When an SSI recipient moves from another State with intent to reside in Arkansas,
Medicaid eligibility resulting from SSI payment or Section 1619(b) is effective the
month after the month of move to Arkansas (SI 01410.030F.).
Arkansas DHS Certification for Medicaid
Eligibility Exhibit 1
TO:Arkansas Department of Human Services Date:___________________
Division of County Operations
P. O. Box 1437, Slot S340 Attn: Client
Asst. Unit
Little Rock, Arkansas 72203
I.This individual is eligible for SSI and Medicaid. SSA is unable to establish a record
or to provide complete information on the SDX. Please issue a Medicaid card for the
period of eligibility indicated below.
1. Reason: (check one) __ Systems Limitation __ Medical Emergency
__ Closed/Intervening Period Certification
of Eligibility or Death
2. Type of Recipient:(circle one) AI AS BI BS DI DS DC
3. Social Security Number: ________________ 4. DOB: _____________
5. Name of Recipient: _______________________________________________
6. Mailing Address ________________________________________
Including Repre. ________________________________________
Payee & Zip Code: ________________________________________
7. State/County Code: _________ 8. Living Arrangement Code: ________
County of Residence: ________________________
9. Mo/Day/Year of SSI Application: _____________ 10. Sex: __________
11. First Month/Year of SSI in Arkansas: _______________________
12. Title II/Medicare Claim #: _____________ 13. DOD: _____________
14. TPL Code: _______ 15. Transf. RE? ______ 16. Medicaid Trust? ____
17. Enter an "E" only for months of SSI payments while in Arkansas:
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18. Remarks: ______________________________________________
________________________________________________________
II. SSA previously submitted a manual Medicaid certification for the individual and
SSN. This individual is no longer eligible for SSI effective: _______. Reason: ____________________________
_________________________________________________
III.Social Security Administration ______________________________________
______________________________ (CR Print Name)
______________________________ Phone #: _____________________
______________________________ ______________________________________
(Emerg. Cert.
Auth.-OS/MSS or above)
SS-RVI-304 (12/02)
Exhibit 2
TITLE II COLA/DAC/WIDOW(ER) MEDICAID EXTENSION REFERRAL LETTER
To:Arkansas Department of Human Services Date:__________
Division of County Operations
Attn: Jack Tiner
P. O. Box 1437, Slot S333
Little Rock, Arkansas 72203
(check 1. or 2.)
1.The following individual was last eligible for Supplemental Security Income (SSI)
in ________, 20___, but became ineligible for payment effective with ____________, 20____*
because of a title II cost-of-living adjustment (COLA) increase paid to the eligible
person or their spouse. The person may now be a candidate for preservation of Medicaid
eligibility under the provision of:
(check one)
_____ Section 503 (Pickle) of Public Law 94-566, or
_____ Lynch v. Rank court decree.
2.The following individual was eligible for SSI in __________, 20___, but became ineligible
in __________, 20___ because of entitlement to or an increase in:
(check one) _______ DAC or ________ widow(er) benefits.
Name and Address _______________________________________
(Including _______________________________________
Representative _______________________________________
Payee) _______________________________________
County of Residence ____________________________________
Social Security Number __________________________________
Title II Claim Number ___________________________________
Gross Title II Payment Prior to COLA ______________________
(if applicable)
Current Gross Title II Payment _______________________________
Other Current Month Income (if any) __________________________
* If there is a break in entitlement between these two dates, show the months of ineligibility
and payment status code for each month: ________________________________________
From: Social Security Administration _________________________
______________________________ _ Area Code/Telephone
______________________________ ________________________
Print Name
of SSA Employee
Revised 12/02