California

SI 01415.043B

Delaware

SI 01415.043C

District Of Columbia

SI 01415.043D

Hawaii

SI 01415.043E

Iowa

SI 01415.043F

Massachusetts

SI 01415.043G

Michigan

SI 01415.043H

Montana

SI 01415.043I

Nevada

SI 01415.043J

New Jersey

SI 01415.043K

New York

SI 01415.043L

Pennsylvania

SI 01415.043M

Rhode Island

SI 01415.043N

Utah

SI 01415.043O

Vermont

SI 01415.043P

A

Independent Living with Cooking Facilities for an Eligible individual or couple who meets one of the following situations:

1. Lives in their own household, as defined for Federal living arrangement (FLA) A purposes, and has cooking and food storage facilities, or receives meals as part of the living arrangement;

2. Is a patient in a certified private medical facility where Title XIX does not pay more than 50 percent of the cost of care;

3. Is a blind child under age 18 living in the household of a parent, or parents, or is a disabled child age 18, or over who meets sharing criteria and is living in the household of a parent or parents;

4. Is a blind individual who lives in an independent living arrangement with or without cooking and food storage facilities; or

5. Lives in a private medical facility licensed by the State but not certified under Title XIX.

B

Non-medical Out-of-Home Care (NMOHC) applies when an individual or couple needs non-medical care, or supervision in the following living arrangement situations:

CHILDREN (UNDER AGE 18)

1. Blind child residing in a State licensed NMOHC facility;

2. Blind child residing in the home of a relative who is not a parent and not a legal guardian;

3. Disabled child residing in a State licensed NMOHC facility;

4. Disabled child residing in the home of a legal guardian who is not a relative;

5. Disabled child residing in the home of a relative who is not a parent (Major v. McMahon decision); or

6. A blind or disabled child in a “certified family” home approved by a licensed home-finding agency (“certified family home placement”); or

ADULTS (AGE 18 AND OVER)

1. Aged, blind or disabled individual, or couple has been determined to be in FLA A and resides in the home of a relative, legal conservator or guardian; or

2. Aged, blind, or disabled individual or couple is determined to be in FLA A and resides in a State licensed NMOHC facility.

For California optional supplement (OS) purposes, a relative is defined as a parent, son, daughter, brother, sister, half-brother, half-sister, uncle, aunt, niece, nephew, first cousin, or any person of the preceding generation denoted by the prefix “grand” or “great.”

C

Independent Living Without Cooking Facilities -- Aged or disabled individual or couple who is neither provided any meals, nor has access to adequate cooking or food storage facilities as part of a living arrangement. Transients, as defined in SI 00835.060, are also eligible for OS C.

An individual or couple qualifies for OS C if any of the following situations exists:

1. Immediate living quarters do not have cooking and food storage facilities with which the individual or couple, or another person (who is responsible for preparing their meals) can prepare meals on a daily basis.

2. Does not have access to adequate cooking and food storage facilities as part of the living arrangement (including cooking and food storage facilities that are outside the immediate living quarters), for the preparation of meals or having meals prepared on his or her behalf.

3. Lives in a boarding house that does not have a communal kitchen with adequate cooking and food storage facilities that he or she has access for preparation of meals.

4. Lives with friends or relatives in private living quarters in the same house or in separate living quarters (for example, “over the garage”) or in a similar situation and does not have access to the cooking and food storage facilities in the main residence for preparation of meals.

5. Lives in a room and board facility and does not contract with the facility to have meals prepared and provided as part of the living arrangement (for example, the Supplemental Security Income (SSI) recipient’s arrangement with the facility is to purchase only shelter on a monthly basis).

“Adequate” cooking and food storage facilities exist when an individual or couple has access to:

• A working refrigerator or icebox, and a stove without a working oven, but with at least two working burners. (The capacity of the refrigerator or icebox is not a factor of consideration. Do not consider an ice-chest as adequate storage.)

OR

• A working refrigerator or icebox, and a hotplate with at least two burners with separate temperature controls, or two one-burner hotplates with temperature controls. (Do not consider hotplates that do not have temperature controls for warming food as adequate cooking facilities.)

OR

• A working refrigerator or icebox, and a stove with a working oven or functioning microwave oven, in combination with at least one working burner on a stove, or a one-burner hotplate with a temperature control.

Eligibility for OS C begins in the month the recipient applies for this supplement rate provided they have been without cooking and food storage facilities throughout the month.

NOTE: For purposes of OS C, “throughout a month” does not mean the recipient must lack adequate cooking or food storage facilities from the very first moment of the month. The recipient need only lack them from some time on the first day of the month.

If you based eligibility on temporary loss or nonfunctioning of an appliance, advise the individual of their responsibility to immediately report when the temporary condition ceases. If the individual provides an expected repair or replacement date for the appliance, diary the case for re-contact.

Eligibility for this supplementary payment ceases the month following the month that the recipient receives meals, or adequate cooking and food storage facilities are available.

For a couple, comprised of an aged or disabled individual and a blind individual, whose living arrangement lacks adequate cooking and storage facilities, the couple receives the SSI and State Supplement Payment level for a blind or aged, or disabled couple, plus the restaurant meals allowance for the disabled member of the couple. This living arrangement requires force payment.

D

Living in the Household of Another -- Eligible individual or couple is living in the household of another and receives food and shelter from that individual. Most individuals or couples who are subject to a one-third reduction of their Federal SSI payments are eligible for OS D because the criteria for this supplement level are the same as charging the one-third reduction. However, when the eligible individual or couple lives in the home of a relative (other than a spouse) and needs care and supervision, you must obtain certification for non-medical out-of-home care (OS F) from the county welfare office since this is the highest categorical supplement for which an individual or couple can qualify.

E

Disabled Child Under Age 18 – Disabled (not blind) child under age 18 who resides with a parent or relative by blood or marriage.

NOTE: Only FLA A and C are compatible with OS E. If the value of the one-third reduction (VTR) applies, see code G in this section.

