TN 36 (05-12)

Facilities that were not previously receiving Medicaid payments may be converted to Medicaid facilities (i.e., certified by Medicaid to receive payments). Conversions may affect supplemental security income (SSI) eligibility and payment determinations.

A. Process for facility conversion

Before and during the conversion process, the resident usually pays for his own care. This payment may be from his income, including his SSI benefits, or from a third party on his behalf. We may apply SSI benefits to the cost of care if the special benefits provision for recipients eligible under 1619, or the continuation of benefits provision for recipients temporarily institutionalized applies, see policy in SI 00520.130. When a certification decision is made, the effective date of Medicaid coverage is often retroactive (usually to the date of the survey), and the provider is eligible for reimbursement for Medicaid funds for the retroactive period.

Under Medicaid, determine the amount of reimbursement based on the recipient’s total income (including amounts disregarded in determining Medicaid eligibility) during this period.

We reduce the Medicaid reimbursement rate by the amount of the recipient’s income (including SSI and State supplementary payments). However, any amounts of SSI or State supplementary payments that the recipient or representative payee refunded to SSA or the State (e.g., via the overpayment recovery process) would not be counted in determining Medicaid reimbursement.

Reference

SI 00520.140 Temporary Institutionalization (TI) Benefits

B. Regional Office (RO) responsibilities and notification of certification

ROs establish procedures that ensure that SSA promptly receives notification of certification.

When the RO receives a certification notification directly from the State Medicaid certifying agency or from the Centers for Medicare and Medicaid Services (CMS), the RO is responsible for notifying the appropriate field office (FO).

The RO can negotiate with the State Medicaid certifying agency or have the parallel FO negotiate, to establish a system of direct reporting of certifications from the certifying agency to the retirement and survivors insurance (RSI) and SSI Programs Branch of the SSA RO or to the parallel FO. Appropriate reports show the name of the facility, the date the State Medicaid agency made the certification, and the effective date of the certification.

RO staff should maintain a close working relationship with CMS to ensure that prompt notification of certification to SSA is routine.

The ROs have flexibility in determining who uses what system or systems. ROs and FOs should attempt to develop a system of receiving reports, including negative reports, at least monthly.

C. Policy to determine month of certification

For SSI purposes, the “month of certification” is the month we make the certification decision by the certifying agency, not the month the decision is effective, if retroactive. The recipient becomes a resident of a Medicaid-certified facility in the month of certification.

D. Policy for the application of $30 payment limit

The $30 payment limit applies for the month of certification only if:

• throughout the entire month, the recipient was a resident of the facility or another Medicaid institution; and

• the Medicaid payment exceeds 50 percent of the cost of care for the period in the Medicaid facility during that month; and

• the facility is a public institution.

NOTE: If the facility is private, we apply the $30 payment limit the month after the month of certification.

1. Correct payments

SSI payments (including federally administered State supplementary payments) that we make without applying the $30 payment limit for the month of actual certification (or the effective month of certification, if later) and all months of any retroactive period of certification, we consider correctly made and are not overpayments.

2. Overpayments

SSI payments (including federally administered State supplementary payments) that are made without applying the $30 payment limit for the month following the month of actual certification (or the effective month of certification, if later) and the date we are able to effectuate a change of payment status constitute overpayments.

E. Procedure for notification of certification

1. Parallel FO responsibility

If the parallel FO receives the notification of certification from the Medicaid certifying agency, immediately notify both the RSI and the SSI Programs Branch and the FO that services the affected facility.

2. Servicing FO responsibility

• Identify all the residents of the facility certification change that the certification affects.

• Process any changes to the records of all affected recipients promptly to reduce the possibility of overpaying residents of a converted facility.

NOTE: Since we are not able to effectuate the necessary change in a recipient’s payment prior to official notification that Medicaid certified a facility; any delay in this notice will result in SSI or State supplementary overpayments.