TN 31 (07-11)
NL 00804.167 Exhibits of Notice Language in $30 Limit Situations
This section provides notice language for situations where the $30 payment limit applies.
For the policy on when the $30 payment limit applies, please see SI 00520.011.
NOTE: If you are sending a notice to a claimant, beneficiary, or representative payee who
alleges blindness or being visually impaired follow the special notice procedures
in NL 01001.010.
PICM01
When used: This paragraph explains the change in the law effective 12/96 for children whose payment
changes because of that provision.
New rules for children in medical facilities
Beginning December 1996, a new law changed the Supplemental Security Income (SSI)
rules for some children. Under this law, SSI payments for children under age 18 are
(1) for each month that:
-
•
a child lives in a hospital or other medical facility for the full month, and
-
•
Medicaid pays for, or would usually pay for, more than half the cost of the care,
or
-
•
private health insurance or a combination of Medicaid and private health insurance
pays for more than half the cost of the care.
(2) (3) because of these new rules (4).
Fill-ins:
1. Choice 1: reduced (going from pay status)
Choice 2: changed (going from nonpay status)
2. Choice 1: (child's name—possessive) SSI payment is/was
Choice 2: (child's name—possessive) SSI payments are/were
Choice 3: Your SSI payment is/was
Choice 4: Your SSI payments are/were
3. Choice 1: reduced
Choice 2: stopped
Choice 3: changed
4. Choice 1: and your income
Choice 2: and her income
Choice 3: and his income
Choice 4: Null
PICM02
When used: This paragraph is used with paragraph PICM01 to explain the change in law. This paragraph
specifically shows the facts on our record.
Our records show that:
-
-
•
(3) in a medical facility, and
-
•
private health insurance or Medicaid or both pay for more than half the cost of (4) care.
Fill-ins:
1. Choice 1: you are
Choice 2: she is
Choice 3: he is
2. age of recipient
3. Choice 1: you live
Choice 2: she lives
Choice 3: he lives
4. Choice 1: your
Choice 2: her
Choice 3: his
PICM03
When used: A child under age 18 is eligible for TI benefits.
Based on the facts we have, (1) entered a medical facility in (2). Usually, SSI payments are reduced for each month that (3) a child under age 18, if:
-
•
(4) 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 (5) care, or
-
•
private health insurance or a combination of Medicaid and private health insurance
pays for more than half the cost of (6) care.
However, this rule does not apply for any of the first 3 full months that (7) a patient in a medical facility if:
-
•
(8) doctor expects (9) to stay in a medical facility for less than 91 days, and
-
•
(10) expenses for (11) home that (12) must continue to pay.
This means that (13) .
(14) SSI payments are meant for (15) home expenses. (16) to pay this money to the medical facility.
(17)
Fill-ins:
1. Choice 1: you
Choice 2: she
Choice 3: he
2. Month/Year
3. Choice 1: you are
Choice 2: she is
Choice 3: he is
4. Choice 1: you live
Choice 2: she lives
Choice 3: he lives
5. Choice 1: your
Choice 2: her
Choice 3: his
6. Choice 1: your
Choice 2: her
Choice 3: his
7. Choice 1: you are
Choice 2: she is
Choice 3: he is
8. Choice 1: your
Choice 2: her
Choice 3: his
9. Choice 1: you
Choice 2: her
Choice 3: him
10. Choice 1: you have
Choice 2: she has
Choice 3: he has
11. Choice 1: your
Choice 2: her
Choice 3: his
12. Choice 1: you
Choice 2: she
Choice 3: he
13. Choice 1: beginning (month/year), we are not reducing your payment because you
are in a medical facility.
Choice 2: beginning (month/year), we are not reducing her payment because she is in
a medical facility.
Choice 3: beginning (month/year), we are not reducing his payment because he is in
a medical facility.
Choice 4: for (month/year) we did not reduce your payment because you were in a medical
facility.
Choice 5: for (month/year) and (month/year) we did not reduce your payment because
you were in a medical facility.
Choice 6: for (month/year) through (month/year) we did not reduce your payment because
you were in a medical facility.
Choice 7: for (month/year), we did not reduce her payment because she was in a medical
facility.
