Statement for Determining Continuing Eligibility, Supplemental Security Income Payment--BK & MSSICS Screens

Social Security Administration
Important Facts About Your Supplemental Security Income

Date:
Why We’re Sending You
The Enclosed Form

We must regularly review the cases of people who get
Supplemental Security Income 881. We check to be sure that
each person is still eligible and that we are sending the right
amount of SSI money.
As part of your review we need you to answer the questions on
the enclosed form. It’s called Statement for Determining
Continuing Eligibility For Suppkmentai Security
Income Payments, SSA-8202-Bt If you have a
representative payee that’s someone who receives your SSI
money for you. he or she must complete the form SSA-8202-Pt.
Below, we tell you how to complete the form and what to do if
you need help. We also go over some other important facts.
We explain about:
* Things you need to report to us,
* Special ways we can send letters to blind recipients who get

ssI.

* Medicaid and computer matching.
How To Complete Fonn
ssA-8202.p$,

Here are some things to remember when you complete the
form SSA-8202-%:
* Answer all questions on the form.
* Sign your name in the space marked Your Signature. If
both you and your husband or wife get SSI, be or she should
sign in the space marked Spouse’s Signature.
* If you are a representative payee and are completing the
SSA-8202-fl for sameone who gets SSI, answer the
questions as if that person were completing the form. Sign
your name in the space marked Representative Payee.
* Check the address that we have for you on page 1 of the
SSA-8202-yJ If it is wrong, let us know.
If you have any questions or need help completing the
SSA-8202-fl. CALL US, TOLL FREE, AT 1-800-772-1213.

When To Return The
Form

Please return your completed, signed SSA-8202-F to us ii’ the
enclosed envelope within 30 days from the date at the top of
page lot these instructions.

Form SSA42O2k EST.NFS C
flnnrcy pnr ditone

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H’ We Don’t Dear From
You

Your SSI Payments will stop if:
* You do not return the completed SSA82O2-BR to us;
OR
* You do not contact us to let us know you are having problems
completing the form.
Before we stop payments, we will send you a letter. The letter
will explain our action and what to do if you think we are
wrong.

Things You Need To
Report

You must report changes to us that affect your SSI. The
easiest way to report a change is to call us, toll free, at
1-800-772-1213. You must tell us about changes within 10
days after the month they happen. A list of the things you
must report is on page 6 of the SSA-8202-$%

Important
Information
About Medicaid

If you have Medicaid or you are filing for Medicaid, the
following information about assets is important to you,
WHAt ARE ASSETS FOR MEDICAID?
Your State looks at all your assets when it decides if you can
get Medicaid. Your assets can include:
* Money you or your spouse get from wages or self-employment;
* Any other money you or your spouse get, such as money from
Social Security or friends or relatives;
* Any free food, clothing or shelter you or your spouse get;
* Things you or your spouse own, like bank accounts or real
estate;
* Money or property you your spouse, or someone acting for
you placed in a trust; and
* Any money or property which you and your spouse have a
right to get but don’t get because of something:
* You
or your spouse did, or
* Someone else did who was acting for you or at your request.
Medicaid may count some things as assets that we do not count
for 891. For example, Medicaid may count things you give
away or sell for less than they arc worth; these do not count for

ssl.

Important Information
About Medicaid is
Continued on Page 3
Form $5A4202,M.U’48T.NFS

j.97j

Page 2

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Important Information
About Medicaid
continued

WHAT HAPPENS WHEN YOU GIVE AWAY OR SELL AN
ASSET
Medicaid may not pay for certain health care for you for a
period of time if you, your spouse, or someone else takes an
asset of yours and gives it away or sells it for less than what it
is worth. Medicaid also may not pay for certain health care if
your assets are used to set up a trust that makes payments to
someone else or cannot make payments to you or for your
benefit.
This rule usually applies to people in nursing homes and
people in other places, such as, hospitals that give nursing
services like those in nursing homes. This rule can also apply
to people who:
* Get care at home or in their community under special
programs called waivers or
* Will soon need these services.
At times this rule also applies to people who are getting other
kinds of services, such as, home health care, help with
activities of daily living, or other forms of long-term care.
REPORTING TO YOUR STATE MEDICAID AGENCY
Your State Medicaid agency uses these rules about assets to
decide if you can get Medicaid. SSA will give your State
Medicaid agency information SSA has about any assets you
may have given away. You also must tell your State Medicaid
agency any time you give away or sell an asset or set up a trust.
IF YOU HAVE QUESTIONS ABOUT MEDICAID
If you have any questions about Medicaid, including how your
assets can affect coverage, please contact the State or local
welfare, public health, or social services agency that handles
Medicaid. They can answer your questions about how your
assets affect your Medicaid,

A Special Notice For
Blind Recipients

Form 8SA.nO24.C’iST.Nn 1-97

If you get $81 because you are blind, you may choose a special
way to receive letters explaining decisions we make about your
SS1. Instead of getting your letters by regular mail, you may
choose to have US:
* Telephone you and read your letters to you. If you choose
this, we will also keep sending you letters through the
regular mail, OR
* Send your lettersby certified mail.
You can choose or change the way you receive our letters at
any time. Just call us, toll free, at 1-800-772-1213.

Pay 3

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Facts About Computer
Matching Programs

We may use the information you give us when we match
records by computer. Matching programs compare our records
with those of other Federal, State, or local government
agencies. Many agencies may use matching programs to find or
prove that a person qualifies for benefits paid by the Federal
Government. The law allows us to do this even if you do not
agree to it. Explanations about these and other reasons why
information you provide us may be used or given out are
available in Social Security offices. If you want to learn more
about this, contact any Social Security office.

The Paperwork
Reduction Act of 1995

Please Note the following:
* See attached updated PRA which will be inserted
at next reprint.
* In addition SSA will update the forms
construction designation from F-6 to BK.

Forni SSA4202.st *INST-NFS I.7I

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UPDA TED PRA STA TEMENT SSA-8202-BK

Thefollowing revised PRA Statement will he insened into the revisedferns
at its scheduled reprinting:
Paperwork Reduction Act Statement This information collection meets the
requirements of 44 U.S.C. § 3507, as amended by section 2 of the Pavftwork Reduction
Act ci 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget control number. We estimate that it will take about 21
minutes to read the instmctions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCiAL SECURITY
OFFICE. The office is listed under U. S. Government agencies in your telephone
directory or you may call Social Security at 1-800-772-1213. You may send comments
on our time estimate above to: 554, 6401 Securily Blvd. Baltimore, ML 2/235-640?.
Send Rfr comments relating to our time estim ate to mix address, not the completed
form,
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