Third Party Liability Information Statement

OMB 0960-0323

OMB 0960-0323

Medicaid state agencies must identify third party insurers liable for medical care or services for Medicaid beneficiaries; this reduces Medicaid costs. Regulations at 42 CFR 433.136–433.139 require Medicaid state agencies to obtain this information on Medicaid applications and redeterminations as a condition of Medicaid eligibility. States may enter into agreements with the Commissioner of Social Security to make Medicaid eligibility determinations for aged, blind, and disabled beneficiaries in those states. Applications for and redeterminations of Supplemental Security Income (SSI) eligibility in jurisdictions with such agreements are applications and redeterminations of Medicaid eligibility. Under these agreements, SSA obtains third party liability information using Form SSA- 8019 and provides that information to the Medicaid state agencies. The Medicaid state agencies use the information to bill third parties liable for medical care, support, or services for a beneficiary to guarantee that Medicaid remains the payer of last resort. The respondents are SSI claimants and recipients.

The latest form for Third Party Liability Information Statement expires 2021-10-31 and can be found here.

All Historical Document Collections
Revision of a currently approved collection 2021-09-10
Approved without change
Revision of a currently approved collection 2018-06-25
Approved with change
Revision of a currently approved collection 2015-07-08
Approved with change
Revision of a currently approved collection 2012-05-02
Approved without change
Revision of a currently approved collection 2009-05-29
Approved without change
Extension without change of a currently approved collection 2006-06-02
Approved without change
Extension without change of a currently approved collection 2003-06-20
Approved without change
No material or nonsubstantive change to a currently approved collection 2001-09-24
Approved without change
Extension without change of a currently approved collection 2000-05-12
Approved without change
Extension without change of a currently approved collection 1997-07-14
Approved without change
Revision of a currently approved collection 1994-02-22
Approved with change
No material or nonsubstantive change to a currently approved collection 1991-02-28
Approved without change
Extension without change of a currently approved collection 1990-12-19
Approved without change
Revision of a currently approved collection 1987-12-10
Approved with change
No material or nonsubstantive change to a currently approved collection 1987-09-01
Approved without change
Revision of a currently approved collection 1985-07-03
Approved without change
Revision of a currently approved collection 1984-10-26
Approved with change
No material or nonsubstantive change to a currently approved collection 1984-08-02
Approved without change
New collection (Request for a new OMB Control Number) 1982-12-03
OMB Details

Third Party Liability Information Statement

Federal Enterprise Architecture: Income Security - General Retirement and Disability


© 2021 OMB.report | Privacy Policy