SI 01730: SSA Determinations of Medicaid Eligibility
TN 9 (05-91)
| A. | Exhibit 1 | Summary of AOR and TPL Procedures For Initial Claims (Applies only in States for which SSA makes Medicaid Eligibility Determinations) |
| B. | Exhibit 2 | Summary of TPL Procedures For Redeterminations (Applies only in States for which SSA makes Medicaid Eligibility Determinations) |
| C. | Exhibit 3 | Form SSA-169, Assignment of Rights Statement |
| D. | Exhibit 4 | Form SSA-8019, Third Party Liability Information Statement |
| E. | Exhibit 5 | Types of Insurance - (Examples) |
| F. | Exhibit 6 | List of States for Which SSA Determines and Redetermines Medicaid Eligibility (34, Including the District of Columbia) |
A. Exhibit 1
Summary of AOR and TPL Procedures For Initial Claims (Applies only in States for which SSA makes Medicaid Eligibility Determinations)
B. Exhibit 2
C. Exhibit 3 — Form SSA-169, Assignment of Rights Statement
To view this form, go to SSA-169.
D. Exhibit 4 — Form SSA-8019, Third Party Liability Information Statement
To view this form, go to SSA-8019.
E. Exhibit 5 - Type of Insurance - (Examples)
| AGED-BLIND- DISABLED ADULTS |
BLIND-DISABLED MINOR CHILDREN | |||
|---|---|---|---|---|
| TYPE OF INSURANCE |
RECIPIENT | SPOUSE | PARENT | STEP-PARENT |
|
INSURANCE HOLDER EMPLOYMENT-RELATED HEALTH INSURANCE |
X |
X |
X |
X |
|
TRICARE* |
X |
X |
X |
X |
|
VETERAN'S |
X |
|||
|
MEDICARE SUPPLEMENTAL POLICIES** |
X |
|||
|
PRIVATELY PURCHASED |
X |
X |
X |
X |
* Civilian Health and medical Plan of the Uniformed Services
** Private insurance that pays Medicare deductibles and insurance
F. Exhibit 6 - List of States for Which SSA Determines and Redetermines Medicaid Eligibility (35, Including the District of Columbia)
| Alabama | Mississippi |
| Arizona | Montana |
| Arkansas | New Jersey |
| California | New Mexico |
| Colorado | New York |
| Delaware | North Carolina |
| District of Columbia | Pennsylvania |
| Ohio | |
| Florida | Rhode Island |
| Georgia | South Carolina |
| Indiana | South Dakota |
| Iowa | Tennessee |
| Kentucky | Texas |
| Louisiana | Vermont |
| Maine | Washington |
| Maryland | West Virginia |
| Massachusetts | Wisconsin |
| Michigan | Wyoming |