)/(he/she) (is/was)

4. (4) 

   month, day, year)/(month, day, year) through (month, day, year)/(month, day, year) on.

Payment Information

We usually reduce SSI payments for each full month that:

• •

  a claimant is a patient in a hospital or other medical facility and

• •

  Medicaid pays for or is expected to pay more than half the cost of his/her care.

We make payments for any of the first 3 full months if:

• •

  we reduce an SSI payment for any of the first 3 full months, and

• •

  patient is eligible for an SSI payment in the month before we reduce an SSI payment, and

• •

  patient gives us proof that he/she must continue to pay his/her home expenses, and

• •

  we have proof that the patient's doctor expects him/her to stay in a medical facility for less than 91 days.

We must receive (1) proof postmarked by the 90th day of (2) stay in the medical facility or by the day of (3) release, if earlier.

Fill-ins:

1. (1) 

   your/Name (possessive)

2. (2) 

   your/his/her

3. (3) 

   your/his/her

Basis of Our Decision

Optional Paragraph 1

(1) not meet all of these requirements because (2) not have expenses for (3) home which (4) must continue to pay.

Fill-ins:

1. (1) 

   You do/(He/She) does

2. (2) 

   you do/(he/she) does

3. (3) 

   your/his/her

4. (4) 

   you/he/she

Optional Paragraph 2

(1) not meet all of these requirements because we did not receive the proof about (2) home expenses postmarked by (3).

Fill-ins:

1. (1) 

   You do/(He/She) does

2. (2) 

   your/his/her

3. (3) 

   (month, day, year)

Optional Paragraph 3

(1) not meet all of these requirements because (2) doctor expects (3) to stay 91days or more.

Fill-ins:

1. (1) 

   You do/(He/She) does

2. (2) 

   your/his/her

3. (3) 

   you/him/her

Optional Paragraph 4

(1) not meet all of these requirements because we did not receive the proof postmarked by (2) of how long (3) doctor expects (4) to stay in a medical facility.

Fill-ins:

1. (1) 

   You do/(He/She) does

2. (2) 

   (month, day, year)

3. (3) 

   your/his/her

4. (4) 

   you/him/her

Optional Paragraph 5

(1) not meet all of these requirements because (2) not eligible for an SSI payment in (3)

Fill-ins:

1. (1) 

   You do/(He/She) does

2. (2) 

   you were/(he/she) was

3. (3) 

   (month, year)

Optional Paragraph 6

(1) not meet all of these requirements because (2) not have expenses for (3) home which (4) must continue to pay. Also, we did not receive the proof postmarked by (5) of how long (6) doctor expects (7) to stay in a medical facility.

Fill-ins:

1. (1) 

   You do/(He/She) does

2. (2) 

   you do/(he/she) does

3. (3) 

   your/his/her

4. (4) 

   you/she/he

5. (5) 

   (month, day, year)

6. (6) 

   your/his/her

7. (7) 

   you/him/her

Optional Paragraph 7

(1) not meet all of these requirements because we did not receive the proof about (2) home expenses or proof postmarked by (3) of how long (4) doctor expects (5) to stay in a medical facility.

Fill-ins:

1. (1) 

   You do/(He/She) does

2. (2) 

   your/his/her

3. (3) 

   (month, day, year)

4. (4) 

   your/his/her

5. (5) 

   you/him/her

Optional Paragraph 8

(1) not meet all of these requirements because we did not receive the proof postmarked by (2) about (3) home expenses or proof of how long (4) doctor expects (5) to stay in a medical facility.

Fill-ins:

1. (1) 

   You do/(He/She) does

2. (2) 

   (month, day, year)

3. (3) 

   your/his/her

4. (4) 

   your/his/her

5. (5) 

   you/him/her

Optional Paragraph 9

(1) not meet all of these requirements because (2) doctor expects (3) to stay in a medical facility 91 days or more.

Fill-ins:

1. (1) 

   You do/(He/She) does

2. (2) 

   your/his/her

3. (3) 

   you/him/her

Optional Paragraph 10

(1) not meet all of these requirements because (2) not eligible for an SSI payment in (3). Also, we did not receive the proof postmarked by (4) of how long (5) doctor expects (6) to stay in a medical facility.

Fill-ins:

1. (1) 

   You do/(He/She) does

2. (2) 

   You were/(he/she) was

3. (3) 

   (month, year)

4. (4) 

   (month, day, year)

5. (5) 

   your/his/her

6. (6) 

   you/him/her

Optional Paragraph 11

(1) not meet all of these requirements because we did not reduce (2) SSI payment for each of the first 3 full months (3) a patient. We can pay continued payments only for those first 3 months.

Fill-ins:

1. (1) 

   You do/(He/She) does

2. (2) 

   your/his/her

3. (3) 

   you were/(he/she) was

INTM51. Situation Where Used:

IC and PE: The recipient is not eligible to receive continued benefits while in a non-Medicaid facility (N02).

Exhibit Letter

We are writing to tell you that (1) not eligible to receive SSI benefits while (2) a patient in a medical facility, e.g., hospital, nursing home. Our records show that (3) entered a medical facility in (4).

Fill-ins:

1. (1) 

   you are/Name is

2. (2) 

   you are/(he/she) is

3. (3) 

   you/he/she

4. (4) 

   (month, day, year)/(month, day, year) through (month, day, year)/(month, day, year) on.

Payment Information

We usually reduce SSI for each full month that:

• •

  a claimant is a patient in a hospital or other medical facility, and

• •

  Medicaid pays for or is expected to pay more than half the cost of his/her care

We make payments for any of the first 3 full months if:

• •

  we would have stopped an SSI payment for any of these months, and

• •

  patient is eligible for an SSI payment in the month before we would have stopped an SSI payment, and

• •

  patient is in a medical facility, and

• •

  patient gives us proof that he/she must continue to pay his/her home expenses, and

• •

  we have proof that patient's doctor expects him/her to stay in a medical facility for less than 91 days.

We must receive (1) proof postmarked by the 90th day of (2) stay in the medical facility or by the day of (3) release, if earlier.

Fill-ins:

1. (1) 

   your/Name's (possessive)

2. (2) 

   your/his/her

3. (3) 

   your/his/her

Basis of Our Decision

Optional Paragraph 1

(1) not meet all of these requirements because (2) not have expenses for (3) home which (4) must continue to pay.

Fill-ins:

1. (1) 

   You do/(He/She) does

2. (2) 

   you do/(he/she) does

3. (3) 

   your/his/her

4. (4) 

   you/he/she

Optional Paragraph 2

(1) not meet all of these requirements because we did not receive the proof about (2) home expenses postmarked by (3).

Fill-ins:

1. (1) 

   You do/(He/She) does

2. (2) 

   your/his/her

3. (3) 

   (month, day, year)

Optional Paragraph 3

(1) not meet all of these requirements because (2) doctor expects (3) to stay 91 days or more.

Fill-ins:

1. (1) 

   You do/(He/She) does

2. (2) 

   your/his/her

3. (3) 

   you/him/her

Optional Paragraph 4

(1) not meet all of these requirements because we did not receive the proof postmarked by (2) of how long (3) doctor expects (4) to stay in a medical facility.

Fill-ins:

1. (1) 

   You do/(He/She) does

2. (2) 

   (month, day, year)

3. (3) 

   your/his/her

4. (4) 

   you/him/her

Optional Paragraph 5

(1) not meet all of these requirements because (2) not eligible for an SSI payment in (3)

Fill-ins:

1. (1) 

   You do/(He/She) does

2. (2) 

   you were/(he/she) was

3. (3) 

   (month, year)

Optional Paragraph 6

(1) not meet all of these requirements because (2) not have expenses for (3) home which (4) must continue to pay. Also, we did not receive the proof postmarked by (5) of how long (6) doctor expects (7) to stay in a medical facility.

Fill-ins:

1. (1) 

   You do/(He/She) does

2. (2) 

   you do/she does/he does

3. (3) 

   your/his/her

4. (4) 

   you/she/he

5. (5) 

   (month, day, year)

6. (6) 

   your/his/her

7. (7) 

   you/him/her

Optional Paragraph 7

(1) not meet all of these requirements because we did not receive the proof of how long (2) doctor expects (3) to stay in a medical facility.

Fill-ins:

1. (1) 

   You do/(He/She) does

2. (2) 

   your/his/her

3. (3) 

   you/him/her

Optional Paragraph 8

(1) not meet all of these requirements because (2) not in a medical facility.

