TN 33 (07-11)

Citations:

Social Security Act, Section 1611(e)(1)(E); Public Law (P.L.) 99-643, section 3;

20 CFR 416.211, 416.212, 416.410, 416.412-414, 416.640, 416.1147, 416.1149, 416.1167, 416.2040

A. Background on special benefits for institutionalized 1619 eligibles

• The Employment Opportunities for Disabled Americans Act amended section 1611(e)(1)(E) of the Social Security Act (Act). This provision created an exception to the prohibition on payment of Supplemental Security Income (SSI) benefits to certain recipients who reside throughout a month in a public institution.

• It further created an exception to the imposition of the Federal payment limit for recipients who reside throughout a month in a public or private institution where Medicaid is paying more than 50 percent toward the cost of care.

• The exception provides that certain recipients, who are eligible under section 1619(a) or section 1619(b) of the Act and become institutionalized, may be eligible for SSI payments for up to the first two full months of their institutionalization. We refer to benefits paid under this provision as “special benefits.”

• Section 1619(a) allows certain recipient to continue to receive SSI payments even though their earnings exceed the substantial gainful activity level.

• Section 1619(b) allows Medicaid eligibility to continue for certain recipient even when their earnings become too high to allow an SSI cash payment. (See SI 02302.001)

B. Policy on special benefits for institutionalized 1619 eligibles

1. Policy on 1619 eligibility criteria

An SSI payment based on the full Federal Benefit Rate (subject to changes in income) is payable for up to two months if the recipient meets the following requirements.

• The recipient was eligible for SSI under section 1619(a) or (b) of the Act in the month prior to the first full month of institutionalization; and

• The recipient is a resident of a public or private medical treatment facility where Medicaid (or private health insurance for children under age 18) is paying or is expected to pay more than 50 percent of the cost of care; and

• The institution has agreed to permit the recipient to retain any SSI benefit payment made under this provision (see SI 00520.131); and

• The month under consideration is the first full month of institutionalization or the subsequent month and the recipient is institutionalized throughout the month.

2. Policy on when the special benefits for institutionalized 1619 eligibles provision applies

The special benefits for institutionalized 1619 eligibles apply only to months throughout which an recipient is a resident in one or more of the institutions described in SI 00520.130B.1. in this section. They do not apply to a month in which an recipient ceases to be a resident of such institutions.

Examples of special benefits for institutionalized 1619 eligibles.

Example 1: Special benefits apply for two full months

Mr. Browne, who was eligible for benefits under 1619(a) in February, entered the hospital on February 17 and was transferred to a nursing home on March 3. Medicaid paid for his care in both facilities. He stayed in the nursing home until May 24, when he returned to his home.

The special benefits apply for March and April, the two full months during which Mr. Browne met the requirements in SI 00520.130B.1. in this section.

Example 2: Special benefits apply for one month only

Mrs. Edwards, who was eligible under 1619(b) in June, was admitted to a state psychiatric hospital on June 12 and was discharged on August 11. Medicaid did not pay for any of her care, and the hospital agreed to permit her to retain her special benefits.

The special benefits apply for July, the only full month during which Mrs. Edwards met the requirements in SI 00520.130B.1 in this section.

3. Policy on when special benefits for institutionalized 1619 eligibles do not apply to residents of penal institutions

The special benefits for institutionalized 1619 eligibles do not apply to residents of penal institutions (SI 00520.009).

4. Policy on computation of benefits prior to June 1996 for 1619 eligibles

Prior to June 1996, we computed the special benefits based on a living arrangement in the institution. We considered a recipient who met all eligibility criteria in SI 00520.130B.1. to be institutionalized for medical reasons for purposes of determining in-kind support and maintenance (ISM) and deeming.

5. Policy on temporary absence effective June 1996 for 1619 eligibles

a. Definition of temporary absence for special benefits purposes

• Effective June 1996, we consider a recipient, including a member of a couple, temporarily absent from the last permanent living arrangement for any months he or she is receiving the special benefits.

• Do not consider couples to be separated during periods of eligibility for special benefits.

• The “last permanent living arrangement” is the living arrangement used to determine benefits for the month before the month for which the $30 payment limit or payment status N02 would otherwise apply.

b. Living arrangements determinations for 1619 eligibles

• To determine the living arrangement from which the recipient is temporarily absent, use the permanent living arrangement as of the first moment of the month before the first full month of institutionalization.