Choice 8: for (month/year) and (month/year) we did not reduce her payment because
she was in a medical facility.
Choice 9: for (month/year) through (month/year) we did not reduce her payment because
she was in a medical facility.
Choice 10: for (month/year), we did not reduce his payment because he was in a medical
facility.
Choice 11: for (month/year) and (month/year) we did not reduce his payment because
he was in a medical facility.
Choice 12: for (month/year) through (month/year) we did not reduce his payment because
he was in a medical facility.
14. Choice 1: Your
Choice 2: Her
Choice 3: His
15. Choice 1: your
Choice 2: her
Choice 3: his
16. Choice 1: You do not have
Choice 2: She does not have
Choice 3: He does not have
17. Choice 1: Please tell us as soon as you know when you will be leaving the medical
facility, so we can continue to pay you correctly.
Choice 2: Please tell us as soon as you know when she will be leaving the medical
facility, so we can continue to pay her correctly.
Choice 3: Please tell us as soon as you know when he will be leaving the medical facility,
so we can continue to pay him correctly.
Choice 4: Null
PICM04
When used: A child under age 18 is not eligible for TI benefits, but is eligible for the $30
reduced benefit.
Based on the facts we have, (1) entered a medical facility in (2) . Our records show that (3) in this facility for (4). Usually, SSI payments are reduced for each month that (5) a child under age 18 if:
-
•
(6) 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 (7) care, or
-
•
private health insurance or a combination of Medicaid and private health insurance
pays for more than half the cost of (8) care.
(9) could be eligible for continued payments for any of the first 3 full months that
(10) a patient in a medical facility if:
-
•
we would have reduced (11) SSI payments for any of these months, and
-
•
(12) eligible for an SSI payment in the month before we would have reduced (13) SSI payment, and
-
•
(14) us proof that (15) home expenses that (16) to continue to pay, and
-
•
we have proof that (17) doctor expects (18) to stay in a medical facility for less than 91 days.
The proofs must be received or postmarked by the 90th day of (19) stay in the medical facility or the day of (20) release, if earlier.
(21) all of these requirements because (22).
Fill-ins:
1. Choice 1: you
Choice 2: she
Choice 3: he
2. month/year
3. Choice 1: you will be
Choice 2: she will be
Choice 3: he will be
Choice 4: you were
Choice 5: she was
Choice 6: he was
4. Choice 1: the full month of (month/year)
Choice 2: each full month (month/year) through (month/year)
Choice 3: each full month (month/ year) on
5. Choice 1: you are
Choice 2: she is
Choice 3: he is
6. Choice 1: you live
Choice 2: she lives
Choice 3: he lives
7. Choice 1: your
Choice 2: her
Choice 3: his
8. Choice 1: your
Choice 2: her
Choice 3: his
9. Choice 1: You
Choice 2: She
Choice 3: He
10. Choice 1: you are
Choice 2: she is
Choice 3: he is
11. Choice 1: your
Choice 2: her
Choice 3: his
12. Choice 1: you are
Choice 2: she is
Choice 3: he is
13. Choice 1: your
Choice 2: her
Choice 3: his
14. Choice 1: you give
Choice 2: she gives
Choice 3: he gives
15. Choice 1: you have
Choice 2: she has
Choice 3: he has
16. Choice 1: you have
Choice 2: she has
Choice 3: he has
17. Choice 1: your
Choice 2: her
Choice 3: his
18. Choice 1: you
Choice 2: her
Choice 3: him
19. Choice 1: your
Choice 2: her
Choice 3: his
20. Choice 1: your
Choice 2: her
Choice 3: his
21. Choice 1: You do not meet
Choice 2: She does not meet
Choice 3: He does not meet
22. Choice 1: you do not have expenses for your home which you must continue to pay
Choice 2: she does not have expenses for her home which she must continue to pay
Choice 3: he does not have expenses for his home which he must continue to pay
Choice 4: the proof about your home expenses was not received
Choice 5: the proof about her home expenses was not received
Choice 6: the proof about his home expenses was not received
Choice 7: the proof about your home expenses was not received or postmarked by (month/day/year)
Choice 8: the proof about her home expenses was not received or postmarked by (month/day/year)
Choice 9: the proof about his home expenses was not received or postmarked by (month/day/year)
Choice 10: your doctor expects you to stay 91 days or more
Choice 11: her doctor expects her to stay 91 days or more
Choice 12: his doctor expects him to stay 91 days or more
Choice 13: the proof of how long your doctor expects you to stay in a medical facility
was not received or postmarked by (month/year)
Choice 14: the proof of how long her doctor expects her to stay in a medical facility
was not received or postmarked by (month/year)
Choice 15: the proof of how long his doctor expects him to stay in a medical facility
was not received or postmarked by (month/year)
Choice 16: the proof of how long your doctor expects you to stay in a medical facility
was not received
Choice 17: the proof of how long her doctor expects her to stay in a medical facility
was not received
Choice 18: the proof of how long his doctor expects him to stay in a medical facility
was not received
Choice 19: you were not eligible for an SSI payment in (month/year)
Choice 20: she was not eligible for an SSI payment in (month/year)
Choice 21: he was not eligible for an SSI payment in (month/year)
Choice 22: you do not have expenses for your home which you must continue to pay.