Fill-ins:

1. (1) 

   You do/(He/She) does

2. (2) 

   you (are/were)/(he/she) (is/was)

Optional Paragraph 9

(1) not meet all of these requirements because we did not receive the proof postmarked by (2) about (3) home expenses or proof of how long (4) doctor expects (5) to stay in a medical facility.

Fill-ins:

1. (1) 

   You do/(He/She) does

2. (2) 

   (month, day, year)

3. (3) 

   your/his/her

4. (4) 

   your/his/her

5. (5) 

   you/he/she

Optional Paragraph 10

(1) not meet all of these requirements because (2) doctor expects (3) to stay 91 days or more. Also, we did not receive the proof postmarked by (4) of how long (5) doctor expects (6) to stay in a medical facility.

Fill-ins:

1. (1) 

   You do/(He/She) does

2. (2) 

   your/his/her

3. (3) 

   you/him/her

4. (4) 

   (month, day, year)

5. (5) 

   your/his/her

6. (6) 

   you/he/she

Optional Paragraph 11

(1) not meet all of these requirements because (2) not eligible for an SSI payment in (3). Also, we did not receive the proof postmarked by (4) of how long (5) doctor expects (6) to stay in a medical facility.

Fill-ins:

1. (1) 

   You do/(He/She) does

2. (2) 

   you were/(he/she) was

3. (3) 

   (month, year)

4. (4) 

   (month, day, year)

5. (5) 

   your/his/her

6. (6) 

   you/him/her

Optional Paragraph 12

(1) not meet all of these requirements because we did not stop (2) SSI payment for all of the first 3 full months (3) a patient. We can pay continued payments only for those first 3 months.

Fill-ins:

1. (1) 

   You do/(He/She) does

2. (2) 

   your/his/her

3. (3) 

   you were/(he/she) was

INTM52. Situation Where Used:

PE: We originally told the recipient he was not eligible to receive continued benefits while in a Medicaid facility. Now, we find he is eligible to receive continued benefits for the same period of time.

Exhibit Letter

We are writing to you to tell you that (1) eligible to receive SSI benefits while (2) a patient in a medical facility, e.g., hospital, nursing home. Our records show that (3) entered a medical facility in (4).

Fill-ins:

1. (1) 

   you are/ Name is

2. (2) 

   you are/(he/she) is

3. (3) 

   you/he/she

4. (4) 

   (month, year)

Payment Information

We usually reduce SSI payments for each full month that:

• •

  a patient in a hospital or other medical facility for a full month, and

• •

  Medicaid pays for or would usually pay for more than half the cost of the patient's care.

However, this rule does not apply for any of the first 3 full months that the patient is in a medical facility

• •

  The patient's doctor expects him/her to stay in a medical facility for less than 91 days, and

• •

  The patient has home expenses that he/she must continue to pay.

We told (1) before that we were (2) payments while (3) in a medical facility. However, now we find that we should not have (4) payments while (5) in a medical facility for (6).

Fill-ins:

1. (1) 

   you/Name

2. (2) 

   reducing/stopping

3. (3) 

   you were/(he/she) was

4. (4) 

   reduced/stopped

5. (5) 

   you were/(he/she was)

6. (6) 

   (month, year)

Basis of Our Decision

Optional Paragraph 1

(1) all of these requirements because (2) had expenses for (3) home which (4) had to continue to pay.

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   you/he/she

3. (3) 

   your/his/her

4. (4) 

   you/he/she

Optional Paragraph 2

(1) the requirements because we received the proof about (2) home expenses on time.

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   your/his/her

Optional Paragraph 3

(1) all of these requirements because (2) doctor expected (3) to stay for less than 91 days.

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   your/his/her

3. (3) 

   you/he/she

Optional Paragraph 4

(1) all of these requirements because we received the proof on time of how long (2) doctor expected (3) to stay in a medical facility.

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   your/his/her

3. (3) 

   you/him/her

Optional Paragraph 5

(1) all of these requirements because (2) eligible for an SSI payment in (3).

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   you were/(he/she) was

3. (3) 

   (month, year)

Optional Paragraph 6

(1) all of these requirements because (2) in a medical facility.

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   you were/(he/she) was

Optional Paragraph 7

(1) all of these requirements because (2) had expenses for (3) home which (4) had to continue to pay. Also, the proof of how long (5) doctor expected (6) to stay in a medical facility was received on time.

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   you/he/she

3. (3) 

   your/his/her

4. (4) 

   you/he/she

5. (5) 

   your/his/her

6. (6) 

   you/him/her

Optional Paragraph 8

(1) all of these requirements because the proof about (2) home expenses was received. Also, the proof of how long (3) doctor expected (4) to stay in a medical facility was received on time.

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   your/his/her

3. (3) 

   your/his/her

4. (4) 

   you/him/her

Optional Paragraph 9

(1) all of these requirements because the proof about (2) home expenses was received on time. Also, the proof of how long (3) doctor expected (4) to stay in a medical facility was received on time.

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   your/his/her

3. (3) 

   your/his/her

4. (4) 

   you/him/her

Optional Paragraph 10

(1) all of these requirements because (2) doctor expected (3) to stay for less than 91 days. Also, the proof of how long (4) doctor expected (5) to stay in a medical facility was received on time.

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   your/his/her

3. (3) 

   you/him/her

4. (4) 

   your/his/her

5. (5) 

   you/him/her

Optional Paragraph 11

(1) all of these requirements because (2) eligible for an SSI payment in (3). Also, the proof of how long (4) doctor expected (5) to stay in a medical facility was received on time.

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   you were/(he/she) was

3. (3) 

   (4)your/his/her

4. (4) 

   (month/year)

5. (5) 

   you/him/her

Optional Paragraph 12

(1) SSI payments are meant for (2) home expenses. (3) to pay this money to the medical facility.

Fill-ins:

1. (1) 

   Your/His/Her

2. (2) 

   your/his/her

3. (3) 

   You do not have/(He/She) does not have

INTM53. Situation Where Used:

PE: We originally told the recipient that he was not eligible to receive continued benefits while in a non-Medicaid facility. Now, we find he is eligible to receive continued benefits for the same period of time.

Exhibit Letter

We are writing to tell (1) that (2) eligible to receive SSI benefits while (3) a patient in a medical facility, e.g., hospital, nursing home. Our records show that (4) entered a medical facility in (5).

Fill-ins:

1. (1) 

   you/(Name)

2. (2) 

   you are/(he/she) is

3. (3) 

   you are/(he/she) is

4. (4) 

   you/he/she

5. (5) 

   (month, year)

Payment Information

We usually stop SSI payments for each full month that:

• •

  a patient spends in a hospital or other medical facility that is run by the Federal, State, or local government, and

• •

  if the patient has Medicaid, it does not pay for more than half the cost of his/her care.

However, this rule does not apply for any of the first 3 full months that he/she is a patient if:

• •

  his/her doctor expects him/her to stay in a medical facility for less than 91 days, and

• •

  the patient has expenses for his/her home that he/she must continue to pay.

We told (1) before that we were stopping (2) payments while (3) in a medical facility. However, now we find that we should not have stopped (4) payments while (5) in a medical facility for (6).

Fill-ins:

1. (1) 

   you/(Name)

2. (2) 

   your/his/her

3. (3) 

   you were/(he/she) was

4. (4) 

   your/his/her

5. (5) 

   you were/(he/she) was

6. (6) 

   (month/year) OR (month/year) and (month/year) OR (month/year) through (month/year)

Basis of Our Decision

Optional Paragraph 1

(1) all of these requirements because (2) had expenses for (3) home which (4) had to continue to pay.

Fill-ins:

1. (1) 

   you/he/she

2. (2) 

   You meet/(He/She) meets

3. (3) 

   your/his/her

4. (4) 

   you/he/she

Optional Paragraph 2

(1) all of these requirements because we received the proof about (2) home expenses on time.

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   your/his/her

Optional Paragraph 3

(1) all of these requirements because (2) doctor expected (3) to stay for less than 91 days.

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   your/his/her

3. (3) 

   you/him/her

Optional Paragraph 4

(1) all of these requirements because we received the proof how long (2) doctor expected (3) to stay in a medical facility on time.

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   your/his/her

3. (3) 

   you/him/her

Optional Paragraph 5

(1) all of these requirements because (2) were eligible for an SSI payment in (3).

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   you/he/she

3. (3) 

   (month, year)

Optional Paragraph 6

(1) all of these requirements because (2) in a medical facility.

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   you were/(he/she) was

Optional Paragraph 7

(1) all of these requirements because (2) had expenses for (3) home which (4) had to continue to pay. Also, we received the proof of how long (5) doctor expected (6) to stay in a medical facility on time.