F

Non-medical Out-of-Home Care Living in the Household of Another -- Applies whenever an eligible individual or couple meets the criteria for the non-medical out-of-home care payment rate, and is determined to receive the Federal code B payment for living in the household of another. For the One-Third Reduction Provision see SI 00835.200.

G

Disabled Child Under Age 18 Living in the Household of Another -- Applies to a disabled (not blind) child under age 18, who resides with a parent or relative by blood or marriage, and is determined to receive the Federal code B payment for living in the household of another individual. For the One-Third Reduction Provision, see SI 00835.200.

J

Residents of Title XIX facilities.

Use this State code to supplement Section 1619 cases.

Y

Optional Supplementation Waived -- Individual is eligible for, but waives the right to receive an optional supplement.

Z

No Supplement Cases -- Eligible recipient who is a patient:

1. In a medical facility where Title XIX pays more than 50 percent of the costs; or

2. In a private medical facility not certified under Title XIX, and not licensed by the State.

Includes residents of publicly operated emergency shelters throughout a month.

NOTE: California is a concurrent category State, and permits SSI recipients to receive the highest categorical supplement for which they can qualify.

A

A

Aged

674.00

156.40

830.40

Blind

674.00

211.40

885.40

Disabled

674.00

156.40

830.40

B

All

674.00

412.00

1,086.00

C

Aged

674.00

240.40

914.40

Blind

674.00

0.00

674.00

Disabled

674.00

240.40

914.40

E

Disabled

674.00

63.40

737.40

Z

All

674.00

0.00

674.00

B

D

Aged

449.34¹

159.83

609.17

Blind

449.34¹

214.83

664.17

Disabled

449.34¹

159.83

609.17

F

All

449.34¹

407.00

856.34

G

Disabled

449.34¹

66.83

516.17

C

A

Blind

674.00

211.40

885.40

E

Disabled

674.00

63.40

737.40

D

J

All

30.00²

20.00

50.00

A

A

Aged/Aged

1011.00

396.20

1407.20

Blind/Blind

1011.00

543.20

1554.20

Disabled/Disabled

1011.00

396.20

1407.20

Aged/Blind

1011.00

487.20

1498.20

Aged/Disabled

1011.00

396.20

1407.20

Blind/Disabled

1011.00

487.20

1498.20

B

All

1011.00

1161.00

2172.00

C

Aged/Aged

1011.00

564.20

1575.20

Disabled/Disabled

1011.00

564.20

1575.20

Aged/Disabled

1011.00

564.20

1575.20

Z

All

1011.00

0.00

1011.00

B

D

Aged/Aged

674.00¹

401.33

1075.33

Blind/Blind

674.00¹

548.33

1222.33

Disabled/Disabled

674.00¹

401.33

1075.33

Aged/Blind

674.00¹

492.33

1166.33

Aged/Disabled

674.00¹

401.33

1075.33

Blind/Disabled

674.00¹

492.33

1166.33

F

All

674.00¹

1045.66

1719.66

D

J

All

60.00²

40.00

100.00

A

A

Aged

674.00

171.00

845.00

Blind

674.00

234.00

908.00

Disabled

674.00

171.00

845.00

B

All

674.00

412.00

1,086.00

C

Aged

674.00

255.00

929.00

Blind

674.00

0.00

674.00

Disabled

674.00

255.00

929.00

E

Disabled

674.00

63.40

737.40

Z

All

674.00

0.00

674.00

B

D

Aged

449.34¹

190.32

639.66

Blind

449.34¹

268.98

718.32

Disabled

449.34¹

190.32

639.66

F

All

449.34¹

407.00

856.34

G

Disabled

449.34¹

67.96

517.30

C

A

Blind

674.00

234.00

908.00

E

Disabled

674.00

63.40

737.40

D

J

All

30.00²

20.00

50.00

A

A

Aged/Aged

1011.00

396.20

1407.20

Blind/Blind

1011.00

543.20

1554.20

Disabled/Disabled

1011.00

396.20

1407.20

Aged/Blind

1011.00

487.20

1498.20

Aged/Disabled

1011.00

396.20

1407.20

Blind/Disabled

1011.00

487.20

1498.20

B

All

1011.00

1161.00

2172.00

C

Aged/Aged

1011.00

564.20

1575.20

Disabled/Disabled

1011.00

564.20

1575.20

Aged/Disabled

1011.00

564.20

1575.20

Z

All

1011.00

0.00

1011.00

B

D

Aged/Aged

674.00¹

401.33

1075.33

Blind/Blind

674.00¹

548.33

1222.33

Disabled/Disabled

674.00¹

401.33

1075.33

Aged/Blind

674.00¹

492.33

1166.33

Aged/Disabled

674.00¹

401.33

1075.33

Blind/Disabled

674.00¹

492.33

1166.33

F

All

674.00¹

1045.66

1719.66

D

J

All

60.00²

40.00

100.00

A

Adult Residential Care Facility, Assisted Living Facility, or Adult Foster Care Home -- Only living arrangement variation in Delaware and includes only those recipients who are certified by the State medical unit as residents of one of the above adult facilities.

Y

Optional Supplementation Waived -- Individual is eligible for, but waives the right to receive an optional supplement.

Z

No Supplement Cases -- All recipients who are not included in A or Y.

Use optional supplementation code Z with an “intervening” Federal code A. For Optional State Supplement codes, see SM 01301.535.

A

A

All

674.00

140.00

814.00

Z

All

674.00

0.00

674.00

B

Z

All

449.34¹

0.00

449.34

C

Z

All

674.00

0.00

674.00

D

Z

All

30.00²

0.00

30.00

A

A

All

1011.00

448.00

1459.00

Z

All

1011.00

0.00

1011.00

B

Z

All

674.00¹

0.00

674.00

D

Z

All

60.00²

0.00

60.00

A

Adult Foster Care Home with 50 or Fewer Residents --Recipients who are certified by the District of Columbia, Department of Health, as residents of an adult foster care home with 50 or fewer residents.

B

Adult Foster Care Home with More than 50 Residents --Recipients who are certified by the District of Columbia, Department of Health, as residents of an adult foster care home with more than 50 residents.

