NL 00804: Manual Paragraphs for Use in SSI Initial Claims, Posteligibility and Overpayment Notices
TN 24 (12-94)
1160. Situation Where Used:
Recipient's marital status changed during initial period of eligibility. (This paragraph may be used more than once on the same notice.)
(You) (1) married (2) .
| (1) | Choice 1 - are |
| Choice 2 - are not | |
| Choice 3 - were | |
| Choice 4 - were not | |
| Choice 5 - is | |
| Choice 6 - is not | |
| Choice 7 - was | |
| Choice 8 - was not | |
| (3) | Choice 1 - for (Month/Year) |
| Choice 2 - for (Month/Year) through (Month/Year) | |
| Choice 3 - for (Month/Year) on |
1165. Situation Where Used:
IC and PE: Used to show periods of FLA-C or D.
(1) (2) living (3) (4) (5)
| (1) | Choice 1 - | (You) |
| Choice 2 - | (Your) spouse | |
| Choice 3 - | (You) and (your) spouse | |
| (2) | Choice 1 - | are |
| Choice 2 - | were | |
| Choice 3 - | is | |
| Choice 4 - | was | |
| (3) | Choice 1 - | with (your) spouse |
| Choice 2 - | Null | |
| (4) | Choice 1 - | in (your) parents' household |
| Choice 2 - | in a hospital or other institution and more than half the cost of (your) care is provided by Medicaid | |
| Choice 3 - | in a hospital or other institution and more than half the cost of your care was provided by Medicaid | |
| Choice 4 - | in a hospital or other institution and more than half the cost of the care is provided by Medicaid | |
| ((5) | Choice 1 - | for (month/year) |
| Choice 2 - | for (month/year) through (month/year) | |
| Choice 3 - | for (month/year) on |
2160. Situation Where Used:
Individual and/or spouse changes Federal living arrangement and is paid for living in own household for month of change, even though not living in own household for the entire month of change.
(1) (2) not living (3) (4) or (5) (6) for the full month of (7) .
| (1) | Choice 1 - | (You) |
| Choice 4 - | (Your) spouse | |
| (2) | Choice 1 - | are |
| Choice 2 - | is | |
| Choice 3 - | were | |
| Choice 4 - | was | |
| (3) | Choice 1 - | with (your) spouse |
| Choice 2 - | Null | |
| (4) | Choice 1 - | in the household of someone else and receiving support and maintenance |
| Choice 2 - | in a hospital or other institution and more than half the cost of care was provided by Medicaid | |
| Choice 3 - | in a hospital or other institution and more than half the cost of care is provided by Medicaid | |
| (5) | Choice 1 - | with (your) spouse |
| Choice 2 - | Null | |
| (6) | Choice 1 - | in the household of someone else and receiving support and maintenance |
| Choice 2 - | in a hospital or other institution and more than half the cost of care was provided by Medicaid | |
| Choice 3 - | in a hospital or other institution and more than half the cost of care is provided by Medicaid | |
| (7) | (Month/Year) |
2161. Situation Where Used:
PE: When a recipient moves from FLA-B to FLA-A.
(Your) SSI payment has been changed because (you) are no longer receiving free food and shelter while living in someone else's home or apartment.
2162. Situation Where Used:
PE: When a recipient moves from FLA-C or D to FLA-A.
(You) are no longer living in (1) .
| (1) | Choice 1 - | (your) parents' household |
| Choice 2 - | a hospital or other institution where more than half of the cost of the care was provided by Medicaid |
MANUAL PARAGRAPHS
FLAM01. Situation Where Used:
Individual is considered to be married because of “holding out” for one or more months of the period of initial eligibility.
For Supplemental Security Income eligibility purposes, it has been determined that (1) (your) spouse and that (2) were living together (3) .
| (1) | Choice 1 - (Name of Spouse) is |
| Choice 2 - (Name of Spouse) was | |
| (2) | Choice 1 - you |
| Choice 2 - they | |
| (3) | Choice 1 - for (Month/Year) |
| Choice 2 - for (Month/Year) through (Month/Year) | |
| Choice 3 - for (Month/Year) on |
FLAM02. Situation Where Used:
Use this language for manual notices for recipients in LA-D. This includes situations where the $30.00 payment limit is imposed because of a transfer of resources.
(Your) SSI for (1) is based on the following facts:
-
(2) (3) living in a medical care facility, like a hospital or nursing home, for a full month;
and
(4)
| (1) | Choice 1 - | month/year |
| Choice 2 - | month/year through month/year | |
| Choice 3 - | month/year on | |
| (2) | Choice 1 - | (You) |
| Choice 2 - | (Your) spouse | |
| Choice 3 - | (You) and (your) spouse | |
| (3) | Choice 1 - | are |
| Choice 2 - | were | |
| Choice 3 - | is | |
| Choice 4 - | was | |
| (4) | Choice 1 - | Medicaid pays for or would usually pay for more than half the cost of the care. |
| Choice 2 - | Medicaid paid for or would usually have paid for more than half the cost of the care. |
FLAM03. Situation Where Used:
When this paragraph is automated it will replace 2162. Currently, use this paragraph instead of 2162 when preparing manual notices.
(1) (2) no longer living in a medical care facility, like a hospital or nursing home, where (3)
| (1) | Choice 1 - | (You) |
| Choice 4 - | (Your) spouse | |
| Choice 7 - | (You) and (your) spouse | |
| (2) | Choice 1 - | are |
| Choice 2 - | were | |
| Choice 3 - | is | |
| Choice 4 - | was | |
| (3) | Choice 1 - | Medicaid pays for or would usually pay for more than half the cost of the care. |
| Choice 2 - | Medicaid paid for or would usually have paid for more than half the cost of the care. |
REFERENCE:
Recipients in LA-D, paid under section 1611(e)(1)(E), SI 02302.320, for Notices 3, 4, 7, 8, 10 and 11