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   you/he/she

3. (3) 

   your/his/her

4. (4) 

   you/he/she

5. (5) 

   your/his/her

6. (6) 

   you/he/she

Optional Paragraph 8

(1) all of these requirements because we received the proof about (2) home expenses and of how long (3) doctor expected (4) to stay in a medical facility on time.

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   your/his/her

3. (3) 

   your/his/her

4. (4) 

   you/he/she

Optional Paragraph 9

(1) all of these requirements because we received the proof about (2) home expenses and of how long (3) doctor expected (4) to stay in a medical facility on time.

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   your/his/her

3. (3) 

   your/his/her

4. (4) 

   you/he/she

Optional Paragraph 10

(1) all of these requirements because (2) doctor expected (3) to stay in a medical facility for less than 91 days.

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   your/his/her

3. (3) 

   you/him/her

Optional Paragraph 11

(1) all of these requirements because (2) doctor expected (3) to stay for less than 91 days. Also, we received the proof of how long (4) doctor expected (5) to stay in a medical facility on time.

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   your/his/her

3. (3) 

   you/him/her

4. (4) 

   your/his/her

5. (5) 

   you/him/her

Optional Paragraph 12

(1) all of the requirements because (2) eligible for an SSI payment in (3). Also, we received the proof of how long (4) doctor expected (5) to stay in a medical facility on time.

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   you were/(he/she) was

3. (3) 

   (month, year)

4. (4) 

   your/his/her

5. (5) 

   you/him/her

INTM54. Situation Where Used:

PE: We originally told the recipient that he was eligible to receive continued benefits while in a Medicaid facility. Now we find he is not eligible to receive continued benefits for the same period of time.

Exhibit Letter

We are writing to you to tell you that (1) not eligible to receive SSI benefits while (2) a patient in a medical facility, e.g., hospital, nursing home. Our records show that (3) entered a medical facility in (4).

Fill-ins:

1. (1) 

   you are/Name is

2. (2) 

   you are/(he/she) is

3. (3) 

   you/he/she

4. (4) 

   (month, year)

Payment Information

• •

  (1) in a medical care facility, like a hospital or nursing home, and

• •

  (2) lived there for the full month, and

• •

  Medicaid paid for or would usually pay for more than half the cost of (3) care, and

• •

  (4) eligible for SSI payments for the first three full months (5) in the facility.

Fill-ins:

1. (1) 

   You were/Name was

2. (2) 

   you/he/she

3. (3) 

   your/his/her

4. (4) 

   you were not/(he/she) was not

5. (5) 

   you were/(he/she) was

As a result, there is a limit of (1) on the Supplemental Security Income that (2) due for months (3) in the facility. If (4) income, (5) due less.

Fill-ins:

1. (1) 

   (amount equal to the Federal payment for LA-D plus any optional State supplementary payment, if applicable).

2. (2) 

   you are/(he/she) is

3. (3) 

   you are/(he/she) is

4. (4) 

   you have/(he/she) has

5. (5) 

   you are/(he/she) is

We told (1) before that (2) eligible for SSI payments while (3) in a medical facility. However, now we find that (4) eligible while (5) in a medical facility for (6).

Fill-ins:

1. (1) 

   you/him/her

2. (2) 

   you were/(he/she) was

3. (3) 

   you were/(he/she) was

4. (4) 

   you are not/(he/she) is not

5. (5) 

   you are/(he/she) is

6. (6) 

   (month/year)/(month/year) and (month/year)/(month/year) through (month/year)

Basis of Our Decision

Optional Paragraph 1

(1) not meet all of these requirements because (2) did not have expenses for your home which (3) must continue to pay.

Fill-ins:

1. (1) 

   You do/(He/She) does

2. (2) 

   you/he/she

3. (3) 

   you/he/she

Optional Paragraph 2

(1) not meet all of these requirements because we did not receive the proof about (2) home expenses.

Fill-ins:

1. (1) 

   You do/(He/She) does

2. (2) 

   your/his/her

Optional Paragraph 3

(1) not meet all of these requirements because we did not receive the proof about (2) home expenses postmarked by (3).

Fill-ins:

1. (1) 

   You do/(He/She) does

2. (2) 

   your/his/her

3. (3) 

   (month, day, year)

Optional Paragraph 4

(1) not meet all of these requirements because we did not receive the proof of how long (2) doctor expected (3) to stay in a medical facility postmarked by (4).

Fill-ins:

1. (1) 

   You do/(He/She) does

2. (2) 

   your/his/her

3. (3) 

   you/him/her

4. (4) 

   (month, day, year)

Optional Paragraph 5

(1) all of these requirements because we did not receive the proof of how long (2) doctor expected (3) to stay in a medical facility.

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   your/his/her

3. (3) 

   you/him/her

Optional Paragraph 6

(1) all of these requirements because (2) not eligible for an SSI payment in (3).

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   you were/(he/she) was

3. (3) 

   (month, day, year)

Optional Paragraph 7

(1) all of these requirements because (2) did not have expenses for (3) home which (4) must continue to pay. Also, we did not receive the proof of how long (5) doctor expected (6) stay in a medical facility postmarked by (7).

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   you/he/she

3. (3) 

   your/his/her

4. (4) 

   you/he/she

5. (5) 

   your/his/her

6. (6) 

   you/him/her

7. (7) 

   (month, day, year)

Optional Paragraph 8

(1) all of these requirements because the proof about (2) home expenses was not received. Also, we did not receive the proof of how long (3) doctor expected (4) stay in a medical facility postmarked by (5).

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   your/his/her

3. (3) 

   your/his/her

4. (4) 

   you/him/her

5. (5) 

   (month, day, year)

Optional Paragraph 9

(1) all of these requirements because we did not receive the proof postmarked by (2) about (3) home expenses or of how long (4) doctor expected (5) to stay in a medical facility.

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   (month, day, year)

3. (3) 

   your/his/her

4. (4) 

   your/his/her

5. (5) 

   you/him/her

Optional Paragraph 10

(1) all of these requirements because (2) not eligible for an SSI payment in (3). Also, we did not receive the proof of how long (4) doctor expected (5) to stay in a medical facility postmarked by (6).

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   you were/(he/she) was

3. (3) 

   (month, day, year)

4. (4) 

   your/his/her

5. (5) 

   you/him/her

6. (6) 

   (month, day, year)

INTM55. Situation Where Used:

PE: We originally told the recipient that he was eligible to receive continued benefits while in a non-Medicaid facility. Now, we find he is not eligible to receive continued benefits for the same period of time.

Exhibit Letter

We are writing to tell you that (1) not eligible to receive SSI benefits while (2) a patient in a medical facility, e.g., hospital, nursing home. Our records show that (3) a patient in a facility as of (4).

Fill-ins:

1. (1) 

   you are/Name is

2. (2) 

   you are/(he/she) is

3. (3) 

   you (are/were)/(he/she) (is/were)

4. (4) 

   (month, day, year)

Payment Information

• •

  in a medical facility, run by the Federal, State or local government, and

• •

  (2) lived there for the full month, and

• •

  if (3) Medicaid, it did not pay for more than half the cost of (4) care, and

• •

  (5) eligible for SSI payments for the first three full months (6) in the facility.

Fill-ins:

1. (1) 

   You were/Name was

2. (2) 

   you/he/she

3. (3) 

   you had/(he/she) has

4. (4) 

   your/his/her

5. (5) 

   you were/(he/she) were

6. (6) 

   you were/(he/she) was

We told (1) before that (2) eligible for SSI payments while (3) in a medical facility. However, now we find that (4) eligible while (5) in the facility for (6).

Fill-ins:

1. (1) 

   you/Name

2. (2) 

   you were/(he/she) was

3. (3) 

   you were/(he/she) was

4. (4) 

   you were not/(he/she) was not

5. (5) 

   you were/(he/she) was

6. (6) 

   (month/year)/(month/year) and (month/year)/(month/year) through (month/year)

Basis of Our Decision

Optional Paragraph 1

(1) all of these requirements because (2) did not have expenses for (3) home which (4) must continue to pay.

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   you/he/she

3. (3) 

   your/his/her

4. (4) 

   you/he/she

Optional Paragraph 2

(1) all these requirements because we did not receive the proof about (2) home expenses postmarked by (3).

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   your/his/her

3. (3) 

   (month, day, year)

Optional Paragraph 3

(1) all of these requirements because we did not receive the proof of how long (2) doctor expected (3) to stay in a medical facility postmarked by (4).

