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. __________________________________________________________________________________________________________
Signature of State Agency Employee ______________________________________________
Title ___________________________Telephone Number ____________