• The circumstances that existed in that living arrangement for a particular month are the circumstances to use to determine the Federal living arrangement, ISM, deeming, and federally administered state supplementary payments for the months of eligibility to special benefits.

c. End of temporary absence determinations for 1619 eligibles

• The temporary absence continues through the last month we pay special benefits unless the recipient is discharged in the month following the last month we pay special benefits.

• In that case, temporary absence continues through the date of discharge.

• If an recipient is eligible for temporary institutionalization (TI) benefits per SI 00520.140 for the third full month of institutionalization, the temporary absence would continue through the last month TI benefits are paid or through the discharge date occurring in the month following the TI period.

See SI 00520.140B.8. for information about temporary absence and TI benefits.

Example:

A 1619(a) recipient lives with her ineligible spouse in their son's home. On December 20, she went to visit her sister. On December 29, she was admitted to a Medicaid institution and was determined to be eligible for special benefits for the months of January and February. Her son's home was her permanent living arrangement on December 1. Therefore, we would continue deeming from her ineligible spouse and we would continue to count any ISM as if she were physically residing in her son's home.

6. Policy when a special benefits recipient is temporarily institutionalized (TI)

• A recipient who is eligible for special benefits for the first two full months of institutionalization also could be eligible (if all applicable requirements are met) for TI benefits (see SI 00520.140) for the same two months, as well as for the third full month of institutionalization.

• Recipients who are eligible under section 1619(b) in the month prior to the first full month of institutionalization cannot meet the requirements for TI benefits, because they are not eligible for an SSI payment in the month prior to their first full month of institutionalization (see SI 00520.140B.4.).

• Prior to June 1996, whichever provision was more advantageous for the recipient could apply for the first two months. (For example, the applicability of the deeming or ISM provisions may have made TI benefits less advantageous than special benefits that were not subject to deeming or chargeable ISM.) Effective June 1996, we compute benefits under both provisions the same way.

7. Policy on when a recipient may decline special benefits

Any recipient who meets all the requirements for receipt of special benefits may decline to receive them and instead have eligibility and payment computed under regular rules. For example, there may be cases where an institutionalized recipient who would be subject to deeming under the special benefits rules would be eligible for a higher payment amount under regular rules.

C. Procedure when a section 1619 eligible recipient is institutionalized

1. Procedure for systems and notice instructions when a section 1619 eligible recipient is institutionalized.

• Whenever the special benefits provision applies, suppress all systems-generated notices (see SM 01301.675).

• Enter the code 1619, ELIG and the payment months for which there is eligibility under this provision (e.g., 1619, ELIG,0709,0809) in the Case Related Data (CG) field (see SM 01301.785).

• Prepare manual notices using the sample notices found at SI 02302.320 as guides. Be sure to use current and appropriate appeals language.

• Ensure that the system reflects the recipient’s permanent living arrangement as of the first moment of the month before the first full month of institutionalization.

NOTE: Follow the special notice procedures in NL 01001.010 if you send the notice to a claimant, recipient, or representative payee who alleges being blind, or visually impaired.

2. Procedure for documentation when a section 1619 eligible recipient is institutionalized

Document the file, as applicable:

• with a copy of any manual denial notice (saved in NDRED), or

• in cases where an recipient chooses to decline the special benefits, with an explanation recorded in Remarks as to why the benefits were declined.

3. Procedure for case followup when a section 1619 eligible recipient is institutionalized

• Diary the case for review at the beginning of the second month for which special benefits could apply.

• Assume the recipient is still in the facility absent a report to the contrary, and send a notice informing the recipient of any planned reduction or suspension of payment for the following month.

• If the recipient is not eligible for TI benefits (see NL 01001.010), include appropriate denial language.

D. References when a section 1619 eligible recipient is institutionalized

• Continuing benefits and recipient status under sections 1619(a) and 1619(b) for recipient who work, SI 02302.006

• Instructions on preparing a manual notice, NL 00801.010

• Paragraphs to use in a manual notice, NL 00804.100

• Information about TI benefits, SI 00520.140.

• Instructions on preparing notices about TI benefits,
  SI 00520.141