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_________________ REGIONAL OFFICE

Appendix A-16-3 – RB285 DIVISION OF MEDICAID

(DATE) (ADDRESS) (CITY, STATE, ZIP)

(NAME)

ID#: 00000000000000000 (ADDRESS)

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

DIVISION OF MEDICAID

NOTICE OF DENIAL OF 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 you failed to assign your third party medical payments to the Division of Medicaid. As a result, your Medicaid coverage has been denied.

If you disagree with the decision to deny your Medicaid based on the reason cited above, you may notify us immediately in writing to request a hearing in this matter.

Per Federal (P.L. 98-39, Section 2367) and State laws, it is mandatory that you assign your third party medical payments (medical insurance) to the Medicaid agency in order to be eligible for Medicaid benefits.

Send your request for a hearing to:

Office of Eligibility

Mississippi Division of Medicaid

550 High Street

Suite 1000

Jackson, MS 39201-1399

Enclosure: Medicaid Notice of Non-Discrimination