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SI 00520: Institutionalization

Effective Dates: 12/04/2012 - Present

TN 22 (04-96)

A. Procedure — Manual Notice Situations

See the exceptions listed in SI 00520.140 D.2. for the corresponding letters used to identify particular situations.

1. Exceptions a, b, c

When notifying members of an eligible couple, use the appropriate paragraphs listed in B.2. and B.3. below for both notices. However, modify the language for the notice to the spouse not in the institution. For example, in paragraph 1922, instead of saying “you entered a medical facility,” say “your spouse entered a medical facility.”

2. Exception d

Send a manual notice using the appropriate paragraphs listed in B.2. and B.3. below.

3. Exception e

Send a manual notice using the appropriate paragraphs listed in B.2. and B.3. below if you identify this situation before initial input and you are not changing the living arrangement. If the living arrangement is changing, also include either paragraph 2161 or paragraph 2162.

NOTE: If you identify this situation after initial input, and the living arrangement is not changing, no manual notice is necessary.

If you are changing the living arrangement, send a manual notice and include paragraph 2161 or 2162. Also, when deleting the continued benefit eligibility information from the record, suppress the notice. See SM 01305.760E.4.

4. Exception f

Suppress the automated notice and send a manual notice using the appropriate paragraphs listed in B.3.c. below. Send the notice in the month the individual is placed in LA D or NO2 status. Include in the denial notice either:

  • paragraph INTM50, fill-in 20, choice 37, 38, or 39; or

  • paragraph INTM51, fill-in 25, choice 43, 44, or 45.

5. Eligible Couple — Eligible for TI Benefits

When one or both members of an eligible couple are eligible to receive TI benefits, you must prepare manual notices to each member of the couple if you can notify them before the individual(s) leaves the institution.

NOTE: Manual notices are needed because the system can generate notices only after a month of resolution (MOR) is input. (See SM 01305.750 and SM 01005.750.)

Send the notice(s) of eligibility as soon as you determine eligibility. Do not wait until you make input to the system. (For example, one member of an eligible couple is eligible for TI benefits in May 1993, but no MOR has been determined yet. Send manual notices of eligibility in May 1993.)

6. Reversal of Denial of TI Benefits

When you are reversing a denial of TI benefits, send a manual notice. See B.3.d. below for paragraphs to be used.

B. Procedure— Preparing Manual Notices

Follow the instructions below whenever you must send a manual notice.

NOTE: Follow the special notice procedures in NL 01001.000 if the notice will be sent to a claimant, beneficiary, or representative payee who alleges being blind or visually impaired.

1. Forms to Use

Use the following forms:

  1. no change in payment amount— SSA-L8166-U2.

  2. reduction of payment amount, suspension or denial—SSA-L8155-U2.

  3. change to retroactive payments only— SSA-L8100-U2.

2. Chart of Captions and Paragraphs

Refer to the following chart which shows the automated captions and paragraphs generated to explain continued benefits payments when an individual is temporarily institutionalized. (The captions and paragraphs are shown in the order they should appear on the notice.) Use this chart and the information in 3. below to decide which paragraphs to use in a manual notice.

Number   Caption Title/Paragraph Description
1905   Information About Your Payments (caption)
1623   Reducing/stopping payment in 4th full month of institutionalization (check can be reduced/stopped timely)
1624   Reducing/stopping payment in 4th full month of institutionalization (check cannot be reduced/stopped timely)
1626   Reducing/stopping payment in 4th full month; recipient already notified that eligibility met
1907   Your Payment Is Based On These Facts (caption)
1622   Eligibility met; Medicaid facility
1625   Eligibility met; non-Medicaid facility
INTM52   Denial of 1611(e)(1)(G) status is reversed; eligibility now met; Medicaid facility
INTM53   Denial of 1611(e)(1)(G) status is reversed; eligibility now met; non-Medicaid facility
1633   Eligible couple; both members eligible for same time period and MOR is input; Medicaid facility
1634   Eligible couple; both members eligible for same time period and MOR is input; non- Medicaid public facility
1903   Why We Cannot Pay You (caption)
INTM50   Eligibility not met; Medicaid facility
INTM51   Eligibility not met; non-Medicaid public facility
INTM54   Eligibility decision reversed; now not eligible; Medicaid facility
INTM55   Eligibility decision reversed; now not eligible; non-Medicaid facility

3. Which Paragraphs to Use

To decide which paragraphs about continued benefits to include in a manual notice, use this section and the chart in 2. above.

  1. Notifying Recipients of Eligibility to Continuing Benefits

    Use the following paragraphs as applicable:

    • 1622

    • 1625

    • INTM52

    • INTM53

    • 1633

    • 1634

    When you must send a manual notice to an eligible individual, prepare a notice using the above paragraphs as needed.

  2. Notifying Recipients of Payment Reduction When Eligibility to Continued Benefits Ends

    Use the following paragraphs as applicable:

    • 1623

    • 1624

    • 1626

    If a recipient remains in the institution beyond the third full month of institutionalization, and a manual notice is needed, the FO must notify the recipient that his payment will be reduced or stopped using the appropriate paragraphs.

  3. Notifying Recipients of Denial of Eligibility to Continuing Benefits

    Send a manual notice. Use the following paragraphs as applicable:

    • INTM50

    • INTM51

    • INTM54

    • INTM55

  4. Notifying Recipients of Reversal of Denial Decision for Continuing Benefits

    Use the following paragraphs as applicable:

    • INTM52

    • INTM53

NOTE: The following paragraphs are on the Field Office Notice System:

  • 1622

  • 1623

  • 1624

  • 1625

  • 1626

  • INTM50

  • INTM51

C. References

NL 00801.010, instructions on preparing a manual notice.

NL 00804.166 and NL 00804.166, paragraphs about continued benefits for individuals temporarily institutionalized.

NL 00804.100, paragraphs to use in a manual notice.

SI 02301.307, SM 01305.530, and SM 01305.540, preparing a manual Goldberg/Kelly notice and suppressing a systems generated Goldberg /Kelly notice.

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