Third Party Liability Information Statement

To reduce Medicaid costs, Medicaid state agencies identify third party insurers liable for medical care or services for Medicaid beneficiaries. Applications for and redeterminations of 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 2027-08-31 and can be found here.

Third Party Liability Information Statement - SSI Claims System

Federal Enterprise Architecture: Income Security - General Retirement and Disability