When an SSI recipient moves from another State with intent to reside in New Mexico,
Medicaid eligibility resulting from SSI payment or Section 1619(b) is effective the
month after the month of move to New Mexico (SI 01410.030F).
Exhibit 1
New Mexico HSD Certification for Medicaid Eligibility
TO: New Mexico Human Services Department Date:___________________
Medical Assistance Division
P. O. Box 2348 Attn: SSI Coordinator
Santa Fe, New Mexico 87504-2348
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 __ Emergency __ Closed/Intervening
Period ___ Certification of Eligibility or Death
2. Type of Recipient (circle one): Aged(01) Blind(03) Disabled(04)
3. Social Security Number: _______________ 4. DOB: _______________
5. Name of Recipient: ___________________________
6. Mailing Address __________________________
Including Representative ______________________
Payee & Zip Code: ______________________
7. State/County Code: _______________ 8. Living Arrangement Code: ________________
9. First Month/Year of SSI Paymentin New
Mexico: ____________________
10. Title II/Medicare Claim #: _________________ 11. Sex: ________
12. Mo/Day/Year of SSI Application: _____ 13. DOD: ____ Underpayment paid?
Yes or No
14. TPL Code: ____ 15. Transfer RE? _______ 16. Medicaid Trust? ___________
17. If closed/intervening period of eligibility or death, show all months of SSI eligibility:
_________________
18. If the individual is not currently eligible for SSI, give reason for suspension
or termination and the effective date of non-pay: _____________________________________________________
19. Remarks: ________________________________________________________________
II. SSA previously submitted a manual Medicaid certification for the above named individual
and SSN. This individual is no longer eligible for SSI effective __________. Reason:
____________________________________________________.
III. Social Security Administration ____________________________
___________________________ (CR Print Name)
___________________________ Phone #: ____________________
________________________________________
(Emergency Certification Authority
- O/S or above)
SS-RVI-317 (06/2002)
Exhibit 2
C01/E01 Medicaid Extension Referral
To: New Mexico Human Services Department Date: ____________
__________________________________ Attn: Medical Assistance
Worker
__________________________________
cc: NM HSD Buy-In Coordinator, Medical Assistance Division,
P. O. Box 2348, Santa Fe, New Mexico 87504-2348
Because of title II income, entitlement to Medicare, and the Supplemental Security
Income (SSI) Federal benefit rate, the SSI recipient identified below receives an
SSI payment and Medicaid one month, but does not receive an SSI payment and Medicaid
the next month. With the loss of Medicaid comes the loss of buy-in for Medicare. The
situation repeats itself resulting in alternating months of eligibility for SSI payments.
The SSI recipient identified below has elected to forgo the receipt of an SSI payment
and to be covered under the New Mexico Human Services Department optional Medicaid
extension provision cited in the NM Medical Assistance Program Manual 402.6.
We believe the following individual qualifies for coverage under the State optional
Medicaid extension provision.
Name: _________________________________ SSN: __________________________
Add: _________________________________ DOB: __________________________
_________________________________ Phone: _________________________
Gross title II income: $ _______________ Current E01 Effective Date: _____________
Please take appropriate action to accrete the individual to the State program.
If you have any questions, please call __________ at (AC & Phone) ________________.
From: Social Security Administration
________________________
________________________
(Revised 06/2002)
Exhibit 3
TITLE II COLA/DAC/SURVIVING SPOUSE MEDICAID EXTENSION REFERRAL LETTER
To: New Mexico Human Services Department Date:__________
Medical Assistance Division
P. O. Box 2348
Santa Fe, New Mexico 87504-2348
(check 1. or 2.)
_____1. The following individual was eligible for Supplemental Security Income
(SSI) in ______, but became ineligible effective with __________ because of a title
II cost-of-living adjustment (COLA) increase paid to the eligible person or their
spouse or due to ___________. This person may now be a candidate for preservation
of Medicaid eligibility under the provision of:
(check one)
_____ Section 503 of Public Law 94-566, or
_____ Lynch v. Rank court decree.
_____2. The following individual was eligible for SSI in ______,____ but became
ineligible in ______,_____ because of entitlement to or an increase in:
(check one)
_____ DAC, or
_____ surviving spouse 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 06/2002