SSO Report of State Buy-In Problem

Form Approved
oMB No. 0938-0035

Department of Health and Human Services

Hsalth Care FinancingAdminbtralion

sso REPORT OF STATE BUY-IN

IDENTIFICATION

PROBLEM[ Name

To:

ECFA

Medicare Claim Number

P.O. Box 11977
Baltimore, Maryland 21207-0977

Social Security Number (BOAN)

Sex

Welfare ID Number

O M O F
Social Security Number

From:
State and County of Residence
Claimant's Mailing Address

PART i Report d Problem by SSO
Carder
Claim Denfed Name

0

C. Being billed
B, Pramlum
being deducted from for premiums
bma. cheek

El ~ ~ a r t 0
U

D. Individual
rttceived Pad B Tarinln,

N0.W

- --

E. Other (Explain-Give Form Nos. if applicable)

PART 2 SSI Status at SSO
Receiving:
Federal SSI Check
Federal Adrnln. State Supp.

Start Date

Stop Date

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(Attach SSR & HMO Printouts)

Signature of SSO Representative

Date

Title

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PART 3 Rcpod of Buy-ln status by We&te- Depaliment (Chack and Carnplete Applicable Items)

ACCORDING TO

0
0

1.

WELFARE OFFICE, THE INDIVIDUAL IDENTIFIEDABOVE,

Has never been eligible for state buy-in.

2. Has been continuously eligible for state buy-in beginning (Mo.,Yr.)
3.

If eligibility ended because of death give date of
death.

Has been eligible for state buy-in only for months of

(Inclusive)

through

PART 4 Informatfonfrom State's momls and/or actions being taken by State

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1.

Individualis shown on State's bill as Code 41 continuing item beginning (Mo.. Yr.)

2.

Individual is shown on State's bill as other code. (Show code)

3.

State will submit (Show code) Accretion Effective (Mo., Yr.)

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4.

-

in the monthly date exchange (Show month) -

-

Deletion Effective (Mo., Yr.)

-

Other

CONTINUED ON REVERSE
Dept. of Public Welfare Sgnat~lre

Data

Title

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Form HCI-A-195/ (3-94)