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   your/his/her

3. (3) 

   you/him/her

4. (4) 

   (month, day, year)

Optional Paragraph 4

(1) all of these requirements because (2) eligible for an SSI payment in (3).

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   you were not/(he/she) was not

3. (3) 

   (month, year)

Optional Paragraph 5

(1) all of these requirements because (2) in a medical facility.

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   you were not/(he/she) was not

Optional Paragraph 6

(1) all of these requirements because (2) did not have expenses for (3) home which (4) must continue to pay. Also, we did not receive the proof of how long (5) doctor expected (6) to stay in a medical facility postmarked by (7).

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   you/he/she

3. (3) 

   your/his/her

4. (4) 

   you/he/she

5. (5) 

   your/his/her

6. (6) 

   you/him/her

7. (7) 

   (month, day, year)

Optional Paragraph 7

(1) all of these requirements because we did not receive the proof about (2) home expenses or of how long (3) doctor expected (4) to stay in a medical facility postmarked by (5).

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   your/his/her

3. (3) 

   your/his/her

4. (4) 

   you/him/her

5. (5) 

   (month, day, year)

Optional Paragraph 8

(1) all of these requirements because we did not receive the proof about (2) home expenses or of how long (3) doctor expected (4) to stay in a medical facility postmarked by (5).

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   your/his/her

3. (3) 

   your/his/her

4. (4) 

   you/him/her

5. (5) 

   (month, day, year)

Optional Paragraph 9

(1) all of these requirements because (2) eligible for an SSI payment in (3). Also, we did not receive the proof of how long (4) doctor expected (5) to stay in a medical facility postmarked by (6).

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   you were not/(he/she) was not

3. (3) 

   (month, year)

4. (4) 

   your/his/her

5. (5) 

   you/him/her

6. (6) 

   (month, day, year)

1622. Situation Where Used:

IC and PE: The recipient is eligible to receive continued benefits while in a Medicaid facility.

Exhibit Letter

We are writing you to tell you that (1) eligible to receive SSI benefits while (2) a patient in a medical facility, e.g., hospital, nursing home. Our records show that (3) entered a medical facility in (4).

Fill-ins:

1. (1) 

   you are/Name is

2. (2) 

   you are/(he/she) is

3. (3) 

   you/he/she

4. (4) 

   (month, year)

Payment Information

We usually reduce SSI payments for each full month that:

• •

  a claimant is a patient in a hospital or other medical facility and

• •

  Medicaid pays for or is expected to pay more than half the cost of his/her care.

However, this rule does not apply for any of the first 3 full months that (1) a patient if:

• •

  (2) doctor expects (3) to stay in a medical facility for less than 91 days, and

• •

  (4) expenses for (5) home that (6) must continue to pay.

Fill-ins:

1. (1) 

   you are/(he/she) is

2. (2) 

   your/his/her

3. (3) 

   you/him/her

4. (4) 

   you have/(he/she) has

5. (5) 

   your/his/her

6. (6) 

   you/he/she

Basis of Our Decision

Optional Paragraph 1

This means that beginning (1), we (2) (3) payment because (4) in a medical facility.

Fill-ins:

1. (1) 

   (month/year)/(month/year) and (month/year)/(month/year) through (month/year)

2. (2) 

   are not reducing/did not reduce

3. (3) 

   your/his/her

4. (4) 

   you (are/were)/(he/she) is/were

Optional Paragraph 2

(1) SSI payments are meant for (2) home expenses. (3) to pay this money to the medical facility.

Please tell us as soon as (4) when (5) will be leaving the medical facility, so we can continue to pay (6) correctly.

Fill-ins:

1. (1) 

   Your/His/Her

2. (2) 

   your/his/her

3. (3) 

   You do not have/(He/She) does not have

4. (4) 

   you know/(he/she) knows

5. (5) 

   you/he/she

6. (6) 

   you/him/her

1623. Situation Where Used:

IC and PE: The recipient is eligible to receive continued benefits while in a Medicaid or non-Medicaid facility and we are sending the eligibility notice in the second or third month of institutionalization, but prior to the Goldberg/Kelly cutoff date for reducing/ stopping the SSI payment in the fourth month.

Exhibit Letter

Basis of Our Decision

Optional paragraph 1 to be used with either paragraph 1622 or 1625

• •

  (1) SSI payment for (2) will be (3) if (4) still in the medical facility for the full month (5).

Fill-ins:

1. (1) 

   Your/His/Her

2. (2) 

   (month, year)

3. (3) 

   reduced/stopped

4. (4) 

   you are/(he/she) is

5. (5) 

   you have income/(he/she) has income

1624. Situation Where Used:

IC and PE: The recipient is eligible to receive continued benefits while in a Medicaid or non-Medicaid facility and we are sending the eligibility notice after the Goldberg/Kelly cutoff date for reducing/stopping the SSI payment in the fourth month.

Exhibit Letter

Basis of Our Decision

Optional paragraph 1 to be used with either paragraph 1622 or 1625

• •

  (1) (2) SSI beginning (3) if (4) still in the medical facility (5). Even though (6) (7) money for that month, we will not reduce (8) payment of (9). This is to give (10) time to appeal this decision.

• •

  However, (11) may have to pay back any money (12) not eligible to receive. We will let (13) know later if (14) payment for (15) changes.

Fill-ins:

1. (1) 

   You are/(He/She) is

2. (2) 

   due less/not due

3. (3) 

   (month, year)

4. (4) 

   you are/(he/she) is

5. (5) 

   and have income/and has income

6. (6) 

   you are/(he/she) is

7. (7) 

   due less/not due

8. (8) 

   your/his/her

9. (9) 

   ($amount)

10. (10) 

    you/him/her

11. (11) 

    you/he/she

12. (12) 

    you are/(he/she) is

13. (13) 

    you/him/her

14. (14) 

    your/his/her

15. (15) 

    (month, year)

1625. Situation Where Used:

IC and PE: The recipient is eligible to receive continued benefits while in a non-Medicaid facility.

Exhibit Letter

We are writing you to tell you that (1) eligible to receive SSI benefits while (2) a patient in a medical facility, e.g., hospital, nursing home. Our records show that (3) entered a medical facility in (4).

Fill-ins:

1. (1) 

   you are/Name is

2. (2) 

   you are/(he/she) is

3. (3) 

   you/he/she

4. (4) 

   (month, year)

Payment Information

We usually reduce SSI payments for each full month that:

• •

  a claimant is a patient in a hospital or other medical facility and

• •

  Medicaid pays for or is expected to pay more than half the cost of his/her care.

However, this rule does not apply for any of the first 3 full months that (1) a patient if:

• •

  (2) doctor expects (3) to stay in a medical facility for less than 91 days, and

• •

  (4) expenses for (5) home that (6) must continue to pay.

Fill-ins:

1. (1) 

   you are/(he/she) is

2. (2) 

   your/his/her

3. (3) 

   you/him/her

4. (4) 

   you have/(he/she) has

5. (5) 

   your/his/her

6. (6) 

   you/he/she

Basis of Our Decision

Optional Paragraph 1

This means that beginning (1), we (2) (3) payment because (4) in a medical facility.

Fill-ins:

1. (1) 

   (month, year)/(month/year) and (month/year)/(month/year) through (month/year)

2. (2) 

   are not stopping/did not stop

3. (3) 

   your/his/her

4. (4) 

   you are/(he/she) is

Please tell us as soon as (1) when (2) will be leaving the medical facility, so we can continue to pay (3) correctly.

Fill-ins:

1. (1) 

   you know/(he/she) knows

2. (2) 

   you/he/she

3. (3) 

   you/him/her

1626. Situation Where Used:

PE: The recipient was previously notified of his eligibility to continued benefits. When using this paragraph we are notifying the recipient that his payment with be reduced or stopped in his fourth month of institutionalization.

Basis of Our Decision

Optional Paragraph 1

We wrote (1) earlier to tell (2) that we would not (3) (4) SSI payment because (5) a patient in a medical facility for (6).

(7) SSI payment for (8) will be reduced if (9) still in the medical facility for the full month.

Please tell us when (10) the medical facility so we can continue to pay (11) correctly.

Fill-ins:

1. (1) 

   you/him/her

2. (2) 

   you/him/her

3. (3) 

   reduce/stop

4. (4) 

   your/his/her

5. (5) 

   you (are/were)/(he/she) (is/was)

6. (6) 

   (month, year)

7. (7) 

   Your/His/Her

8. (8) 

   (month, year)/(month, year) and (month, year)/(month, year) through (month, year)

9. (9) 

   you are/(he/she) is

10. (10) 

    you leave/(he/she) leaves

11. (11) 

    you/him/her

Optional Paragraph 2

(1) SSI payment for (2) will be (3) if (4) still in the medical facility for the full month.