G

Residents of Title XIX facilities.

Y

Optional Supplementation Waived -- Individual is eligible for, but waives the right to receive an optional supplement.

Z

No Supplement Cases -- All recipients who are not included in A, B, G, or Y.

A

A

All

674.00

485.00

1159.00

B

All

674.00

595.00

1269.00

B

Z

All

449.34¹

0.00

449.34

C

Z

All

674.00

0.00

674.00

D

G

All

30.00²

40.00

70.00

A

A

All

1011.00

1307.00

2318.00

B

All

1011.00

1527.00

2538.00

B

Z

All

674.00¹

0.00

674.00

D

G

All

60.00²

80.00

140.00

B

Living in a Community Care or Foster Care Home --

Persons eligible for SSI who are both over age 18, and live in a State approved Care or Foster Care Home.

D

Living in a Certified Medical Facility – Eligible individual living in a medical treatment facility where a substantial part (more than 50 percent) of the cost of care is paid under Title XIX.

H

Domiciliary Care I -- (Maximum of five residents) - Eligible individual (including a child), or couple living in a domiciliary care facility which provides varying levels of care and services. A domiciliary care facility is a private, non-medical facility established and maintained to provide personal care and services to aged, infirm, or handicapped persons. The State provides SSA with listings of these facilities.

I

Domiciliary Care II -- Same as H, except care provided for six or more residents.

Y

Optional Supplementation Waived -- Eligible for, but waives his or her right to receive an optional supplement.

Z

No Supplement Cases -- Eligible recipient who is living in the household of another, or an eligible recipient who is a patient in a private medical facility not certified under Title XIX.

Also includes residents of publicly operated emergency shelters throughout a month.

A 

B

All

674.00

651.90

1325.90

H

All

674.00

651.90

1325.90

I

All

674.00

759.90

1433.90

B

Z

All

449.34¹

0.00

449.34

D

D

All

30.00²

20.00

50.00

 A

B

All

1011.00

1640.80

2651.80

H

All

1011.00

1640.80

2651.80

I

All

1011.00

1856.80

2867.80

B

Z

All

674.00¹

0.00

674.00

D

D

All

60.00²

40.00

100.00

A

Living in Own Household (Blind Only) -- Only an eligible blind individual and the blind member of a couple who does not live in any other State living arrangement variation, does not have an Essential Person (EP), and is not otherwise excepted from supplementation. Also included are blind recipients in Title XIX facilities where Medicaid pays 50 percent or less of the cost of care. Optional supplement code A is also compatible with Federal codes A and C.

Use optional supplement code A with an “intervening” Federal code A. For State Supplement codes, see SM 01301.535.

B

Living in the Household of Another (Blind Only) -- Only an eligible blind individual and the blind member of a couple who does not live in any other State living arrangement variation, lives in the household of another for Federal purposes, does not have an EP, and is not otherwise excepted from supplementation.

C

Living with a Dependent Person -- Eligible individual or each member of an eligible couple in Federal living arrangement A or C who has an ineligible spouse, parent, child, or adult child living in the home with them, and who is financially dependent upon the eligible individual as defined by the State Department of Human Services.

The payment level for this variation increases by $22 for each blind individual or blind member of a couple to reflect the categorical blind supplement.

H

Living with a Dependent Person -- Eligible individual or each member of an eligible couple in Federal living arrangement B who has an ineligible spouse, parent, child, or adult child living in the home with them, and who is financially dependent upon the eligible individual as defined by the State Department of Human Services.

The payment level for this variation increases by $22 for each blind individual or blind member of a couple to reflect the categorical blind supplement.

I

Living in a Family Life or Boarding Home -- Eligible individual or each member of an eligible couple in FLA A or B, who resides in a family life home or boarding home licensed by the State Department of Health, or certified by the State Department of Human Services.

G

Indicates that no supplement is payable to a recipient living in a Title XIX facility and Title XIX pays more than 50 percent of the cost of care; however, a Federal D living arrangement is not appropriate because the “throughout a month” requirement is not met at the time of the initial claim input.

Y

Optional Supplementation Waived -- Individual is eligible for, but waives the right to receive an optional supplement.

Z

No Supplement Cases = Residents of publicly operated emergency shelters throughout a month and aged and disabled recipients living in their own households, or living in the households of others. “No supplement” also applies to all recipients living in medical facilities not certified under Title XIX, or all recipients who receive reduced Federal payments of $30 or $60 due to living in a Title XIX facility. In addition, aged and disabled recipients whose Federal payments are not reduced, and who live in a Title XIX facility where Medicaid pays 50 percent or less of the cost of care do not receive a supplement.

NOTE: The State Department of Human Services administers three optional supplementation programs:

• In-Home Health Related Care

• Residential Care

• Supplement for Medicare and Medicaid Eligibles.

