TN 10 (06-96)

Citations:

Social Security Act, Sections 1634(a), 1912(a)

A. Policy — applicant agreement

Each State’s Medicaid plan requires that as a condition of eligibility for Medicaid, applicants must at the time of application:

• Assign to the State any rights they may have (or any other Medicaid eligible may have for whom they can legally assign rights) to support and payment for medical care from any responsible third party (e.g., from an insurance company settling an accident claim);

• Agree to cooperate in identifying and providing information to assist the State in pursuing any third party who may be liable to pay for care and services;

• Agree to cooperate with the State in obtaining medical support and payments (e.g., signing papers necessary to pursue payments from absent parents); and

• Agree to cooperate in establishing the paternity of a child born out of wedlock for whom the applicant can legally assign rights.

  EXCEPTION: A woman need not agree to cooperate in establishing the paternity of a fetus she is carrying or for her child less than 60 days old.

NOTE: The Medicaid program uses the term “applicant” to refer to both “applicants” and “claimants”.

B. Policy — SSA role

The requirement that SSA secure an individual’s assignment of rights applies only in section 1634 States.

SSA must inform applicants and recipients who move into section 1634 States from non-1634 States about the requirements in A. above and attempt to secure their assignment in States which do not have automatic assignment laws (see H. below). Assignment of rights (AOR) is discussed:

• during the application path for aged claims and simultaneously developed disability/blindness claims,

• at the pre-effectuation review contact (PERC)for a deferred claim following medical allowance,

• during the first redetermination after a State’s section 1634 Agreement becomes effective with SSA, and

• during the first FO contact with an eligible individual after moving into a section 1634 State from an SSI State or section 209(b) State. (See SI 01715.010A for a discussion of the three different types of States for Medicaid purposes.)

After AOR has been annotated on the record, there is no need to raise the issue again, unless the recipient wishes to change AOR status or the State requests our records to be changed.

NOTE: Some States have enacted automatic assignment laws which make completion of the AOR question unnecessary in applications (question 59(a), form SSA-8000-BK or in Modernized SSI Claims System (MSSICS) claims (see MSOM INTRANETSSI 019.020)) and completion of Form SSA-169, “Assignment of Rights Statement” unnecessary in post-eligibility situations. States with automatic assignment laws are identified in H. below. They also may be discussed in Regional instructions.

C. Definition of responsible third party

Responsible Third Party — Any insurance company, individual, entity, or program that is or may be liable to pay all or part of the expenditures that would otherwise be paid by Medicaid. (See SI 01730.045 for further discussion of third-party insurance.)

D. Procedure — explanations

In section 1634 States, explain the AOR requirements in A. above in all aged and simultaneously developed applications, PERCs for deferred claims, and at the first post-eligibility contact with an individual who has moved from an SSI State or a section 209(b) State into a section 1634 State.

Do not attempt to personalize the requirements by using the second person “you must assign your rights. . . .” Just state that the AOR requirements must be met in order to become Medicaid eligible.

Never ask a woman if she is pregnant or if she has recently delivered a child out of wedlock. Just state the four requirements.

If the applicant wishes a detailed explanation of the AOR requirements, explain that he/she may contact the Medicaid State Agency for more detailed information. If the individual resides in a State which does not have automatic assignment (see E. below), explain that the individual has the right to refuse assignment, but the consequences of such a refusal will probably be a denial of Medicaid.

NOTE: Refusal to assign rights will not affect SSI, Social Security or Medicare benefits.

E. Procedure — automatic assignment

1. Paper Applications

After explaining AOR, do not complete block 59(a) of the paper application in automatic assignment section 1634 States. Continue with the rest of block 59 and complete an SSA-8019-U2 (“Health Insurance Information Request”, SI 01730.045) when the claimant/beneficiary alleges third-party health insurance.

2. MSSICS Applications

In MSSICS claims, code BMEN with a “Y” to bring up the BHLT screen. Code BHLT (see MSOM INTRANETSSI 019.020) with an “A” for automatic.

3. Post-Eligibility Situations

In post-eligibility(PE) situations when there is no assignment of rights(AOR) coding on the SSR:

• do not get a signed SSA-169 (“Assignment of Rights
  Statement”), instead,

• read the AOR statement on the SSA-169 or the SSA-8000-BK to an individual, and

• ask if the recipient has any third-party health insurance (not Medicare or Medicaid). (See SI 01730.045C.3. for guidance on redeterminations.)

