Rescinded 1982
SSR 78-9: Computation and Payment of Benefits Where an Eligible Individual or His Eligible Spouse Is in a Medicaid Facility
SSR 78-9
PURPOSE:
To state new policy requiring separate computations of Federal supplemental security income (SSI) benefits for an eligible individual and his eligible spouse when one is in a hospital, skilled nursing facility, or intermediate care facility which is receiving payments under a State plan approved under title XIX.
CITATIONS (AUTHORITY):
Sections 1611(b), 1611(e)(1)(B)(ii) as amended by Section 502 of Public Law 94-566, 1612, 1631(a)(2) of the Social Security Act; Sections 416.120(c)(5), 416.231(a)(2), 416.231(b)(5), 416.248(c), 416.424, 416.430, 416.432(b), 416.432(c), 416.1040(a), 416.1040(c(1) and 416.1146 of Regulations No. 16 (20 CFR Chap. III).
PERTINENT HISTORY:
In determining SSI benefits for an eligible individual and his eligible spouse, one of whom is throughout any month in an institution receiving payments under a State plan approved under title XIX (hereinafter referred to as a "Medicaid facility") the reduction in the rate of payment required by section 1611(e)(1)(B)(ii) of the Act due to such confinement, has heretofore applied to the couple as an entity, and there have been no separate computations for each member. That is, the maximum rate of payment for a couple under section 1611(b)(2) of the Act (currently $3,021.60 per year) was reduced to the sum of the maximum payable to an individual under section 1611(b)(1) of the Act (currently $2,013.60 per year) plus $300 ($25 per month), the maximum payable to an individual in a Medicaid facility in a year, and the total thus produced became the maximum rate of payment per year for such eligible individual with an eligible spouse. This, in turn, was subject to reduction by the countable income chargeable to them as a couple. The total was then disbursed in amounts of not more than $25 per month to the member in the Medicaid facility, and the remainder to the other member, or in equal amounts if the total did not exceed $50.
In the event the noninstitutionalized member of the couple was living throughout a month in the household of another from whom he was receiving support and maintenance, computation of the rate of payment as described above was modified so as to reduce the rate of payment to such member of the couple as an individual under section 1611(b)(1) by one-third, in accordance with section 1612(a)(2)(A) of the Act and section 416.432(c) of the regulations. In the event an essential person was living with the couple, the payment increment attributable to the essential person was added to the rate of payment for the couple. Where there was a separation, retention of essential person status depended on whether the essential person continued to reside with a qualified individual. However, where the qualified individual is temporarily absent from home (as would be the case where confined to a Medicaid facility for not more than 6 months), the increment to the rate of payment because of the presence of the essential person is, under the regulations (section 416.248(c)), allowed to continue until 6 full months elapse or earlier where evidence indicates that the qualified individual does not intend to return to the home. Consequently, confinement in a Medicaid facility did not necessarily terminate the essential person increment or affect the rate of payment to the couple.
In all such cases of confinement to which the reduced rates of payment applied, such reduction was predicated by law (section 1611(e)(1)(B)) and regulation (see section 416.231(b)(5) of the regulations) on the receipt by the institution of more than 50 percent of the cost of services being provided by title XIX funds on behalf of the individual so confined.
The policies described above are applicable to the computation of payment rates for such an eligible couple for all months prior to October 1976. However, Section 502 of Public Law 94-566 amended Section 1611(e)(1)(B)(ii) of the Social Security Act to provide a new method of computation and payment for an eligible individual with an eligible spouse when one of them is so confined throughout a month.
POLICY DIRECTIVE STATEMENT:
Effective October 1976, for the purposes of computing and paying SSI benefits to an eligible individual with an eligible spouse when one of them is throughout a month in an institution which is receiving payments of more than 50 percent of the cost of services under a State plan approved under title XIX, each member of the couple will be treated as an individual; for each of these months the benefit payment to each individual will be computed separately in accordance with the following formula:
From the maximum rate prescribed for an individual under section 1611(b)(1) of the Act, there will be deducted the countable income of the member of the couple who is not in a Medicaid facility, computed as if he were an eligible individual who does not have an eligible spouse and without regard to any income of the other eligible member of the couple. That is, the amount specified in section 1611(b)(1) of the Act (after reduction by one-third, if such noninstitutionalized individual is living in the household of another as required by section 1612(a)(2)(A) of the Act) will be reduced by the amount of such individual's income, if any, that is not excludable under section 1612(b) of the Act (Subpart K of Regulations No. 16 generally), or excludable under any other Federal statute. (Section 416.1146 of such Subpart K). The difference, if any, will be the amount of the Federal SSI payment to the eligible spouse who is not confined in a Medicaid facility.
From the maximum rate prescribed for an individual in a Medicaid facility under section 1611(e)(1)(B)(ii) of the Act, there will be deducted the countable income of the member who is confined throughout any month in a Medicaid facility, computed as if such member were an individual and without regard to any income of the institutionalized eligible member of the couple. That is, the rate specified in 1611(e)(1)(B)(ii), namely $300 per year, will be reduced by the amount of such individual's income, if any, that is not excludable under section 1612(b) of the Act (Subpart K of the Regulations No. 16, generally) or excludable under any other Federal statute (Section 416.1146 of such Subpart K). The difference, if any, will be the amount of the Federal SSI payment to the eligible spouse confined in a Medicaid facility.
In the event an essential person(s) is living with the couple at the time the eligible individual or spouse enters the Medicaid facility, and the separation is temporary (section 416.1040(c)(1), the income deemed from the essential person(s), if any, will be added to the income of the noninstitutionalized individual, and the essential person(s) increment(s) will be added to the benefit rate for the noninstitutionalized individual. The above is applicable even though the confined member is the sole qualified person.
Federally administered State supplementary payments and State administered mandatory minimum supplements will be computed in the same manner as stated in this Policy Directive Statement, that is, when Public Law 94-566 applies, the State supplementary payment level (combined Federal plus State) applicable for an individual is used for the noninstitutionalized member.
The computation and payment polices prescribed in the preceding paragraphs of this Policy Directive Statement are applicable for each month in which an eligible individual or eligible spouse remain in a Medicaid facility throughout a month.
DOCUMENTATION:
Evidence that one member of a couple is in a hospital, skilled nursing facility or intermediate care facility throughout a month, and that such institution is receiving payments of more than 50 percent of the cost of services on behalf of the individual under a State plan approved under title XIX will be obtained.
FURTHER INFORMATION:
The amended rules, as described above, for computing benefits where a member of a couple is in a Medicaid facility are not applicable to a determination of initial eligibility for such couple; the rules for determinations of eligibility applicable prior to the enactment of Section 502 of Public Law 94-566 will continue in effect. In other words, upon application, a couple's eligibility will be determined based on a couple's benefit amount and a couple's resource limit, and where applicable computation and payment to the eligible individual and eligible spouse will be based on the formula set out in the above Policy Directive Statement. The application resources limit continues to be that of a couple ($2,250.00). The effect of Section 502 of Public Law 94-566 was to amend title XVI for computation and payment purposes when one member of an eligible couple is confined throughout a month in an institution and the institution is receiving payments of more than 50 percent of the cost of services on behalf of the individual under a State plan approved under title XIX. Policies related to such areas as liability for overpayments are not changed by the above policy statement in view of the fact that this section of the law as amended does not change eligibility status of the couple.