A

A

Blind

674.00

22.00

696.00

C

Aged

674.00

344.00

1018.00

Blind

674.00

366.00

1040.00

Disabled

674.00

344.00

1018.00

D

Aged

674.00

142.00

816.00

Blind

674.00

164.00

838.00

Disabled

674.00

142.00

816.00

Z

Aged

674.00

0.00

674.00

Disabled

674.00

0.00

674.00

B

B

Blind

449.34¹

22.00

471.34

H³

Aged

449.34¹

344.00

793.34

Blind

449.34¹

366.00

815.34

Disabled

449.34¹

344.00

793.34

I³

Aged

449.34¹

142.00

591.34

Disabled

449.34

142.00

591.34

Blind

449.34

164.00

613.34

Z

Aged

449.34¹

0.00

449.34

Disabled

449.34¹

0.00

449.34

C

A

Blind

674.00

22.00

696.00

C

Blind

674.00

366.00

1040.00

Disabled

674.00

344.00

1018.00

Z

Disabled

674.00

0.00

674.00

D

Z

All

30.00²

0.00

30.00

A

A

Blind/Blind

1011.00

44.00

1055.00

Blind/Aged

1011.00

22.00

1033.00

Blind/Disabled

1011.00

22.00

1033.00

C

Aged/Aged

1011.00

344.00

1355.00

Blind/Blind

1011.00

388.00

1399.00

Disabled/Disabled

1011.00

344.00

1355.00

Aged/Blind

1011.00

366.00

1377.00

Aged/Disabled

1011.00

344.00

1355.00

Blind/Disabled

1011.00

366.00

1377.00

D

Aged/Aged

1011.00

641.00

1652.00

Blind/Blind

1011.00

685.00

1696.00

Disabled/Disabled

1011.00

641.00

1652.00

Aged/Blind

1011.00

663.00

1674.00

Aged/Disabled

1011.00

641.00

1652.00

Blind/Disabled

1011.00

663.00

1674.00

Z

Aged/Aged

1011.00

0.00

1011.00

Disabled/Disabled

1011.00

0.00

1011.00

Aged/Disabled

1011.00

0.00

1011.00

B

B

Blind/Blind

674.00¹

44.00

718.00

Blind/Aged

674.00¹

22.00

696.00

Blind/Disabled

674.00¹

22.00

696.00

H

Aged/Aged

674.00¹

344.00

1018.00

Blind/Blind

674.00¹

388.00

1062.00

Disabled/Disabled

674.00¹

344.00

1018.00

Aged/Blind

674.00¹

366.00

1040.00

Aged/Disabled

674.00¹

344.00

1018.00

Blind/Disabled

674.00¹

366.00

1040.00

I

Aged/Aged

674.00¹

641.00

1315.00

Blind/Blind

674.00¹

685.00

1359.00

Disabled/Disabled

674.00¹

641.00

1315.00

Aged/Blind

674.00¹

663.00

1337.00

Aged/Disabled

674.00¹

641.00

1315.00

Blind/Disabled

674.00¹

663.00

1337.00

Z

Aged/Aged

674.00¹

0.00

674.00

Disabled/Disabled

674.00¹

0.00

674.00

Aged/Disabled

674.00¹

0.00

674.00

D

Z

All

60.00²

0.00

60.00

A

Full Cost-of-Living:

An individual who is in FLA A is in State living arrangement A, if they are living in their own household¹ and meets one of the following conditions:

1. Living alone -- Individuals who live alone, who rent rooms in commercial rooming houses which openly advertise to the public and which do not provide board, or who live in a hotel. Also, consider those who rent only rooms in private residences as living alone, provided they do not use the residential kitchen facilities for preparing meals;

2. Living only with their eligible spouse;

3. Living with their eligible spouse and ineligible child or children ² none of whom (children) receive public income maintenance payments;³ or

4. Living only with their ineligible spouse or their ineligible child or children, none of whom (spouse and children) receive public income maintenance payments.

NOTE: For purposes of 1 through 4, do not consider foster children placed with anyone other than their parents to be living with the foster parent.

An individual who is in FLA C is in State living arrangement A if none of the other people with whom they are living receive public income maintenance payments.

An individual who is in FLA A or C, and who does not meet the criteria in SI 01415.040G.1. (see Code A, 1, or 2 (in this chart)) is in State living arrangement A, if they pay at least two-thirds of the household expenses. In making a determination as to whether the individual pays two-thirds or more of the expenses, use the method defined in, SI 00835.160. Only use the household expenses shown in that section. You may use an ineligible spouse's income (except any assistance based upon need) to determine if the eligible person is paying two-thirds of the household expenses.

A person living in a public congregate housing development is in A. The State makes the determination that a public congregate housing development is eligible for listing. Use optional supplement code A with an “intervening” Federal code A. For Optional State Supplement codes, see SM 01301.535.

B

Shared Living Expenses -- An individual who is in FLA A or C, and who does not meet the criteria listed for State living arrangement A, E, or G is in State living arrangement B. Also included in this living arrangement are transients, the homeless, and residents of public emergency shelters for the homeless (PESH).

Those residing in group-care facilities, such as halfway houses, private medical facilities where Medicaid is paying 50 percent or less of the cost of care, foster homes, commercial boarding homes, or other facilities which do not meet the criteria for living arrangement E or public congregate housing defined in SI 01415.040G.1., Code A.4. (in this section). This includes children under the age of 18, who are in Federal living arrangement D because a private health insurance policy, or a combination of Medicaid and a private health insurance policy pays, or is expected to pay over 50 percent of the cost of care for that month. For determination of applicability of $30 payment limit, see SI 00520.011C.1.b. This also includes individuals placed under the auspices of the State adult foster care program, and residents of publicly operated emergency shelters throughout a month.

An individual living in a household where all members receive public income maintenance payments, unless they are paying at least two-thirds of the household expenses (A).

An individual living in a mixed household; i.e., a household where one or more other members receive a public income maintenance payment, is also included, unless the individual is paying at least two-thirds of the household expenses (A).

C

Living in the Household of Another -- Recipients determined under Federal rules to be living in the household of another and receiving support and maintenance which reduce the Federal benefit by one-third.

E

Licensed Rest Home -- Persons residing in a licensed rest home, all of which or the portion in which they live in is licensed by, and has a provider agreement with the State. This does not include residents of a Medicaid certified portion of a rest home.

F

Effective 07/01/87, the State elected Federal administration of this optional State supplementary payment to residents of Title XIX facilities where Medicaid pays more than 50 percent of the cost of care. This includes children under the age of 18 for whom Medicaid alone pays or expects to pay over 50 percent of the cost of care for that month.

G

Assisted Living -- Effective 07/01/94, the State elected Federal administration of this variation. Includes an individual, certified by the State to be residing in an Assisted Living residence served by a certified Group Adult Foster Care provider, who does not receive assistance under any other Federal or State rental assistance program, and who pays a fixed, non-separable fee for rent and supportive services, other than medically necessary services reimbursed by Medicaid. The State certifies to SSA each individual who is eligible for this optional supplement living arrangement. This living arrangement was discontinued effective 01/01/96; but restored, retroactively, to 01/01/97.

Y

Optional Supplementation Waived -- Individual is eligible for, but waives the right to receive, an optional supplement.

