Identification Number:
SI 00604 TN 21
Intended Audience:See Transmittal Sheet
Originating Office:ORDP OISP
Title:Completion of Form SSA-8000-BK, Application for Supplemental Security Income
Type:POMS Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part SI – Supplemental Security Income
Chapter 006 – The SSI Application Process
Subchapter 04 – Completion of Form SSA-8000-BK, Application for Supplemental Security Income
Transmittal No. 21, 05/11/2020

Audience

OCO-OEIO: CR, FCR, FDE, RECONE;
OCO-ODO: CR, CST, CTE, CTE TE;
FO/TSC: CS, CS TXVI, CSR, CTE, DRT, FR, OA, TA, TSC-CSR;

Originating Component

OISP

Effective Date

Upon Receipt

Background

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

Section D

  • 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.

SI 00604.097 Medical Assistance: Question 59

A. Introduction

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.

B. When to explain question 59

Explain the statement to all claimants residing in States for which we make Medicaid eligibility determinations, including states with automatic assignment of rights laws.

C. When to complete question 59(a)

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.

D. When to complete question 59(b)

When the claimant answers (a) "YES" or resides in a state with automatic assignment of rights laws, complete (b).

E. When to complete question 59(c)

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.

F. Documentation

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.

G. References

  • 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


SI 00604 TN 21 - Completion of Form SSA-8000-BK, Application for Supplemental Security Income - 5/11/2020