Fill-ins:

1. (1) 

   Your/His/Her

2. (2) 

   (month, year)

3. (3) 

   reduced/stopped

4. (4) 

   you are/(he/she) is

Optional Paragraph 3

(1) SSI payment for (2) will be stopped if (3) still in the medical facility for the full month and (4) income.

Fill-ins:

1. (1) 

   Your/His/Her

2. (2) 

   (month, year)

3. (3) 

   you are/(he/she) is

4. (4) 

   you have/(he/she) has

1627. Situation Where Used:

IC and PE: The recipient is not eligible to receive continued benefits while in a Medicaid facility.

Optional Paragraph 15 is only used in a manual denial notice.

Exhibit Letter

We are writing you to tell you that (1) not eligible to receive SSI benefits while (2) a patient in a medical facility, e.g., hospital, nursing home. Our records show that (3) entered a medical facility in (4).

Fill-ins:

1. (1) 

   you are/Name is

2. (2) 

   you are/(he/she) is

3. (3) 

   you/he/she

4. (4) 

   (month, year)

Payment Information

We usually reduce SSI payments for each full month that:

• •

  a claimant is a patient in a hospital or other medical facility and

• •

  Medicaid pays for or is expected to pay more than half the cost of his/her care.

(1) could be eligible for continued payments for any of the first 3 full months that (2) a patient if:

• •

  we would have reduced (3) payment for any of these months, and

• •

  (4) eligible for an SSI payment in the month before we would have reduced (5) SSI payment, and

• •

  (6) us proof that (7) home expenses that (8) to continue to pay, and

• •

  we have proof that (9) doctor expects (10) to stay in a medical facility for less than 91 days.

We must receive the proofs by the 10^th of the month after the month (11) admitted to the medical facility.

Fill-ins:

1. (1) 

   You/He/She

2. (2) 

   you are/(he/she) is

3. (3) 

   your/his/her

4. (4) 

   you are/(he/she) is

5. (5) 

   your/his/her

6. (6) 

   you give/(he/she) gives

7. (7) 

   you have/(he/she) has

8. (8) 

   you have/(he/she) has

9. (9) 

   your/his/her

10. (10) 

    you/him/her

11. (11) 

    you are/(he/she) is

Basis of Our Decision

Optional Paragraph 1

(1) all of these requirements because (2) not have expenses for (3) home which (4) must continue to pay.

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   you do/(he/she) does

3. (3) 

   your/his/her

4. (4) 

   you/he/she

Optional Paragraph 2

(1) all of these requirements because we did not receive the proof about (2) home expenses postmarked by (3).

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   your/his/her

3. (3) 

   (month, day, year)

Optional Paragraph 3

(1) all of these requirements because (2) doctor expects (3) to stay 91 days or more.

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   your/his/her

3. (3) 

   you/him/her

Optional Paragraph 4

(1) all of these requirements because we did not receive the proof of how long (2) doctor expects (3) to stay in a medical facility by (4), and we could not find a good reason why it was received late

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   your/his/her

3. (3) 

   you/him/her

4. (4) 

   (month, day, year)

Optional Paragraph 5

(1) all of these requirements because the proof of how long (2) doctor expects (3) to stay in a medical facility was not prepared and dated by (4).

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   your/his/her

3. (3) 

   you/him/her

4. (4) 

   (month, day, year)

Optional Paragraph 6

(1) all of these requirements because the proof of how long (2) doctor expects (3) to stay in a medical facility was not received.

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   your/his/her

3. (3) 

   you/him/her

Optional Paragraph 7

(1) all of these requirements because (2) eligible for an SSI payment in (3).

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   you were not/(he/she) was not

3. (3) 

   (month, year)

Optional Paragraph 8

(1) all of these requirements because (2) expenses for (3) home which you must continue to pay. Also, we did not receive the proof of how long (4) doctor expects (5) to stay in a medical facility by (6), and we could not find a good reason why it was received late.

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   you do not have/(he/she) does not have

3. (3) 

   your/his/her

4. (4) 

   your/his/her

5. (5) 

   you/him/her

6. (6) 

   (month, day, year)

Optional Paragraph 9

(1) all of these requirements because we did not receive the proof about (2) home expenses or of how long (3) doctor expects (4) to stay in a medical facility by (5), and we could not find a good reason why it was received late.

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   your/his/her

3. (3) 

   your/his/her

4. (4) 

   you/him/her

5. (5) 

   (month, day, year)

Optional Paragraph 10

(1) all of these requirements because we did not receive the proof about (2) home expenses or of how long (3) doctor expects (4) to stay in a medical facility by (5)

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   your/his/her

3. (3) 

   your/his/her

4. (4) 

   you/him/her

5. (5) 

   (month, day, year)

Optional Paragraph 11

(1) all of these requirements because (2) doctor expects (3) to stay 91 days or more. Also, we did not receive the proof of how long (4) doctor expects (5) to stay in a medical facility by (6), and we could not find a good reason why it was received late.

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   your/his/her

3. (3) 

   you/him/her

4. (4) 

   your/his/her

5. (5) 

   you/him/her

6. (6) 

   (month, day, year)

Optional Paragraph 12

(1) all of these requirements because we did not receive the proof of how long (2) doctor expects (3) to stay in a medical facility or of how long (4) doctor expects (5) to stay in a medical facility by (6), and we could not find a good reason why it was received late.

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   your/his/her

3. (3) 

   you/him/her

4. (4) 

   your/his/her

5. (5) 

   you/him/her

6. (6) 

   (month, day, year)

Optional Paragraph 13

(1) all of these requirements because (2) eligible for an SSI payment in (3). Also, we did not receive the proof of how long (4) doctor expects (5) to stay in a medical facility by (6), and we could not find a good reason why it was received late

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   you were not/(he/she) was not

3. (3) 

   (month, year)

4. (4) 

   your/his/her

5. (5) 

   you/him/her

6. (6) 

   (month, day, year)

Optional Paragraph 14

(1) all of these requirements because we did not reduce (2) SSI payment for all of the first 3 full months (3) a patient. We can pay continued payments only for the first 3 months.

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   your/his/her

3. (3) 

   you were/(he/she) was

1628. Situation Where Used:

IC and PE: The recipient is not eligible to receive continued benefits while in a non-Medicaid facility.

Fill-in 24, choices 49, 50 and 51 [THESE CHOICES DO NOT APPEAR IN THIS SECTION] are only used in a manual denial notice.

Exhibit Letter

We are writing you to tell you that (1) not eligible to receive SSI benefits while (2) a patient in a medical facility, e.g., hospital, nursing home. Our records show that (3) in this facility for (4).

Fill-ins:

1. (1) 

   you are/Name is

2. (2) 

   you are/(he/she) is

3. (3) 

   you will be/(he/she) will be

4. (4) 

   for the full month of (month/year)/for each full month through (month/year)/for each full month on (month, year)

Payment Information

We usually reduce SSI payments for each full month that:

• •

  a claimant is a patient in a hospital or other medical facility that is run by the Federal, State, or local government, or an institution run by the Federal, State, or local government, including some hospitals, nursing homes, other care facilities or prisons, and

• •

  if the claimant had Medicaid, it does not pay for more than half the cost of his/her care.

(1) could be eligible for continued payments for any of the first 3 full months that (2) a patient if:

• •

  we would have stopped (3) SSI payment for any of these months, and

• •

  (4) eligible for an SSI payment in the month before we would have stopped (5) SSI payment, and

• •

  (6) in a medical facility, and

• •

  (7) us proof that (8) home expenses that (9) to continue to pay, and

• •

  we have proof that (10) doctor expects (11) to stay in a medical facility for less than 91 days.

We must receive the proofs by the 10th of the month after the month (12) admitted to the medical facility.

Fill-ins:

1. (1) 

   You/He/She

2. (2) 

   you are/(he/she) is

3. (3) 

   your/his/her

4. (4) 

   you are/(he/she) is

5. (5) 

   your/his/her

6. (6) 

   you are/(he/she is)

7. (7) 

   you give/(he/she) gives

8. (8) 

   you have/(he/she has)

9. (9) 

   you have/(he/she has)

10. (10) 

    your/his/her

11. (11) 

    you/him/her

12. (12) 

    you are/(he/she) is

Basis of Our Decision

Optional Paragraph 1

(1) all of these requirements because (2) expenses for (3) home which (4) must continue to pay.

