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_________________ REGIONAL OFFICE Appendix A-16-6-RB 291 DIVISION OF MEDICAID (DATE) (ADDRESS) (CITY,STATE,ZIP)
ID#: 0000000000000 (NAME) SSN#: 000-00-0000 (ADDRESS) SSI APPLICATION DATE: 00/00/0000 (CITY,STATE,ZIP)
DIVISION OF MEDICAID
NOTICE OF APPROVAL OF RETROACTIVE SSI-RELATED MEDICAID
The Division of Medicaid has been informed by the Social Security Administration that you were eligible for Supplemental Security Income (SSI) in the past. Individuals who are eligible for SSI are also eligible for Medicaid. Your eligibility for SSI Medicaid begins (DATE) and ends (DATE). You will not receive a Medicaid card for this prior period so you will need to show this notice to any providers of medical services, such as doctors or hospitals, if you have medical bills from this period of time. Your Medicaid ID# for this period is shown above.
If you have medical bills in the three months prior to your application for SSI, notify the regional office shown below and show them this letter to verify receipt of medical assistance. If you are found eligible for medical assistance during any of those three months, some or all of your medical bills may be paid.
ADDRESS: _________REGIONAL OFFICE DIVISION OF MEDICAID (ADDRESS) (CITY,STATE,ZIP)
TELEPHONE: __________________
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.