A

A

Aged

674.00

128.82

802.82

Blind

674.00

149.74

823.74

Disabled

674.00

114.39

788.39

B

Aged

674.00

39.26

713.26

Blind

674.00

149.74

823.74

Disabled

674.00

30.40

704.40

E

Aged

674.00

293.00

967.00

Blind

674.00

149.74

823.74

Disabled

674.00

293.00

967.00

G

Aged

674.00

454.00

1128.00

Blind

674.00

454.00

1128.00

Disabled

674.00

454.00

1128.00

B

C

Aged

449.34¹

104.36

553.70

Blind

449.34¹

374.40

823.74

Disabled

449.34¹

87.58

536.92

C

A

Blind

674.00

149.74

823.74

Disabled

674.00

114.39

788.39

B

Blind

674.00

149.74

823.74

Disabled

674.00

30.40

704.40

D

B²

Blind

30.00³

149.74

179.74

Disabled

30.00³

30.40

60.40

F

All

30.00³

42.80

72.80

A

A

Aged/Aged

1011.00

201.72

1212.72

Blind/Blind

1011.00

636.48

1647.48

Disabled/Disabled

1011.00

180.06

1191.06

Aged/Blind

1011.00

419.10

1430.10

Aged/Disabled

1011.00

190.89

1201.89

Blind/Disabled

1011.00

408.27

1419.27

B

Aged/Aged

1011.00

201.72

1212.72

Blind/Blind

1011.00

636.48

1647.48

Disabled/Disabled

1011.00

180.06

1191.06

Aged/Blind

1011.00

419.10

1430.10

Aged/Disabled

1011.00

190.89

1201.89

Blind/Disabled

1011.00

408.27

1419.27

E

Aged/Aged

1011.00

923.00

1934.00

Blind/Blind

1011.00

636.48

1647.48

Disabled/Disabled

1011.00

923.00

1934.00

Aged/Blind

1011.00

779.74

1790.74

Aged/Disabled

1011.00

923.00

1934.00

Blind/Disabled

1011.00

779.74

1790.74

G

All

1011.00

681.00

1692.00

B

C

Aged/Aged

674.00¹

215.80

889.80

Blind/Blind

674.00¹

973.48

1647.48

Disabled/Disabled

674.00¹

194.18

868.18

Aged/Blind

674.00¹

594.64

1268.64

Aged/Disabled

674.00¹

204.99

878.99

Blind/Disabled

674.00¹

583.83

1257.83

D

F

All

60.00²

85.60

145.60

D

Domiciliary Care -- Recipients residing in licensed non-medical facilities that provide room, board, and supervision. The State provides a list of these facilities and certifies which recipients are residents requiring this level of care.

E

Personal Care -- Recipients residing in licensed non-medical facilities that provide general supervision, physical care, and assistance in carrying out the basic activities of daily living. The State provides a list of these facilities and certifies which recipients are residents requiring this level of care. Such care situations include, but are not limited to, licensed homes for the aged.

F

Home for the Aged -- Recipients residing in a non-medical facility for the aged. The State provides SSA with a list of these facilities and certifies which recipients are residents requiring this level of care.

G

Independent Living with an EP -- Recipients with an EP, not living in the household of another. (Exclude children under age 18.)

H

Living in the Household of Another with an EP -- Recipients with an EP and living in the household of another for Federal purposes. (Exclude children under age 18.)

I

Effective 01/01/88, the State elected Federal administration of an optional State supplementary payment to residents of Title XIX facilities.

Y

Optional Supplementation Waived -- Individual is eligible for, but waives the right to receive an optional supplement.

Z

No Supplement Cases -- Recipients in Title XIX facilities where Medicaid pays more than 50 percent of the cost of care and recipients in medical facilities not certified under Title XIX.

A

D

All

674.00

87.00

761.00

E

All

674.00

157.50

831.50

F

All

674.00

179.30

853.30

G

All

1012.00²

14.00

1026.00

B

H

All

674.67¹

9.33

684.00

D

I

All

  30.00³

7.00

37.00

A

D

All

1011.00

511.00

1522.00

E

All

1011.00

652.00

1663.00

F

All

1011.00

695.60

1706.60

G

All

1349.00²

21.00

1370.00

B

H

All

899.34

14.00

913.34

D

I

All

60.00³

14.00

74.00

G

State-Certified Personal Care

H

State-Certified Residence in Group Home for Mentally Disabled

I

State-Certified Residence in Group Home for Physically or Developmentally Disabled

J

State-Certified Residence for Child and Adult Foster Care

K

State-Certified Transitional Living for Developmentally Disabled

Y

Optional Supplementation Waived -- Individual is eligible for, but waives the right to receive an optional supplement.

Z

No Supplement Cases -- Includes all individuals and couples not certified in State codes G, H, I, J, or K.

A

G

All

674.00

94.00

768.00

H

All

674.00

94.00

768.00

I

All

674.00

94.00

768.00

J

All

674.00

52.75

726.75

K

All

674.00

26.00

700.00

Z

All

674.00

0.00

674.00

B

Z

All

449.34¹

0.00

449.34

C

Z

All

674.00

0.00

674.00

D

Z

All

30.00²

0.00

30.00

A

G

All

1011.00

193.00

1204.00

H

All

1011.00

193.00

1204.00

I

All

1011.00

193.00

1204.00

J

All

1011.00

110.50

1121.50

K

All

1011.00

57.00

1068.00

Z

All

1011.00

0.00

1011.00

B

Z

All

674.00¹

0.00

674.00

D

Z

All

60.00²

0.00

60.00

A

Independent Living or Living in Parental Household -- Aged or blind eligible recipient who meets one of the following situations:

1. Lives in their own household as defined for Federal living arrangement A purposes;

2. Is a patient in a certified private medical facility where Title XIX does not pay more than 50 percent of the cost of care; or

3. Is a blind child under age 18 (age 21 for individuals who qualify as a “protected child”) living in a parent's household.

Use with an “intervening” Federal code A. For Optional State Supplement codes see SM 01301.535.

