TN 12 (01-00)

SI 02005.020 Living in a Title XIX Institution

A. POLICY — GENERAL

For any full month that an individual is living in a facility where Medicaid pays over 50 percent of the cost of care (FLA-D), the Federal SSI payment for the individual may be limited to $30 minus the CI from the BM. See SI 00520.001 for the explanation of when the payment limit applies.

For any full month that a couple is in FLA D, the couple's Federal SSI payment may be limited to $60 minus the sum of the CI from the BM. See SI 02005.030. when a couple separates and only one member of an eligible couple is subject to the $30 payment limit. See SI 02005.050 if one or both members of the couple are temporarily absent from home in a Title XIX facility.

B. POLICY — COMPUTATION WHEN NO OSS INVOLVEMENT

1. The Eligibility Test

  1. Use the CI in the CM. Compare it to the FBR, not the FLA D payment limit.

  2. If CI is less than or equal to the FBR, the person is federally eligible.

  3. If CI is greater than the FBR, the person is federally ineligible and no Federal SSI payment is due.

2. The Payment Computation

  1. Use the CI in the BM (adjusted, if needed, by “COLA coordination” as explained in SI 02005.015). Compare it to the FLA D payment limit.

  2. If CI is less than the payment limit, the difference is the Federal SSI payment due (if subject to “Proration” see SI 02005.007).

  3. If CI is equal to or greater than the payment limit, no Federal SSI payment is due.

C. POLICY — COMPUTATION WHEN THERE IS OSS INVOLVEMENT

1. The Eligibility Test

  1. Use the CI in the CM. Compare it to the FBR (not the FLA D Federal payment limit) and the OSS level for FLA D.

  2. If CI is less than or equal to the FBR, the person is federally eligible and OSS eligible.

  3. If CI is greater than the FBR, and the excess income is less than the OSS level, the person is federally ineligible (no Federal SSI is due) but OSS eligible.

  4. If CI is greater than the FBR and the excess income is equal to or greater than the OSS level, the person is federally ineligible (no Federal SSI due) and OSS ineligible (no OSS payment due).

2. The Payment Computation

  1. Use the CI in the BM (adjusted by COLA coordination). Compare it to the FLA D Federal payment limit and the OSS level for FLA D.

  2. If CI is less than the Federal payment limit, the difference is the Federal SSI payment due (subject to proration for months before 9/1/96) and the full OSS level is the OSS payment due (subject to proration for months before 9/1/96).

  3. If CI is equal to the Federal payment limit, no Federal SSI payment is due, but the full OSS level is the OSS payment due (subject to proration for months before 9/1/96). See SI 02005.020D. and SM 01305.001N. for payment status E01.)

  4. If CI is greater than the Federal payment limit and the excess income (the CI in excess of the payment limit) is less than the OSS level, no Federal SSI payment is due. The difference between the excess income and the OSS level is the OSS payment due (subject to proration for months before 9/1/96).

  5. If CI is greater than the Federal payment limit and the excess income is equal to or greater than the OSS level, no Federal SSI payment is due and no OSS payment is due.

D. POLICY - E01 STATUS

1. Overview

An individual or couple in “FLA D” is ineligible for a Federal SSI benefit because of CI only if the CI exceeds the FBR. Although no Federal SSI payment is made if the CI from the BM exceeds $30 ($60 for an eligible couple), the individual (or couple) may still be federally eligible.

For example, because the payment limit for an individual is $30, if the CI is continuously $31, no Federal SSI payment is due. However, since the CI does not exceed the FBR for an individual ($674 in 2011), this individual is federally eligible. (See SM 01305.001N.)

2. E01 Status and Medicaid

An individual or couple who is “eligible but not payable” does not qualify automatically for Medicaid and social services. The individual or couple must contact the State to establish eligibility for Medicaid and social services.

E. EXAMPLE — MOVE FROM OWN HOUSEHOLD TO A TITLE XIX FACILITY

1. Facts

Mr. Miller is an SSI recipient living in his own household. On 8/23/2000, he begins residence (a permanent living arrangement change) in a title XIX facility.

He begins receiving a union pension of $240 per month in 9/2000. The FBR for an individual is $512. There is no OSS involvement. He is subject to the $30 payment limit.

2. Eligibility Test

His CI in September is $220 ($240 - $20 general exclusion). He is eligible every month. His CI never exceeds the FBR.

3. Payment Computation

  1. September 2000: This is the first full month of residence in the institution and the first month for which the $30 limit applies. The budget month is July.

$ 30Limit in September
- 0CI in July
$ 30Payment due for September
  1. October 2000: The budget month is August.

$ 30Limit in October
- 0CI in August
$ 30Payment due for October
  1. November 2000: The budget month is September.

$ 30Limit in November
-220CI in September ($240 pension - $20 general exclusion)
$ 0Payment due for November

No SSI payment is due, but Mr. Collins is eligible (E01) because his CI in November does not exceed the FBR ($512).

  1. December 2000: The budget month is October.

$ 30Limit in December
-220CI in October
$ 0Payment due for December

No SSI payment is due, but Mr. Collins is eligible because his CI does not exceed the FBR.

F. EXAMPLE — MOVE FROM OWN HOUSEHOLD TO A TITLE XIX FACILITY, OSS INVOLVED

1. Facts

Mr. Simpson is an SSI recipient who lives in his own household. The FBR is $512 and the OSS level is $32. On 9/15/2000, he begins residence (a permanent living arrangement change) in a title XIX facility. The Federal payment limit is $30, and the OSS level is $10. In every month, his income is a $58 private pension.

2. Federal Eligibility Test

His CI of $38 ($58-$20 general exclusion) does not exceed the FBR, so he is federally eligible every month.

3. Federal Payment Computation

  1. September

$512FBR
- 38CI in July
$474Payment
  1. October

$30Limit in October
- 38CI in August
$ 8Excess income

4. OSS Eligibility Test

Mr. Simpson is federally eligible each month (no excess income in Federal eligibility test), so he is OSS eligible each month.

5. OSS Payment Computation

  1. September

$32OSS level in September
- 0Excess income
$32OSS payment
  1. October

$10OSS level in October
- 8Excess income
$ 2OSS payment

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0502005020
SI 02005.020 - Living in a Title XIX Institution - 07/03/2012
Batch run: 07/03/2012
Rev:07/03/2012