Also, the proof of how long your doctor expects you to stay in a medical facility
was not received or postmarked by (month/day/year)
Choice 23: she does not have expenses for her home which she must continue to pay.
Also, the proof of how long her doctor expects her to stay in a medical facility was
not received or postmarked by (month/day/year)
Choice 24: he does not have expenses for his home which he must continue to pay. Also,
the proof of how long his doctor expects him to stay in a medical facility was not
received or postmarked by (month/day/year)
Choice 25: the proof about your home expenses was not received. Also, the proof of
how long your doctor expects you to stay in a medical facility was not received or
postmarked by (month/day/year)
Choice 26: the proof about her home expenses was not received. Also, the proof of
how long her doctor expects her to stay in a medical facility was not received or
postmarked by (month/day/year)
Choice 27: the proof about his home expenses was not received. Also, the proof of
how long his doctor expects him to stay in a medical facility was not received or
postmarked by (month/day/year)
Choice 28: the proof about your home expenses was not received or postmarked by (month/day/year).
Also, the proof of how long your doctor expects you to stay in a medical facility
was not received or postmarked by (month/day/year)
Choice 29: the proof about her home expenses was not received or postmarked by (month/day/year).
Also, the proof of how long her doctor expects her to stay in a medical facility was
not received or postmarked by (month/day/year)
Choice 30: the proof about his home expenses was not received or postmarked by (month/day/year).
Also, the proof of how long his doctor expects him to stay in a medical facility was
not received or postmarked by (month/day/year)
Choice 31: your doctor expects you to stay 91 days or more and the proof of how long
your doctor expects you to stay in a medical facility was not received or postmarked
by (month/day/year)
Choice 32: her doctor expects her to stay 91 days or more and the proof of how long
her doctor expects her to stay in a medical facility was not received or postmarked
by (month/day/year)
Choice 33: his doctor expects him to stay 91 days or more and the proof of how long
his doctor expects him to stay in a medical facility was not received or postmarked
by (month/day/year)
Choice 34: you were not eligible for an SSI payment in (month/year). Also, the proof
of how long your doctor expects you to stay in a medical facility was not received
or postmarked by (month/day/year)
Choice 35: she was not eligible for an SSI payment in (month/year). Also, the proof
of how long her doctor expects her to stay in a medical facility was not received
or postmarked by (month/day/year)
Choice 36: he was not eligible for an SSI payment in (month/year). Also, the proof
of how long his doctor expects him to stay in a medical facility was not received
or postmarked by (month/day/year)
Choice 37: we did not reduce your SSI payment for all of the first 3 full months you
were a patient. We can pay continued payments only for those first 3 months.
Choice 38: we did not reduce her SSI payment for all of the first 3 full months she
was a patient. We can pay continued payments only for those first 3 months.
Choice 39: we did not reduce his SSI payment for all of the first 3 full months he
was a patient. We can pay continued payments only for those first 3 months.
PICM05
When used: A child under age 18 is in a public facility and is not eligible for TI benefits or
for the $30 reduced benefit.