B

Living in the Household of Another -- Aged or blind eligible recipient who is living in the household of another individual and receiving food and shelter from that individual. Aged or blind recipients who are subject to a one-third reduction (VTR) of their Federal SSI payment, are eligible for optional supplement B because the criteria for this supplement level are the same as for Federal code B.

C

Domiciliary Care -- Aged or blind eligible recipient who lives in a private non-medical facility or, a residential facility serving 16 or fewer persons, which provides personal care and services to aged, infirm, or handicapped adult persons who are unrelated to the proprietor.

The State provides licenses and authorizes these facilities to receive payment. The State provides SSA with listings of these facilities.

Y

Optional Supplementation Waived -- Individual is eligible for, but waives the right to receive an optional supplement.

Z

No Supplement Cases -- No supplement cases include one of the following:

1. Disabled eligible individual or disabled member of eligible couple;

2. Eligible individual or member of eligible couple in a medical facility where Title XIX pays more than 50 percent of the cost;

3. Eligible individual or member of eligible couple who is a patient in a private medical facility which is not certified under Title XIX; or

4. Residents of publicly operated emergency shelters throughout a month.

A

A

Aged

674.00

36.40

710.40

Blind

674.00

109.30

783.30

C

Aged

674.00

391.00

1065.00

Blind

674.00

391.00

1065.00

Z

Disabled

674.00

0.00

674.00

B

B

Aged

449.34¹

24.27

473.61

Blind

449.34¹

213.96

663.30

Z

Disabled

449.34¹

0.00

449.34

C

A

Blind

674.00

109.30

783.30

Z

Disabled

674.00

0.00

674.00

D

Z

All

30.00²

0.00

30.00

A

A

Aged/Aged

1011.00

74.46

1085.46

Blind/Blind

1011.00

374.60

1385.60

Aged/Blind

1011.00

224.53

1235.53

Aged/Disabled

1011.00

37.23

1048.23

Blind/Disabled

1011.00

187.30

1198.30

C

Aged/Aged

1011.00

881.00

1892.00

Blind/Blind

1011.00

881.00

1892.00

Aged/Blind

1011.00

881.00

1892.00

Aged/Disabled

1011.00

440.50

1451.50

Blind/Disabled

1011.00

440.50

1451.50

Z

Disabled

1011.00

0.00

1011.00

B

B

Aged/Aged

674.00¹

49.64

723.64

Blind/Blind

674.00¹

531.94

1205.94

Aged/Blind

674.00¹

290.79

964.79

Aged/Disabled

674.00¹

24.82

698.82

Blind/Disabled

674.00¹

265.97

939.97

Z

Disabled

674.00¹

0.00

674.00

D

Z

All

60.00²

0.00

60.00

A

Congregate Care - Eligible recipient in FLA A. The living arrangement includes the following:

• Recipients in residential facilities who are under the supervision of the Department of Human Services

• Children and adults under the supervision of, or placed by, the NJ Department of Human Services’ Division of Developmental Disabilities (DDD) or

• Division of Youth and Family Services (DYFS) who are in residential facilities (both in and outside of NJ); and

• Recipients in Assisted Living Residences and in Comprehensive Personal Care Homes (CPCH) licensed by the Department of Health and Senior Services.

B

Living Alone or with Others -- Eligible recipients FLA A or C who do not meet the requirements defined in other supplementation categories.

Therefore, any eligible recipient who meets the requirement for FLA A is in optional supplement B unless residing in a residential health care facility or living alone with an ineligible spouse.

Automatically entitle any child meeting the criteria for a Federal code C to optional supplement B.

This category includes, but is not limited to, those eligible recipients who are in one of the following situations:

1. Living physically alone;

2. Living with others in a private dwelling, but meeting some criteria for Federal living arrangement A; or

3. Living in the Transitional Residency Program when the placement is through the Division of Mental Health and Hospitals, Department of Human Services.

Use optional supplement code B with an “intervening” Federal code A. For State Supplement codes, see SM 01301.535.

Also, use this State code to supplement Section 1619 cases.

C

Living Alone with an Ineligible Spouse -- An individual lives with their ineligible spouse, and there are no other persons who are part of the household. Determine who is an ineligible spouse for State supplementation purposes by using Federal criteria; i.e., a spouse, either by marriage or holding out, who is either not eligible for SSI, or who chooses not to apply. Once other persons, even minor children, are present in the household, this supplementary payment variation cannot exist. However, it is possible that a claimant and their ineligible spouse live with others and allege that they are a separate “household” by virtue of the fact that they eat their meals out or have separate purchase and preparation of food. In this instance, an optional supplement C is permissible as long as no other person is in his or her “household.” There is no couple counterpart in this category.

Consider parent(s) with minor children to be in the same household and therefore the presence of minor children in the household of an ineligible spouse would result in optional supplement B.

A transient individual who co-exists only with an ineligible spouse also qualifies for the Optional Supplement C rate.

D

Living in the Household of Another -- Persons who are “living in the household of another” for Federal purposes.

I

Licensed Residential Health Care Facilities -- Attached to a nursing home; Assisted Living Residence; CPCH; or “free standing”. Prior to 01/01/06, residents of these facilities were paid at the OS “A” rate.

Base authorization to make this payment on the recipient's residence at a facility listed in the New Jersey Congregate Care Directory .

Only the RHCF section of a multipurpose facility is eligible for the OS “I” rate. Pay residents of the Assisted Living Resident (ALR, or CPCH section of a multipurpose facility at the OS “A” rate. Nursing home residents are in living arrangement (D/G) if Medicaid pays more than 50 percent of the cost of care.

G

Effective 09/01/88, the State elected Federal administration of an optional State supplementary payment to residents of Title XIX facilities.

Y

Optional Supplementation Waived -- Individual is eligible for, but waives the right to receive an optional supplement.

Z

No Supplement Cases – Recipients in licensed medical facilities where Medicaid pays less than 50 percent of the cost of care, recipients in publicly operated community residences having 16 or less residents, and residents of publicly operated emergency shelters throughout a month.

