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___________ REGIONAL OFFICE Appendix A-16-2-RB284 DIVISION OF MEDICAID (DATE) (ADDRESS) (CITY,STATE,ZIP)

ID#: (NAME) SSN#: 000-00-0000 (ADDRESS) SSI APPLICATION DATE: (DATE) (CITY,STATE,ZIP)

DIVISION OF MEDICAID

NOTICE OF DENIAL AND RETROACTIVE MEDICAID

In Mississippi, individuals who are eligible for Supplemental Security Income (SSI) are automatically eligible for Medicaid. However, the Division of Medicaid has been advised by the Social Security Administration that your application for SSI (SSI APPLICATION DATE) has been denied. Therefore, you are not eligible for Medicaid as a SSI recipient.

If you disagree with the decision on your application for SSI and Medicaid, you should immediately contact your local Social Security Office as directed on the Supplemental Security Income notice of disapproved claim which you recently received. Your local Social Security Office is located in (LOCATION OF SSA OFFICE).

If you have medical bills in one or more of the 3 months before you applied for SSI and you believe you would have been eligible for SSI at the time, you should apply for Medicaid at the Medicaid Regional Office shown at the end of this notice.

Although you are not eligible for Medicaid as a recipient of SSI, you may be eligible for Medicaid under one of the following Medicaid-only groups if you have Medicare or you are disabled. Medicaid disability rules are the same as SSI and Social Security.

1. You have or can get Medicare Part A Hospital Insurance and your income does not exceed the federal poverty level for an individual or couple. There is no resource test for this coverage. Medicaid will pay Medicare cost-sharing expenses under the Qualified Medicare Beneficiary (QMB) group.

2. You have Medicare Part A and your income does not exceed 135% of the federal poverty level for an individual or couple. There is no resource test for this group. Medicaid will pay your Medicare Part B premiums only under either the Specified Low Income Beneficiary (SLMB) or Qualified Individual (QI) groups.

3. You are a disabled child living at home and are age 18 or under and receiving medical care at home that would be provided in a medical institution.