Based on the facts we have, (1) entered a public (2) facility in (3). Our records show that (4) in this facility for (5). Usually, SSI payments are stopped for each month that (6) a child under age 18 if:
-
•
(7) in a hospital or other medical facility for a full month, and
-
•
Medicaid, private health insurance, or a combination of Medicaid and private health
insurance does not pay for more than half the cost of (8) care.
(9) could be eligible for continued payments for any of the first 3 full months that
(10) a patient in a medical facility if:
-
•
we would have stopped (11) SSI payments for any of these months, and
-
•
(12) eligible for an SSI payment in the month before we would have stopped (13) SSI payment, and
-
•
(14) us proof that (15) home expenses that (16) to continue to pay, and
-
•
we have proof that (17) doctor expects (18) to stay in a medical facility for less than 91 days.
The proofs must be received or postmarked by the 90th day of (19) stay in the (20) facility or the day of (21) release, if earlier. (22) all of these requirements because (23).
Fill-ins:
1. Choice 1: you
Choice 2: she
Choice 3: he
2. Choice 1: medical
Choice 2: null
3. month/year
4. Choice 1: you will be
Choice 2: she will be
Choice 3: he will be
Choice 4: you were
Choice 5: she was
Choice 6: he was
5. Choice 1: the full month of (month/year)
Choice 2: each full month (month/year) through (month/year)
Choice 3: each full month (month/ year) on
6. Choice 1: you are
Choice 2: she is
Choice 3: he is
7. Choice 1: you live
Choice 2: she lives
Choice 3: he lives
8. Choice 1: your
Choice 2: her
Choice 3: his
9. Choice 1: You
Choice 2: She
Choice 3: He
10. Choice 1: you are
Choice 2: she is
Choice 3: he is
11. Choice 1: your
Choice 2: her
Choice 3: his
12. Choice 1: you are
Choice 2: she is
Choice 3: he is
13. Choice 1: your
Choice 2: her
Choice 3: his
14. Choice 1: you give
Choice 2: she gives
Choice 3: he gives
15. Choice 1: you have
Choice 2: she has
Choice 3: he has
16. Choice 1: you have
Choice 2: she has
Choice 3: he has
17. Choice 1: your
Choice 2: her
Choice 3: his
18. Choice 1: you
Choice 2: her
Choice 3: him
19. Choice 1: your
Choice 2: her
Choice 3: his
20. Choice 1: medical
Choice 2: null
21. Choice 1: your
Choice 2: her
Choice 3: his
22. Choice 1: You do not meet
Choice 2: She does not meet
Choice 3: He does not meet
23. Choice 1: you do not have expenses for your home which you must continue to pay
Choice 2: she does not have expenses for her home which she must continue to pay
Choice 3: he does not have expenses for his home which he must continue to pay
Choice 4: the proof about your home expenses was not received
Choice 5: the proof about her home expenses was not received
Choice 6: the proof about his home expenses was not received
Choice 7: the proof about your home expenses was not received or postmarked by (month/day/year)
Choice 8: the proof about her home expenses was not received or postmarked by (month/day/year)
Choice 9: the proof about his home expenses was not received or postmarked by (month/day/year)
Choice 10: your doctor expects you to stay 91 days or more
Choice 11: her doctor expects her to stay 91 days or more
Choice 12: his doctor expects him to stay 91 days or more
Choice 13: the proof of how long your doctor expects you to stay in a medical facility
was not received or postmarked by (month/year)
Choice 14: the proof of how long her doctor expects her to stay in a medical facility
was not received or postmarked by (month/year)
Choice 15: the proof of how long his doctor expects him to stay in a medical facility
was not received or postmarked by (month/year)
Choice 16: the proof of how long your doctor expects you to stay in a medical facility
was not received
Choice 17: the proof of how long her doctor expects her to stay in a medical facility
was not received
Choice 18: the proof of how long his doctor expects him to stay in a medical facility
was not received
Choice 19: you were not eligible for an SSI payment in (month/year)
Choice 20: she was not eligible for an SSI payment in (month/year)
Choice 21: he was not eligible for an SSI payment in (month/year)
Choice 22: you are not in a medical facility
Choice 23: she is not in a medical facility
Choice 24: he is not in a medical facility
Choice 25: you were not in a medical facility
Choice 26: she was not in a medical facility
Choice 27: he was not in a medical facility
Choice 28: you do not have expenses for your home which you must continue to pay.