It also includes cases that were FLA D prior to 01/1988, or effective 12/01/96, for children under age 18 residing in certain public or private facilities, receiving payment for their care under any health insurance policy issued by a private provider. For determination of applicability of $30 payment limit, see SI 00520.011.

A

A

All

674.00

150.05

824.05

B

All

674.00

31.25

705.25

C

Individual

674.00

153.00

827.00

w/EP

1012.00²

24.36

1036.36

I

All

674.00

210.05

884.05

Z

All

674.00

0.00

674.00

B

D

All

449.34¹

44.31

493.65

C

B

All

674.00

31.25

705.25

D

G

All

30.00³

10.00

40.00

A

A

All

1011.00

618.36

1629.36

B

All

1011.00

25.36

1036.36

I

All

1011.00

738.36

1749.36

Z

All

1011.00

  0.00

1011.00

B

D

All

674.00¹

93.09

767.09

D

G

All

60.00²

20.00

80.00

A

Living Alone - Eligible recipient who meet one of the following situations:

1. Live physically alone;

2. Pay a fixed, pre-established flat fee for both room and board in a commercial establishment;

3. Lives with others but takes all meals outside the dwelling;

4. Live with others but separately prepares or has someone separately prepare their food. Occasional preparation of meals in common does not preclude a finding of separate preparation;

5. Receive a fixed, pre-established flat fee for room and board from all others in the dwelling;

6. Live with only a foster child, or a homemaker authorized by the local department of social services (DSS), or a family care recipient placed by the Office of Mental Health (OMH), or the Office of Mental Retardation and Developmentally Disabilities (OMRDD) or local DSS; or

7. Have no permanent living arrangement (i.e., transient or street person) and is not with a spouse or a child for whom they have primary responsibility.

B

Living with Others - Recipient who meets one of the following situations:

1. Resides in a dwelling with others and prepares food in common with at least one other person in the dwelling.

NOTE: You must consider an individual living with an ineligible spouse to be living with others despite any separate preparation. The same is true if a recipient lives with a child for whom they have primary responsibility (except if the child is a foster child).

2. Is a child who does not meet the criteria for OS C, or OS D (as follows):

Lives in a religious community that provides room and board in full, or in part by the religious community; or

Has no permanent living arrangement (i.e., transient or street person), but is with an ineligible spouse, or child for whom they have primary responsibility.

C

Congregate Care Level I

1. New York State (NYS) places the recipient in a family type home certified by NYS Office of Children and Family Services and supervised by a local DSS.

2. OMH or OMRDD places the recipient in a certified family care home.

D

Congregate Care Level II – Payable to an eligible recipient who is a resident of a licensed Level II care facility. These consist of facilities, which provide supportive living environments and include:

• Residences for Adults certified by the NYS Department of Health;

• Privately-operated facilities certified by the NYS OMH;

• Privately-operated facilities certified by the NYS OMH and OMRDD;

• Privately-operated facilities certified by OASAS.

E

Congregate Care Level III -- Enhanced Residential Care

Payable to an eligible recipient who is a resident of a licensed level 3 care facility which includes:

Adult Homes; and Enriched Housing programs, certified by the NYS Department of Health, or

Schools for the Mentally Retarded, certified by the NYS Office of Mental Retardation and Developmental Disabilities.

Schools for the Mentally Retarded usually meet the basic Federal definition of institution, and consist of residential facilities that provide academic, vocational, recreational, and social skills programs. Although sometimes called schools, they often do not meet the Federal definition of schools.

NOTE - A child residing in a Level III facility cannot receive OS E; they receive OS B.

F

Living in the Household of Another -- Payable to recipients who are FLA B.

G

Effective 01/01/88, the State elected Federal administration of an optional State supplementary payment to residents of Title XIX facilities. Federal administration was terminated effective 09/30/03. State began administering this payment 10/01/03.

Y

Optional Supplementation Waived -- Individual is eligible for, but waives the right to receive an optional supplement.

Z

No Supplement Cases – Includes Eligible recipient in FLA A, or D who meet one of the following:

1. Is in a licensed medical facility where Medicaid is paying less than 50 percent of the cost of care;

2. Is in a publicly operated community residence which serves 16 or fewer residents;

3. Is in a publicly operated emergency shelter (PESH);

4. Qualifies under the special provision in SI 00520.130 (1619 eligible goes into medical institution);

5. Effective 10/01/03, eligible recipient in FLA D, and also FLA D cases prior to January 1988; or

6. Effective 12/01/96, children under age 18 residing in certain public or private facilities receiving payment for their care under any health insurance policy issued by a private provider. (For determination of applicability of $30 payment limit, see SI 00520.011).

A,C

A

All

674.00

87.00

761.00

B

All

674.00

23.00

697.00

C

NY City and selected counties¹

674.00

266.48

940.48

All other counties

674.00

228.48

902.48

D

NY City and selected counties¹

674.00

435.00

1109.00

All other counties

674.00

405.00

1079.00

E

NY City and selected counties¹

674.00

694.00

1368.00

All other counties

674.00

694.00

1368.00

Z

All

674.00

  0.00

674.00

B

F

All

449.34²

23.00

472.34

D

Z

All

30.00³

0.00⁴

30.00

A,C

A

All

1011.00

104.00

1115.00

B

All

1011.00

46.00

1057.00

C

NY City and selected counties¹

1011.00

869.96

1880.96

All other counties

1011.00

793.96

1804.96

D

NY City and selected counties¹

1011.00

1207.00

2218.00

All other counties

1011.00

1147.00

2158.00

E

NY City and selected counties¹

1011.00

1725.00

2736.00

All other counties

1011.00

1725.00

2736.00

Z

All

1011.00

0.00

1011.00

B

F

All

674.00²

46.00

720.00

D

Z

All

60.00³

0.00⁴

60.00

C

Living with an EP -- Recipients who are not living in the household of another or in a foster care home for adults and who have one or more EP’s as defined under the Federal rules.