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   you do not have/(he/she) does not have

3. (3) 

   your/his/her

4. (4) 

   you/he/she

Optional Paragraph 2

(1) all of these requirements because we did not receive the proof about (2) home expenses by (3).

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   your/his/her

3. (3) 

   (month, day, year)

Optional Paragraph 3

(1) all of these requirements because (2) doctor expects (3) to stay 91 days or more.

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   your/his/her

3. (3) 

   you/he/she

Optional Paragraph 4

(1) all of these requirements because we did not receive the proof of how long (2) doctor expects (3) to stay in a medical facility by (4), and we could not find a good reason why it was received late.

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   your/his/her

3. (3) 

   you/he/she

4. (4) 

   (month, day, year)

Optional Paragraph 5

(1) all of these requirements because the proof of how long (2) doctor expects (3) to stay in a medical facility was not prepared and dated by (4).

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   your/his/her

3. (3) 

   you/he/she

4. (4) 

   (month, day, year)

Optional Paragraph 6

(1) all of these requirements because we did not receive the proof of how long (2) doctor expects (3) to stay in a medical facility by (4).

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   your/his/her

3. (3) 

   you/him/her

4. (4) 

   (month, day, year)

Optional Paragraph 7

(1) all of these requirements because (2) eligible for an SSI payment in (3).

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   you were not/(he/she) was not

3. (3) 

   (month, year)

Optional Paragraph 8

(1) all of these requirements because (2) in a medical facility.

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   you are not/(he/she) is not

Optional Paragraph 9

(1) all of these requirements because (2) in a medical facility.

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   you were not/(he/she) was not

Optional Paragraph 10

(1) all of these requirements because (2) have expenses for (3) home which (4) must continue to pay. Also, the proof of how long (5) doctor expects (6) to stay in a medical facility was not received by (7), and we could not find a good reason why it was received late.

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   you do not/(he/she) does not

3. (3) 

   your/his/her

4. (4) 

   you/he/she

5. (5) 

   your/(his/her)

6. (6) 

   you/him/her

7. (7) 

   (month, day, year)

Optional Paragraph 11

(1) all of these requirements because we did not receive postmarked by (2) the proof about (3) home expenses or of how long (4) doctor expects (5) to stay in a medical facility, and we could not find a good reason why it was received late.

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   (month, day, year)

3. (3) 

   your/his/her

4. (4) 

   your/his/her

5. (5) 

   you/him/her

Optional Paragraph 12

(1) all of these requirements because we did not receive postmarked by (2) the proof about (3) home expenses or of how long (4) doctor expects (5) to stay in a medical facility, and we could not find a good reason why it was received late.

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   (month, day, year)

3. (3) 

   your/his/her

4. (4) 

   your/his/her

5. (5) 

   you/him/her

Optional Paragraph 13

(1) all of these requirements because (2) doctor expects (3) to stay 91 days or more. Also, we did not receive postmarked by (4) the proof of how long (5) doctor expects (6) to stay in a medical facility, and we could not find a good reason why it was received late.

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   your/his/her

3. (3) 

   you/him/her

4. (4) 

   (month, day, year)

5. (5) 

   your/his/her

6. (6) 

   you/him/her

1630. Situation Where Used:

PE: We originally told the recipient that he was not eligible to receive continued benefits while in a non-Medicaid facility. Now, we find he is eligible to receive continued benefits for the same period of time.

Exhibit Letter

We are writing you to tell you that (1) eligible to receive SSI benefits while (2) a patient in a medical facility, e.g., hospital, nursing home. Our records show that (3) entered this facility on (4).

Fill-ins:

1. (1) 

   you are/Name is

2. (2) 

   you are/(he/she) is

3. (3) 

   you/he/she

4. (4) 

   (month, day, year)

Payment Information

We usually reduce SSI payments for each full month that:

• •

  a claimant is a patient in a hospital or other medical facility and that is run by the Federal, State, or local government, and

• •

  if the claimant has Medicaid, it does not pay for more than half the cost of his/her care.

(1) could be eligible for continued payments for any of the first 3 full months that (2) a patient if:

• •

  (3) doctor expects (4) to stay in a medical facility for less than 91 days, and

• •

  (5) expenses for (6) home that (7) must continue to pay.

We told (8) before that we were stopping (9) payment while (10) in a medical facility. However, now we find that we should not have stopped (11) payments while (12) in a medical facility for (13).

Fill-ins:

1. (1) 

   You/He/She

2. (2) 

   you are/(he/she) is

3. (3) 

   your/his/her

4. (4) 

   you/him/her

5. (5) 

   you have/(he/she) has

6. (6) 

   your/his/her

7. (7) 

   you/he/she

8. (8) 

   you/him/her

9. (9) 

   your/his/her

10. (10) 

    you were/(he/she) was

11. (11) 

    your/his/her

12. (12) 

    you were/(he/she) was

13. (13) 

    (month, year)/(month, year and month, year)/(month, year) through (month, year)

Basis of Our Decision

Optional Paragraph 1

(1) all of these requirements because (2) had expenses for (3) home which (4) had to continue to pay.

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   you/he/she

3. (3) 

   your/his/her

4. (4) 

   you/he/she

Optional Paragraph 2

(1) all of these requirements because we received the proof about (2) home expenses (3).

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   your/his/her

3. (3) 

   (month, day, year)

Optional Paragraph 3

(1) all of these requirements because (2) doctor expected (3) to stay for less than 91 days.

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   your/his/her

3. (3) 

   you/him/her

Optional Paragraph 4

(1) all of these requirements because we did not receive the proof of how long (2) doctor expected (3) to stay in a medical facility by (4), but we found a good reason why it was received late.

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   your/his/her

3. (3) 

   you/him/her

4. (4) 

   (month, day, year)

Optional Paragraph 5

(1) all of these requirements because the proof of how long (2) doctor expected (3) to stay in a medical facility was prepared and dated by (4).

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   your/his/her

3. (3) 

   you/him/her

4. (4) 

   (month, day, year)

Optional Paragraph 6

(1) all of these requirements because we received the proof of how long (2) doctor expected (3) to stay in a medical facility by (4).

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   your/his/her

3. (3) 

   you/him/her

4. (4) 

   (month, day, year)

Optional Paragraph 7

(1) all of these requirements because (2) were eligible for an SSI payment in (3).

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   you/him/her

3. (3) 

   (month, year)

Optional Paragraph 8

(1) all of these requirements because (2) in a medical facility.

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   you/him/her

1631. Situation Where Used:

PE: We originally told the recipient that he was eligible to receive continued benefits while in a Medicaid facility. Now, we find he is not eligible to receive continued benefits for the same period of time.

Exhibit Letter

We are writing you to tell you that (1) not eligible to receive SSI benefits while (2) a patient in a medical facility, e.g., hospital, nursing home. Our records show that (3) entered this facility on (4).

Fill-ins:

1. (1) 

   you are/Name is

2. (2) 

   you are/(he/she) is

3. (3) 

   you/he/she

4. (4) 

   (month, day, year)

Payment Information

We understand that

• •

  (1) in a medical care facility, like a hospital or nursing home, and

• •

  (2) lived there for the full month, and

• •

  Medicaid paid for or would usually pay for more than half the cost of (3) care, and

• •

  (4) eligible for SSI payments for the first three full months (5) in the facility.

As a result, there is a limit of (6) on the Supplemental Security Income (7) due for months (8) in the facility. If (9) income, (10) due less.

We told (11) before that (12) eligible for SSI payments while (13) in a medical facility. However, now we find that (14) eligible while (15) in a medical facility for (16).

Fill-ins:

1. (1) 

   you were/(he/she) was

2. (2) 

   you/he/she

3. (3) 

   your/his/her

4. (4) 

   you were not/(he/she) was not

5. (5) 

   you were/(he/she) was

6. (6) 

   ($amount)

7. (7) 

   you are/(he/she) is

8. (8) 

   you are/(he/she) is

9. (9) 

   you have/(he/she) has

10. (10) 

    you are/(he/she) is

11. (11) 

    you/him/her

12. (12) 

    you were/(he/she) was

13. (13) 

    you were/(he/she) was

14. (14) 

    you were not/(he/she) was not

15. (15) 

    you were/(he/she) was

16. (16) 

    (month, year)/(month/year) and (month/year)/(month, year) through (month/year)

Basis of Our Decision

Optional Paragraph 1

(1) all of these requirements because (2) did not have expenses for (3) home which (4) must continue to pay.

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   you/him/her

3. (3) 

   your/his/her

4. (4) 

   you/he/she

Optional Paragraph 2

(1) all of these requirements because the proof about (2) home expenses was not received by (3).