Also, the proof of how long your doctor expects you to stay in a medical facility
was not received or postmarked by (month/day/year)
Choice 29: she does not have expenses for her home which she must continue to pay.
Also, the proof of how long her doctor expects her to stay in a medical facility was
not received or postmarked by (month/day/year)
Choice 30: he does not have expenses for his home which he must continue to pay. Also,
the proof of how long his doctor expects him to stay in a medical facility was not
received or postmarked by (month/day/year)
Choice 31: the proof about your home expenses was not received. Also, the proof of
how long your doctor expects you to stay in a medical facility was not received or
postmarked by (month/day/year)
Choice 32: the proof about her home expenses was not received. Also, the proof of
how long her doctor expects her to stay in a medical facility was not received or
postmarked by (month/day/year)
Choice 33: the proof about his home expenses was not received. Also, the proof of
how long his doctor expects him to stay in a medical facility was not received or
postmarked by (month/day/year)
Choice 34: the proof about your home expenses was not received or postmarked by (month/day/year).
Also, the proof of how long your doctor expects you to stay in a medical facility
was not received or postmarked by (month/day/year)
Choice 35: the proof about her home expenses was not received or postmarked by (month/day/year).
Also, the proof of how long her doctor expects her to stay in a medical facility was
not received or postmarked by (month/day/year)
Choice 36: the proof about his home expenses was not received or postmarked by (month/day/year).
Also, the proof of how long his doctor expects him to stay in a medical facility was
not received or postmarked by (month/day/year)
Choice 37: your doctor expects you to stay 91 days or more and the proof of how long
your doctor expects you to stay in a medical facility was not received or postmarked
by (month/day/year)
Choice 38: her doctor expects her to stay 91 days or more and the proof of how long
her doctor expects her to stay in a medical facility was not received or postmarked
by (month/day/year)
Choice 39: his doctor expects him to stay 91 days or more and the proof of how long
his doctor expects him to stay in a medical facility was not received or postmarked
by (month/day/year)
Choice 40: you were not eligible for an SSI payment in (month/year). Also, the proof
of how long your doctor expects you to stay in a medical facility was not received
or postmarked by (month/day/year)
Choice 41: she was not eligible for an SSI payment in (month/year). Also, the proof
of how long her doctor expects her to stay in a medical facility was not received
or postmarked by (month/day/year)
Choice 42: he was not eligible for an SSI payment in (month/year). Also, the proof
of how long his doctor expects him to stay in a medical facility was not received
or postmarked by (month/day/year)
Choice 43: we did not reduce your SSI payment for all of the first 3 full months you
were a patient. We can pay continued payments only for those first 3 months.
Choice 44: we did not reduce her SSI payment for all of the first 3 full months she
was a patient. We can pay continued payments only for those first 3 months.
Choice 45: we did not reduce his SSI payment for all of the first 3 full months he
was a patient. We can pay continued payments only for those first 3 months.
PICM06
When used: This paragraph is used with PICM07 to explain that the recipient with private health
insurance is no longer eligible for the $30 reduced benefit, because he or she attained
age 18 and is living in a public institution where Medicaid does not pay over 50 percent
of the cost of care.
We cannot pay (1) any SSI beginning (2) because (3) age 18 or older, (4) in a public institution, and Medicaid does not pay for more than half the cost of
(5) care.
Fill-ins:
1. Choice 1: you
Choice 2: her
Choice 3: him
2. Month/Year
3. Choice 1: you are
Choice 2: she is
Choice 3: he is
4. Choice 1: live
Choice 2: lives
5. Choice 1: your
Choice 2: her
Choice 3: his
PICM07
When used: This paragraph is used to give the facts that show the recipient is no longer eligible
for the $30 reduced benefit because he or she attained age 18.
