PROGRAM OPERATIONS MANUAL SYSTEMPart SI – Supplemental Security IncomeChapter 006 – The SSI Application ProcessSubchapter 04 – Completion of Form SSA-8000-BK, Application for Supplemental Security IncomeTransmittal No. 21, 05/11/2020
This is a Quick Action Transmittal. These revisions do not change or introduce new policy or procedure.
Summary of Changes
SI 00604.097 Medical Assistance: Question 59
We removed the obsoleted link to the BTPL screen in MSSICS, MSOM MSSICS
019.014, and the BHLT screen in MSSICS, MSOM MSSICS 019.012. We replaced the obsoleted references with a link to the Health Expenses & Third Party Liability screen in the SSI Claims System, MS 08119.020.
These questions satisfy Medicaid eligibility requirements where the SSA-8000-BK (Application for Supplemental Security Income) is an application for Medicaid. The claimant must agree to assign his or her rights to third party payments for services covered under the State Medicaid plan and provide third party information.
Explain the statement to all claimants residing in States for which we make Medicaid eligibility determinations, including states with automatic assignment of rights laws.
For all claimants residing in states for which we make Medicaid eligibility determinations, complete 59(a), e xcept in states with automatic assignment of rights laws. Consult regional instructions to determine which states have these laws.
NOTE: Although a "NO" response to (a) eliminates the need to answer (b) and (c), explain that refusal to assign their rights will not affect their entitlement to Medicare, Social Security, or eligibility to Supplemental Security Income (SSI), but will probably result in a Medicaid denial as described in SI 01730.040F.1.
When the claimant answers (a) "YES" or resides in a state with automatic assignment of rights laws, complete (b).
Consult regional instructions to determine in which States to ask question 59(c). For these states, complete question (c) when the claimant answers:
(a) "YES" or in automatic assignment of rights states; and
(b) (regardless of response).
NOTE: We send the answers to 59(a), (b), and (c) to the state via the SDX and serve as the basis for us to bill the Centers for Medicare and Medicaid Services.
I f the claimant answers
5 9 (b) "YES," complete SSA-8019 (Third Party Liability Information Statement). For more information on third party liability for Medicaid eligibility, see SI 01730.045.
SI 01715.020 List of State Medicaid Programs for the Aged, Blind and Disabled
SI 01730.040 Assignment of Rights for Medicaid Eligibility
SI 01730.045 Third Party Liability for Medicaid Eligibility
SI 01730.010 Determinations of Medicaid Eligibility
SI 00604.130 Filing for Medicaid Based on SSI
MS 08119.020, Health Expenses & Third Party Liability