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___________ REGIONAL OFFICE Appendix A-16-4-RB286 DIVISION OF MEDICAID (DATE) (ADDRESS) (CITY,STATE,ZIP)

(NAME) ID#: 0000000000000 (ADDRESS)

SSN#: 000-00-0000

(CITY,STATE,ZIP)

SSI APPLICATION DATE: (DATE)

DIVISION OF MEDICAID

NOTICE OF TERMINATION OF MEDICAID

The Division of Medicaid has been notified by the Social Security Administration that your Supplemental Security Income (SSI) payment has been terminated or suspended. Since the receipt of SSI was the basis of your entitlement to Medicaid, your Medicaid benefits will be terminated effective (DATE).

If you disagree with the decision made to terminate your SSI check and Medicaid, you should immediately contact your local Social Security Office in (LOCATION OF SSA OFFICE)as directed in the Supplemental Security Income notice of change which you recently received.

Although you are no longer eligible for Medicaid as a recipient of SSI, you may continue to be eligible for Medicaid under one of the following 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 ordinarily be provided in a medical institution.