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   your/his/her

3. (3) 

   (month, day, year)

Optional Paragraph 3

(1) all of these requirements because (2) doctor expected you to stay 91 days or more.

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   your/his/her

Optional Paragraph 4

(1) all of these requirements because we did not receive the proof of how long (2) doctor expected (3) to stay in a medical facility by (4), and we could not find a good reason why it was received late.

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   your/his/her

3. (3) 

   you/him/her

4. (4) 

   (month, day, year)

Optional Paragraph 5

(1) all of these requirements because the proof of how long (2) doctor expected (3) to stay in a medical facility was not prepared and dated by (4).

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   your/his/her

3. (3) 

   you/him/her

4. (4) 

   (month, day, year)

Optional Paragraph 6

(1) all of these requirements because we did not receive the proof of how long (2) doctor expected (3) to stay in a medical facility by (4).

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   your/his/her

3. (3) 

   you/him/her

4. (4) 

   (month, day, year)

Optional Paragraph 7

(1) all of these requirements because (2) eligible for an SSI payment in (3).

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   you were not/(he/she) was not

3. (3) 

   (month, year)

Optional Paragraph 8

(1) all of these requirements because (2) did not have expenses for (3) home which (4) must continue to pay. Also, we did not receive the proof of how long (5) doctor expected (6) to stay in a medical facility by (7), and we could not find a good reason why it was received late.

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   you/he/she

3. (3) 

   your/his/her

4. (4) 

   you/he/she

5. (5) 

   your/his/her

6. (6) 

   you/him/her

7. (7) 

   (month, day, year)

Optional Paragraph 9

(1) all of these requirements because we did not receive the proof about (2) home expenses or of how long (3) doctor expected (4) to stay in a medical facility by (5), and we could not find a good reason why it was received late.

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   your/his/her

3. (3) 

   your/his/her

4. (4) 

   you/he/she

5. (5) 

   (month, day, year)

Optional Paragraph 10

(1) all of these requirements because we did not receive postmarked by (2) the proof about (3) home expenses or of how long (4) doctor expected (5) to stay in a medical facility by (6), and we could not find a good reason why it was received late.

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   (month, day, year)

3. (3) 

   your/his/her

4. (4) 

   your/his/her

5. (5) 

   you/him/her

6. (6) 

   (month, day, year)

Optional Paragraph 11

(1) all of these requirements because (2) doctor expected (3) to stay 91 days or more. Also, we did not receive the proof of how long (4) doctor expected (5) to stay in a medical facility by (6), and we could not find a good reason why it was received late.

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   your/his/her

3. (3) 

   you/he/she

4. (4) 

   your/his/her

5. (5) 

   you/him/her

6. (6) 

   (month, day, year)

Optional Paragraph 12

(1) all of these requirements because the proof of how long (2) doctor expected (3) to stay in a medical facility was not prepared and dated by (4). Also, we did not receive the proof of how long (5) doctor expected (6) to stay in a medical facility by (7), and we could not find a good reason why it was received late.

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   your/his/her

3. (3) 

   you/him/her

4. (4) 

   (month, day, year)

5. (5) 

   your/his/her

6. (6) 

   you/he/she

7. (7) 

   (month, day, year)

Optional Paragraph 13

(1) all of these requirements because (2) eligible for an SSI payment in (3). Also, we did not receive the proof of how long (4) doctor expected (5) to stay in a medical facility by (6), and we could not find a good reason why it was received late.

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   you were not/(he/she) was not

3. (3) 

   (month, year)

4. (4) 

   your/his/her

5. (5) 

   you/he/she

6. (6) 

   (month, day, year)

1632. Situation Where Used:

PE: We originally told the recipient that he was eligible to receive continued benefits while in a non-Medicaid facility. Now, we find he is not eligible to receive continued benefits for the same period of time.

Exhibit Letter

We are writing you to tell you that (1) not eligible to receive SSI benefits while (2) a patient in a medical facility, e.g., hospital, nursing home. Our records show that (3) entered this facility on (4).

Fill-ins:

1. (1) 

   you are/Name is

2. (2) 

   you are/(he/she) is

3. (3) 

   you/he/she

4. (4) 

   (month, day, year)

Payment Information

We understand that

• •

  (1) in a medical facility, run by the Federal, State, or local government, and

• •

  (2) lived there at least 1 full month, and

• •

  If (3) Medicaid, it did not pay for more than half the cost of (4) care, and

• •

  (5) eligible for SSI payments for the first three full months (6) in the facility.

We told (7) before that (8) eligible for SSI payments while (9) in a medical facility. However, now we find that (10) eligible while (11) in a medical facility for (12).

Fill-ins:

1. (1) 

   you were/(he/she) was

2. (2) 

   you/he/she

3. (3) 

   you had/(he/she) had

4. (4) 

   your/his/her

5. (5) 

   you were not/(he/she) was not

6. (6) 

   you were/(he/she) was

7. (7) 

   you/him/her

8. (8) 

   you were/(he/she) was

9. (9) 

   you were/(he/she) was

10. (10) 

    you were not/(he/she) was not

11. (11) 

    you were/(he/she) was

12. (12) 

    (month/year)/(month/year) and (month/year)/(month/year) through (month/year)

Basis of Our Decision

Optional Paragraph 1

(1) all of these requirements because (2) did not have expenses for (3) home which (4) must continue to pay.

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   you/him/her

3. (3) 

   your/his/her

4. (4) 

   you/he/she

Optional Paragraph 2

(1) all of these requirements because the proof about (2) home expenses was not received by (3).

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   your/his/her

3. (3) 

   (month, day, year)

Optional Paragraph 3

(1) all of these requirements because we did not receive the proof of how long (2) doctor expected (3) to stay in a medical facility by (4), and we could not find a good reason why it was received late.

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   your/his/her

3. (3) 

   you/him/her

4. (4) 

   (month, day, year)

Optional Paragraph 4

(1) all of these requirements because the proof of how long (2) doctor expected (3) to stay in a medical facility was not prepared and dated by (4).

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   your/his/her

3. (3) 

   you/him/her

4. (4) 

   (month, day, year)

Optional Paragraph 5

(1) all of these requirements because we did not receive the proof of how long (2) doctor expected (3) to stay in a medical facility by (4).

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   your/his/her

3. (3) 

   you/him/her

4. (4) 

   (month, day, year)

Optional Paragraph 6

(1) all of these requirements because (2) were not eligible for an SSI payment in (3).

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   you/him/her

3. (3) 

   (month, year)

Optional Paragraph 7

(1) all of these requirements because (2) in a medical facility.

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   you were not/(he/she) was not

Optional Paragraph 8

(1) all of these requirements because (2) did not have expenses for (3) home which (4) must continue to pay. Also, we did not receive the proof of how long (5) doctor expected (6) to stay in a medical facility by (7), and we could not find a good reason why it was received late.

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   you/he/she

3. (3) 

   your/his/her

4. (4) 

   you/he/she

5. (5) 

   your/his/her

6. (6) 

   you/him/her

7. (7) 

   (month, day, year)

Optional Paragraph 9

(1) all of these requirements because the proof about (2) home expenses was not received. Also, we did not receive the proof of how long (3) doctor expected (4) to stay in a medical facility by (5), and we could not find a good reason why it was received late.

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   your/his/her

3. (3) 

   your/his/her

4. (4) 

   you/him/her

5. (5) 

   (month, day, year)

Optional Paragraph 10

(1) all of these requirements because we did not receive postmarked by (2) the proof about (3) home expenses or of how long (4) doctor expected (5) to stay in a medical facility, and we could not find a good reason why it was received late.

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   (month, day, year)

3. (3) 

   your/his/her

4. (4) 

   your/his/her

5. (5) 

   you/him/her

Optional Paragraph 11

(1) all of these requirements because (2) doctor expected (3) to stay 91 days or more. Also, we did not receive the proof of how long (4) doctor expected (5) to stay in a medical facility by (6), and we could not find a good reason why it was received late.

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   your/his/her

3. (3) 

   you/him/her

4. (4) 

   your/his/her

5. (5) 

   you/him/her

6. (6) 

   (month, day, year)

Optional Paragraph 12

(1) all of these requirements because the proof of how long (2) doctor expected (3) to stay in a medical facility was not prepared and dated by (4). Also, we did not receive the proof of how long (5) doctor expected (6) to stay in a medical facility by (7), and we could not find a good reason why it was received late.