D

Living in the Household of Another with an EP -- Recipients who live in the household of another and have one or more EP’s as defined under the Federal rules.

G

Living in a Domiciliary Care Facility -- Adult persons (age 18 and over) certified by the State to be residing in non-medical residential care facilities.

H

Living in a Personal Care Boarding Home -- Adult Persons (age 18 and over) certified by the State to be residing in non-medical residential care facilities.

Y

Optional Supplementation Waived -- Individual is eligible for, but waives the right to receive an optional supplement.

Z

No Supplement Cases -- Includes all recipients who are residing in a medical facility where Title XIX pays more than 50 percent of the cost of care, and recipients in FLA-A, or FLA-B receive a State-administered supplement.

A

Z

All

674.00

0.00

674.00

C

All

1012.00¹

43.70

1055.70

G

All

674.00

434.30

1108.30

H

All

674.00

439.30

1113.30

B

Z

All

449.34²

0.00

449.34

D

All

674.67³

43.70

718.37

C

Z

All

674.00

0.00

674.00

D

Z

All

30.00⁴

0.00

30.00

A

Z

All

1011.00

0.00

1011.00

C

All

1349.00¹

68.05

1417.05

G

All

1011.00

947.40

1958.40

H

All

1011.00

957.40

1968.40⁵

B

Z

All

674.00²

0.00

674.00

D

All

899.34

68.05

967.39

D

Z

All

60.00⁴

0.00

60.00

D

Residential Care or Assisted Living -- This category applies to individuals only.

Y

Optional Supplementation Waived -- Individual is eligible for, but waived their right to receive, an optional supplement.

Z

No State Supplement payable -- The State of Rhode Island does not pay a supplement unless individual resides in a Licensed Adult Care Facility (“Residential Care or Assisted Living”) as described in category “D” above.

A 

D

All

674.00

332.00

1006.00

A 

D

All

674.00

538.00

1212.00

A

Living Alone or With Others -- This variation includes recipients who are in Federal codes A and C.

B

Living in the Household of Another -- Recipients with no EP who are “living in the household of another” for Federal purposes. (Children under age 18 are included in this living arrangement variation.)

Z

No Supplement Cases -- No supplement cases include all recipients who are not included in A or B.

A,C

Z

All

674.00

0.00

674.00

B

B

All

449.34²

3.13

452.47

D

Z

All

30.00¹

0.00

30.00

A,C

A

All

1011.00

4.60

1015.60

B

B

All

674.00²

9.73

683.73

D

Z

All

60.00¹

0.00

60.00

A

Independent Living (except Chittenden County) – Recipients neither living in the household of another, and nor in a residential or custodial care situation. This includes a child who is living with a parent and recipients residing in a private Title XIX facility where Medicaid is not paying more than 50 percent of the cost of care. It includes children under the age of 18, who are in Federal living arrangement D because a private health insurance policy, or a combination of Medicaid and a private health insurance policy pays, or is expected to pay over 50 percent of the cost of care for that month. For determination of applicability of $30 payment limit, see SI 00520.011C.1.b.

A recipient residing in a publicly operated emergency shelter throughout a month.

B

Independent Living in Chittenden County -- Same as Code A (in this chart) except restricted to residents of Chittenden County.

C

Licensed Residential Care Home or Assisted Living Residence with Assistive Community Care Services (Level III) -- Recipients residing in Level III facilities identified by the State. To determine if a resident meets the requirements for Optional Supplement C, refer to the Vermont Community Care Facilities (OS C and G) list on BOSNET.

E

Living in the Household of Another -- Recipients living in the household of another and receiving support and maintenance (subject to the Federal one-third reduction provisions).

G

Licensed Residential Care Home or Therapeutic Community Residence (Level IV) -- Recipients residing in Level IV facilities identified by the State. To determine if a residence meets the requirements for Optional Supplement G, refer to the Vermont Community Care Facilities (OS C and G) list on BOSNET.

H

Custodial Care: Family Home -- Recipients living in another's home, where the recipient pays room and board and receives one or more of the services outlined under the custodial care definition. The recipient must also receive the room and board and custodial care in the home where he or she resides. In order to qualify as a home under this arrangement, these services must not be provided to more than two persons, and must be provided by a resident of the home.

In some cases, the Vermont Department of Disabilities, Aging, and Independent Living (DAIL) establishes outplacement programs, meeting the definition of living arrangement (L/A) H. To qualify, these programs must meet the requirements stated.

Custodial care means providing basic room and board, plus personal services such as:

• help with feeding,

• dressing,

• bathing,

• moving about under normal circumstances, and

• occasional tray service (tray service two-three times a week), which may include supervision for the recipient's protection.

Supervision for the recipient's protection deals primarily with protection services for retarded and emotionally disturbed individuals. A person who receives one or more of these personal services receives custodial care.

I

Effective 07/01/87, the State elected Federal administration of an optional State supplementary payment to residents in Title XIX facilities. This includes children under the age of 18, for whom Medicaid alone pays, or expects to pay over 50 percent of the cost of care for that month.

Y

Optional Supplementation Waived -- Individual is eligible for, but waives the right to receive an optional supplement.

A

A

All (Except Chittenden County)

674.00

52.04

726.04

B

All (Restricted to Chittenden County)

674.00

52.04

726.04

C

All

674.00

48.38

722.38

G

All

674.00

223.94

897.94

H

All

674.00

98.69

772.69

B

E

All

449.34¹

39.30

488.64

C

A

All (Except Chittenden County)

674.00

52.04

726.04

B

All (Restricted to Chittenden County)

674.00

52.04

726.04

D

A or B²

Children Private Insurance

30.00³

52.04

82.04

I

All

30.00³

17.66

47.66

A

A

All (Except Chittenden County

1011.00

98.88

1109.88

B

All (Restricted to Chittenden County

1011.00

98.88

1109.88

C

All

1011.00

96.77

1107.77

G

All

1011.00

562.06

1573.06

H

All

1011.00

332.82

1343.82

B

E

All

674.00¹

48.31

722.31

D

I

All

60.00²

35.33

95.33