SI 01150.110 instructs field offices (FOs) to obtain transfer of resources information during an initial claim or redetermination interview and to forward this information to the State Medicaid agency. SI 00520.012 imposes the $30 SSI Payment limit to SSI recipients who are ineligible for Medicaid coverage while in an institution due to the transfer of resources provision.

Exhibit 1 and Exhibit 2 provide transmittal memorandums for exchange of information between the local Social Security FO and the Medicaid agency. Exhibits 1 and 2 should be photocopied as needed.

Exhibit 1 is to be completed by the SSA claims representative when an initial claim or redetermination interview is completed and information is obtained that a resource was transferred for less than fair market value on or after July 1, 1988.

Attach a copy to Exhibit 1 of the responses to question 27 of the SSA-8000-BK SSI application concerning the transfer of resources. If a MSSICS claim is taken, attach a printout of the RMEN and RGIV screens. For redeterminations, completing the information shown on Exhibit 1 will meet the documentation requirements explained in SI 01150.110E.3. In addition to transmitting an MN diary, mail Exhibit 1 with attachments to the following addresses:

• •

  For Arkansas, Louisiana, New Mexico and Texas residents, use the State agency addresses in SI DAL01730.045

• •

  For Oklahoma residents:

  Oklahoma Department of Human Services
  
  Family Support Services
  
  Attn: Health Related & Medical Services
  
  P. O. Box 25352
  
  Oklahoma City, Oklahoma 73125

Upon receipt of Exhibit 1, the State Medicaid office will take whatever action is required according to internal State operating procedures.

Exhibit 2 is to be completed by the local Medicaid caseworker only at the point that the SSI recipient is determined to be ineligible for institutional services under Medicaid because of the transfer of resources policy.

The information used to apply the transfer of resources provision may come to the Medicaid agency from a variety of sources, including the Social Security Administration.

The Medicaid caseworker will provide both the first month and the projected last month of ineligibility for institutional services under Medicaid.

The Medicaid caseworker will mail Exhibit 2 to the local Social Security office.

Exhibit 1

TO: State Medicaid Agency                Date: _____________       _____________________

        _____________________

        _____________________

FM: Social Security Administration

       ______________________________

       ______________________________

       ______________________________

SUBJECT: Transfer of Resources - PL 100-360

This memorandum provides information on a transfer of resources for less than the current market value on or after July 1, 1988, obtained by the Social Security Administration during an SSI (check one):

         Initial Claim        Redetermination

SOCIAL SECURITY NUMBER: _______________

NAME: ____________________________________

ADDRESS:_________________________________

               _________________________________

Initial Claim

• •

  Application Date:_______________

• •

  Information Regarding Transfer (See Attached Photocopy of Question 27 from SSI Form SSA-8000-BK or printout of the RMEN and RGIV screens for a computer-generated SSI application)

Redetermination

• •

  Date of Transfer _______________

• •

  Description of Transferred Resource _________________________

• •

  Value of Transferred Resource $ ____________________________

• •

  Compensation (if any) Received or Expected $ ______________

• •

  Recipient or Purchaser of Resource _________________________

• •

  Relationship to Recipient/Purchaser ________________________

• •

  Co-owners (if any) of Resource at Time of Transfer _________

The current living arrangement for SSI purposes is (circle one):

      A   B   C   D

Name of Social Security Representative: _________________________

SSA Area Code and Telephone Number: _________________________

Exhibit 2

TO: Social Security Administration         Date: ___________

        __________________________

        __________________________

        __________________________

FM: State Medicaid Agency

      ______________________________

      ______________________________

SUBJECT: SSI Recipient Ineligible for Medicaid Due to Transfer of Resources Provision (PL 100-360 and PL 100-485)

The SSI recipient listed below is in a Medicaid institution.

The SSI recipient (check one)

____ was determined to be ineligible for institutional services under Medicaid

____ ceased to be eligible for institutional services under Medicaid

due solely to the transfer of resources provision.

NAME: _________________________________________________________

SOCIAL SECURITY NUMBER: _______________________________________

ADDRESS: __________________________________________________

1. 1. 

   The first month/year the SSI recipient is ineligible for institutional services under Medicaid because of a transfer of resources is: _________________________________

2. 2. 

   The estimated last month/year the SSI recipient is ineligible for institutional services under Medicaid because of a transfer of resources is: ____________________

Note to SSA Field Offices: Under Section 303(c) of PL 100-360, an SSI recipient who is a resident of a Medicaid-certified skilled nursing facility or intermediate care facility is subject to the $30 payment cap whenever Medicaid eligibility has been denied or suspended due to the transfer of resources provision.

Medicaid Caseworker: ___________________________________________

Area Code/Telephone Number: ____________________________________