Fill-ins:

1. (1) 

   You do not meet/(He/She) does not meet

2. (2) 

   your/his/her

3. (3) 

   you/him/her

4. (4) 

   (month, day, year)

5. (5) 

   your/his/her

6. (6) 

   you/him/her

7. (7) 

   (month, day, year)

1633. Situation Where Used:

IC and PE: Both members of an eligible couple were entitled to continued benefits while in a Medicaid facility for the same period of time. Use this paragraph for retroactive situation where the couple has remained an eligible couple.

Exhibit Letter

We are writing you to tell you that you and your spouse were eligible to receive SSI benefits while you were patients in a medical facility, e.g., hospital, nursing home. Our records show that you and your spouse entered this facility on (1).

Fill-ins:

1. (1) 

   (month, day, year)

Payment Information

We usually reduce SSI payments for each full month that:

• •

  you and your spouse live in a hospital or other medical facility for a full month, and

• •

  Medicaid pays for or would usually pay for more than half the cost of care for both of you.

However, this rule does not apply to either of you for any of the first 3 full months that you and your spouse are patients if:

• •

  your doctors expect you and your spouse to stay in a medical facility for less than 91 days, and

• •

  you and your spouse have expenses for your home that you must continue to pay.

Your SSI payments are meant for your home expenses. You and your spouse do not have to pay this money to the medical facility.

This means that for (1) we did not reduce your payment and your spouse's payment because you were both in a medical facility.

Fill-ins:

1. (1) 

   (month, day, year)/(month/year) and (month/year)/(month/year) through (month/year)

1634. Situation Where Used:

IC and PE: Both members of an eligible couple were eligible to receive continued benefits while in a non-Medicaid facility for the same period of time. Use this paragraph for retroactive situations where the couple has remained an eligible couple.

Exhibit Letter

We are writing you to tell you that you and your spouse are eligible to receive SSI benefits while you are patients in a medical facility, e.g., hospital, nursing home. Our records show that you and your spouse entered this facility on (1).

Fill-ins:

1. (1) 

   (month, day, year)

Payment Information

We usually reduce SSI payments for each full month that:

• •

  you and your spouse live in a for a full month in a hospital or other medical facility that is run by the Federal, State, or local government, and

• •

  if you and your spouse have Medicaid, it does not pay for more than half the cost of care.

However, this rule does not apply to either of you for any of the first 3 full months that you and your spouse are patients if:

• •

  your doctors expect you and your spouse to stay in a medical facility for less than 91 days, and

• •

  you and your spouse have expenses for your home that you must continue to pay.

This means that for (1) we did not reduce your payment and your spouse's payment because you were both in a medical facility.

Fill-ins:

1. (1) 

   (month, day, year)/(month/year) and (month/year)/(month/year) through (month/year)

1629. Situation Where Used:

PE: We originally told the recipient he was not eligible to receive continued benefits while in a Medicaid facility. Now, we find he is eligible to receive continued benefits for the same period of time.

Exhibit Letter

We are writing you to tell you that (1) eligible to receive SSI benefits while (2) a patient in a medical facility, e.g., hospital, nursing home. Our records show that (3) entered this facility on (4).

Fill-ins:

1. (1) 

   you are/(he/she) is

2. (2) 

   you are/(he/she) is

3. (3) 

   you/he/she

4. (4) 

   (month, day, year)

Payment Information

We usually reduce SSI payments for each full month that:

• •

  a claimant is a patient in a hospital or other medical facility for a full month, and

• •

  Medicaid pays for or would usually pay for more than half the cost of his/her care.

However, this rule does not apply for any of the first 3 full months that (1) a patient if:

• •

  (2) doctor expects (3) to stay in a medical facility for less than 91 days, and

• •

  (4) expenses for (5) home that (6) must continue to pay.

We told (7) before that we were (8)(9) payment while (10) in a medical facility. However, now we find that we should not have (11) (12) payments while (13) in a medical facility for (14).

(15) SSI payments are meant for (16) home expenses. (17) to pay this money to the medical facility.

Fill-ins:

1. (1) 

   you are/(he/she) is

2. (2) 

   your/his/her

3. (3) 

   you/him/her

4. (4) 

   you have/(he/she) has

5. (5) 

   your/his/her

6. (6) 

   you/he/she

7. (7) 

   you/him/her

8. (8) 

   reducing/stopping

9. (9) 

   your/his/her

10. (10) 

    you were/(he/she) was

11. (11) 

    reduced/stopped

12. (12) 

    your/his/her

13. (13) 

    you were/(he/she) was

14. (14) 

    (month/year)/(month/year) and (month/year) (month/year) through (month/year)

15. (15) 

    Your/His/Her

16. (16) 

    your/his/her

17. (17) 

    You do not have/(He/She) does not have

Basis of Our Decision

Optional Paragraph 1

(1) all of these requirements because (2) had expenses for (3) home which (4) must continue to pay.

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   you/he/she

3. (3) 

   your/his/her

4. (4) 

   you/he/she

Optional Paragraph 2

(1) all of these requirements because we received the proof about (2) home expenses by (3).

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   your/his/her

3. (3) 

   (month, day, year)

Optional Paragraph 3

(1) all of these requirements because (2) doctor expected (3) to stay for less than 91 days.

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   your/his/her

3. (3) 

   you/him/her

Optional Paragraph 4

(1) all of these requirements because we did not receive the proof of how long (2) doctor expected (3) to stay in a medical facility by (4), but we found a good reason why it was received late.

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   your/his/her

3. (3) 

   you/him/her

4. (4) 

   (month, day, year)

Optional Paragraph 5

(1) all of these requirements because the proof of how long (2) doctor expected (3) to stay in a medical facility was prepared and dated by (4).

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   your/his/her

3. (3) 

   you/him/her

4. (4) 

   (month, day, year)

Optional Paragraph 6

(1) all of these requirements because we received the proof of how long (2) doctor expected (3) to stay in a medical facility by (4).

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   your/his/her

3. (3) 

   you/him/her

4. (4) 

   (month, day, year)

Optional Paragraph 7

(1) all of these requirements because (2) eligible for an SSI payment in (3).

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   you were/(he/she) was

3. (3) 

   (month, year)

Optional Paragraph 8

(1) all of these requirements because (2) in a medical facility.

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   you were/(he/she) was

Optional Paragraph 9

(1) all of these requirements because (2) had expenses for (3) home which (4) had to continue to pay. Also, we did not receive the proof of how long (5) doctor expected (6) to stay in a medical facility by (7), but we found a good reason why it was received late.

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   you/he/she

3. (3) 

   your/his/her

4. (4) 

   you/he/she

5. (5) 

   your/his/her

6. (6) 

   you/him/her

7. (7) 

   (month, day, year)

Optional Paragraph 10

(1) all of these requirements because we received the proof about (2) home expenses. Also, the proof of how long (3) doctor expected (4) to stay in a medical facility was not received by (5), but we found a good reason why it was received late.

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   you/he/she

3. (3) 

   your/his/her

4. (4) 

   you/him/her

5. (5) 

   (month, day, year)

Optional Paragraph 11

(1) all of these requirements because we received the proof about (2) home expenses on time. Also, we did not receive the proof of how long (3) doctor expected (4) to stay in a medical facility by (5), but we found a good reason why it was received late.

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   your/his/her

3. (3) 

   your/his/her

4. (4) 

   you/him/her

5. (5) 

   (month, day, year)

Optional Paragraph 12

(1) all of these requirements because (2) doctor expected (3) to stay for less than 91 days. Also, we did not receive the proof of how long (4) doctor expected (5) to stay in a medical facility by (6), but we found a good reason why it was received late.

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   your/his/her

3. (3) 

   you/him/her

4. (4) 

   your/his/her

5. (5) 

   you/him/her

6. (6) 

   (month, day, year)

Optional Paragraph 13

(1) all of these requirements because the proof about (2) home expenses was prepared and dated by (3). Also, we did not receive the proof of how long (4) doctor expected (5) to stay in a medical facility by (6), but we found a good reason why it was received late.

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   your/his/her

3. (3) 

   (month, day, year)

4. (4) 

   your/his/her

5. (5) 

   you/him/her

6. (6) 

   (month, day, year)

Optional Paragraph 14

(1) all of these requirements because (2) eligible for an SSI payment in (3). Also, we did not receive the proof of how long (4) doctor expected (5) to stay in a medical facility by (6), but we found a good reason why it was received late.

Fill-ins:

1. (1) 

   You meet/(He/She) meets

2. (2) 

   you were/(he/she) was

3. (3) 

   (month, year)

4. (4) 

   your/his/her

5. (5) 

   you/him/her

6. (6) 

   (month, day, year)