SI 01730.050 Exhibits, Assignment of Rights and Third Party Liability

A.	Exhibit 1	Summary of AOR and TPL Procedures For Initial Claims (Applies only in States for which SSA makes Medicaid Eligibility Determinations)
B.	Exhibit 2	Summary of TPL Procedures For Redeterminations (Applies only in States for which SSA makes Medicaid Eligibility Determinations)
C.	Exhibit 3	Form SSA-169, Assignment of Rights Statement
D.	Exhibit 4	Form SSA-8019, Third Party Liability Information Statement
E.	Exhibit 5	Types of Insurance - (Examples)
F.	Exhibit 6	List of States for Which SSA Determines and Redetermines Medicaid Eligibility (34, Including the District of Columbia)

A. Exhibit 1

Summary of AOR and TPL Procedures For Initial Claims (Applies only in States for which SSA makes Medicaid Eligibility Determinations)

To view this form, go to SSA-169.

To view this form, go to SSA-8019.

	AGED-BLIND- DISABLED ADULTS		BLIND-DISABLED MINOR CHILDREN
TYPE OF INSURANCE	RECIPIENT	SPOUSE	PARENT	STEP-PARENT
INSURANCE HOLDER EMPLOYMENT-RELATED HEALTH INSURANCE	X	X	X	X
TRICARE*	X	X	X	X
VETERAN'S ADMINISTRATION	X
MEDICARE SUPPLEMENTAL POLICIES**	X
PRIVATELY PURCHASED INSURANCE	X	X	X	X

* Civilian Health and medical Plan of the Uniformed Services

** Private insurance that pays Medicare deductibles and insurance

SI 01730.050 - Exhibits, Assignment of Rights and Third Party Liability - 12/09/2016
Batch run: 09/06/2019
Rev:12/09/2016