Our records show:
-
•
(1) became age 18 on (2),
-
•
(3) in a (4) for (5), and
-
•
Medicaid (6) not pay for more than half the cost of (7) care.
Fill-ins:
1. Choice 1: you
Choice 2: she
Choice 3: he
2. Month/Day/Year
3. Choice 1: you live
Choice 2: she lives
Choice 3: he lives
Choice 4: you lived
Choice 5: she lived
Choice 6: he lived
4. Choice 1: medical facility
Choice 2: public institution
5. Choice 1: Month/Year on
Choice 2: Month/Year
Choice 3: Month /Year through Month/Year
6. Choice 1: does
Choice 2: did
7. Choice 1: your
Choice 2: her
Choice 3: his
PICM08
When used: This paragraph is used to explain that we either will not begin or will stop withholding
money to recover an overpayment because the recipient's payment is subject to the
$30 limit.
(1) (2) in an institution where:
Medicaid pays for, or would usually pay for, more than half the cost of (3) care, or
private health insurance or a combination of Medicaid and private health insurance
pays for more than half the cost of (4) care, we will not withhold money to get back money overpaid.
Fill-ins:
1. Choice 1: While (Use when we will not begin withholding an overpayment.)
Choice 2: You/She/He will get an SSI check for (money amount) about the first day
of the month beginning (Month/Year). We were withholding money from your/her/his check
to get back money you were/he was/she was overpaid. Now, while, (Use when we will
stop withholding an overpayment.)
2. Choice 1: you are
Choice 2: she is
Choice 3: he is
3. Choice 1: your
Choice 2: her
Choice 3: his
4. Choice 1: your
Choice 2: her
Choice 3: his
PICM09
When used: This paragraph is used to explain that we will not withhold money to recover an overpayment
because the recipient's payment is subject to the $30 limit.
We will not reduce (1) SSI check
Usually when a person is getting an SSI check, we withhold money from the check to
repay an overpayment. But we will not do this while (2)
AND
-
•
Medicaid is paying for, or would usually pay for, more than half the cost of (3) care, or
-
•
private health insurance or Medicaid or both is paying for more than half the cost
of (4) care.
If any of the above things change, and (5) still (6) an overpayment, we will send you a notice about withholding money from (7) SSI check.
Fill-ins:
1. Choice 1: Your
Choice 2: Her
Choice 3: His
2. Choice 1: you are
Choice 2: she is
Choice 3: he is
3. Choice 1: your
Choice 2: her
Choice 3: his
4. Choice 1: your
Choice 2: her
Choice 3: his
5. Choice 1: you
Choice 2: she
Choice 3: he
6. Choice 1: have
Choice 2: has
7. Choice 1: your
Choice 2: her
Choice 3: his
PICM10
When used: This paragraph is used to explain why the recipient is overpaid.
(1) could not get more than $30 while:
-
•
(2) in a medical care facility, like a hospital or a nursing home, for a full month,
and
-
•
Medicaid paid for, or would usually pay for, more than half the cost of (3) care, or
-
•
private health insurance or Medicaid or both paid for more than half the cost of (4) care.
Also, if there was income on (5) record other than SSI, (6) might get less than $30. As a result, (7) overpaid for (8).
Fill-ins:
1. Choice 1: You
Choice 2: She
Choice 3: He
2. Choice 1: You were
Choice 2: She was
Choice 3: He was
3. Choice 1: your
Choice 2: her
Choice 3: his
4. Choice 1: your
Choice 2: her
Choice 3: his
5. Choice 1: your
Choice 2: her
Choice 3: his
6. Choice 1: you
Choice 2: she
Choice 3: he
7. Choice 1: you were
Choice 2: she was
Choice 3: he was
8. Choice 1: Month/Year
Choice 2: Month/Year through Month/Year
(Repeat choices for fill-in 8 as often as needed to cover overpayment periods.)
References
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SI 00520.012, Payment Limit Due to Medicaid Transfer of Resources penalty,
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•
SI 00520.130, Special Benefits for Institutionalized 1619 Eligibles
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•
SM 01301.785, Case Related Data (CG)
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SM 01301.675, Notice Suppression
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SM 01305.515, Notice Suppression for a SSA-L8155