For MSSICS 4.4 and later, when a recipient moves into an automatic assignment State from a nonsection 1634 State, read the assignment of rights statement, code BMEN with a “Y” and BHLT (see MSOM INTRANETSSI 019.020) with an “A” for automatic.

F. Procedure — nonautomatic assignment states

1. Paper Applications

After explaining AOR, complete block 59(a) in paper applications in section 1634 States. If “Yes” to block 59(a), continue with the rest of block 59 and complete an SSA-8019-U2 (see SI 01730.045) when appropriate. If the individual refuses assignment of rights in block 59(a), explain again that refusal will probably result in a Medicaid denial and skip the remainder of block 59. Code an “A” in the PT field of the SSA-450-SI (“SSI Data Input and Determination”). (See SM 01005.350 ff. about assuring proper coding in the PT field.)

If a claimant who refused AOR changes the decision and the claim has not yet been completed, amend the application with a completed SSA-169 and file in the claims folder.

2. MSSICS Claims

In MSSICS claims, enter “Y” on the BMEN question (“Health Expenses”) to bring up the BHLT screen.

NOTE: An entry of “N” will prevent appearance of the BHLT screen.

Code BHLT (see MSOM INTRANETSSI 019.020) with a “Y” for Yes (agrees to AOR) or an “N” for No (does not agree to AOR). If “N”, provide the reason for refusal, if possible (see MSOM INTRANETSSI 019.020).

In pending MSSICS claims, if the claimant changes the AOR refusal, retrieve BHLT and change the decision. Otherwise, use a PR-9 transmission to change the decision.

3. Post-Eligibility, Paper

In non-MSSICS PE situations when a beneficiary moves from an SSI State or Section 209(b) State into a nonautomatic assignment section 1634 State or SSA implements a section 1634 Agreement with a State, have the individual sign an SSA-169 after the explanation. Route the signed SSA-169 for filing in the claims folder. Ask if the beneficiary has third-party health insurance (i.e., not Medicare or Medicaid) or if someone is responsible for medical expenses. If the recipient alleges third-party insurance or someone is responsible for medical expenses, complete an SSA-8019-U2 and route as instructed in SI 01730.045.

If the recipient refuses AOR, have the individual sign an SSA-795 explaining his or her wish to refuse assignment of rights and the understanding that refusal will probably result in being found ineligible for Medicaid. Use a PR-9 transmission to place this information on the SSR. (See SM 01005.350 ff. about assuring proper coding in the PT field.) Post-eligibility refusals to assign rights will require a manual notice. Suppress any automated notice and prepare the manual notice using Medicaid paragraph 1149 in NL 00804.110. (See NL 00801.010C for notice suppression references.)

If a recipient changes the AOR decision, use a PR-9 transmission.

NOTE: A change from agreement to refusal must be taken on a signed SSA-795. A change from refusal to agreement to assign should be annotated on an SSA-169 if the change is taken from the recipient or the representative payee. A State report that the individual has changed from refusal to agreement may be recorded on a report of contact.

4. Post-Eligibility, MSSICS

In MSSICS 4.4 or later, if an individual reports moving into a nonautomatic assignment section 1634 State, explain assignment of rights and obtain concurrence. Complete the BMEN question with a “Y”, and answer the BHLT question about AOR with a “Y” or an “N” as appropriate. If the answer to BHLT is “Y”, proceed to TPL. If the answer to the BHLT assignment question is “N”, provide the reason for refusal, if possible, and you will have to suppress any automated notice and issue a manual notice using Medicaid paragraph 1149 in NL 00804.110. (See NL 00801.010C for notice suppression references.)

G. Procedure — workflow

See SI 01730.050A, Exhibit 1, for a workflow diagram of the AOR process.

H. List of automatic assignment states

As of the date of this transmittal, the automatic assignment section 1634 States are:

Automatic assignment procedures result from a State notifying the Centers for Medicare & Medicaid Services (CMS) that it wishes the signed AOR statement to be waived because of State law. CMS then notifies SSA when a section 1634 State no longer requires a signed AOR statement.