California

SI 01415.049B

Delaware

SI 01415.049C

District of Columbia

SI 01415.049D

Hawaii

SI 01415.049E

Iowa

SI 01415.049F

Michigan

SI 01415.049G

Montana

SI 01415.049H

Nevada

SI 01415.049I

New Jersey

SI 01415.049J

Pennsylvania

SI 01415.049K

Rhode Island

SI 01415.049L

Vermont

SI 01415.049M

A

Use optional supplement (OS) code “A” for independent living with cooking facilities for an eligible recipient or couple who meet one of the following situations:

• live in their own household, as defined for Federal living arrangement (FLA) “A” purposes, and have cooking and food storage facilities or living arrangement provides meals;

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

• 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;

• a blind recipient who lives in an independent living arrangement with or without cooking and food storage facilities; or

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

B

Apply OS code “B” for non-medical out-of-home care (NMOHC) when a recipient or couple needs non-medical care or supervision in the following living arrangement situations:

Children (under age 18)

• blind child residing in a State licensed NMOHC facility;

• blind child residing in the home of a relative who is not a parent and not a legal guardian;

• disabled child residing in a State licensed NMOHC facility;

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

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

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

Adults (age 18 and over)

An aged, blind, or disabled recipient:

• or couple is determined to be in FLA “A” and resides in the home of a relative, legal conservator, or guardian;

• is determined to be in FLA “A” and resides in a State licensed NMOHC facility; or

• is determined to be in FLA “A” and resides in a family home certified by a family home agency under State law.

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

Apply OS code “C” to aged or disabled recipient or couples who are:

• not given meals, and

• do not have 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.”

A recipient or couple qualifies for OS “C” if any of the following situations exists:

• Immediate living quarters do not have cooking and food storage facilities that the recipient, couple, or another person (who is responsible for preparing their meals) can prepare meals on a daily basis;

• Does not have access to adequate cooking and food storage facilities as part of the living arrangement (including cooking and food storage facilities, which are outside the immediate living quarters) for the purpose of preparing meals or having them prepared on their behalf;

• Lives in a boarding house that does not have a communal kitchen with adequate cooking and food storage facilities that they can access for preparing meals;

• 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 preparing meals; or

• 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 a recipient or couple has access to the following:

• both a working refrigerator or icebox and a stove without a working oven but with at least two working burners. (Do not consider the capacity of the refrigerator or icebox when making this determination. Also, do not consider an ice chest to be adequate storage.);

• both 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 without temperature controls used for warming food as “adequate cooking facilities.”); or

• both 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 recipient of their responsibility to report immediately when the temporary condition ceases.

If the recipient provides an expected date when someone will replace or repair the appliance, diary the case for re-contact.

Eligibility for this supplementary payment ceases the month following the month in which the individual or couple receives meals or adequate cooking and food storage facilities are available.

For a couple, comprised of an aged or disabled recipient and a blind recipient, whose living arrangement lacks adequate cooking and storage facilities, the couple must receive the Supplemental Security Income and State Supplement Payment level for a blind, aged, or disabled couple plus the restaurant meals allowance for the disabled member of the couple. This living arrangement requires force due payment.

D

Living in the household of another

Apply OS code “D” when an eligible individual or couple is living in the household of another and receives food and shelter from that person. Most recipient or couples who are subject to a one-third reduction of his or her Federal SSI payments are eligible for OS “D” because the criteria for this supplement level are the same as for charging the one-third reduction. However, when the eligible recipient 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 that a recipient or couple can qualify.

E

Disabled child under age 18

Apply OS code “E” to a 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.”

F

Non-medical out-of-home care living in the household of another

OS code “F” applies whenever an eligible recipient 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 18 living in the of another

OS code “G” 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 person. For the one-third reduction provision, see SI 00835.200.

J

Residents of Title XIX facilities

Effective July 1, 1987, apply OS State code “J” to an eligible recipient who is a patient in a medical facility where Title XIX pays more than 50 percent of the costs. Apply OS State code “J” to supplement Section 1619 cases.

Y

Optional supplementation waived

Use OS code “Y” to indicate that a recipient is eligible for an optional supplement but waived his or her right to receive the supplement.

Z

No supplement cases

Apply OS code “Z” to an eligible recipient who is a patient in a private medical facility not certified under Title XIX and not licensed by the State. Include in this category those recipients who are residing throughout a month in a publicly operated emergency shelter.

For periods prior to July 1, 1987, apply OS code “Z” to an eligible recipient who is a patient in a medical facility where Title XIX pays more than 50 percent of the costs.

A

A

Aged

735.00

160.72

895.72

Blind

735.00

217.23

952.23

Disabled

735.00

160.72

895.72

B

All

735.00

423.37

1158.37

C

Aged

735.00

247.04

982.04

Disabled

735.00

247.04

982.04

E

Disabled

735.00

65.15

800.15

Z

All

735.00

0.00

735.00

B

D

Aged

490.00¹

164.24

654.24

Blind

490.00¹

220.76

710.76

Disabled

490.00¹

164.24

654.24

F

All

490.00¹

418.23

908.23

G

Disabled

490.00¹

68.67

558.67

C

A

Blind

735.00

217.23

952.23

E

Disabled

735.00

65.15

800.15

Z

All

735.00

0.00

735.00

D

J

All

30.00²

21.00

51.00

A

A

Aged/Aged

1103.00

407.14

1510.14

Blind/Blind

1103.00

558.19

1661.19

Disabled/Disabled

1103.00

407.14

1510.14

Aged/Blind

1103.00

500.65

1603.65

Aged/Disabled

1103.00

407.14

1510.14

Blind/Disabled

1103.00

500.65

1603.65

B

All

1103.00

1213.74

2316.74

C

Aged/Aged

1103.00

579.77

1682.77

Disabled/Disabled

1103.00

579.77

1682.77

Aged/Disabled

1103.00

579.77

1682.77

Z

All

1103.00

0.00

1103.00

B

D

Aged/Aged

735.34¹

412.41

1147.75

Blind/Blind

735.34¹

563.46

1298.80

Disabled/Disabled

735.34¹

412.41

1147.75

Aged/Blind

735.34¹

505.92

1241.26

Aged/Disabled

735.34¹

412.41

1147.75

Blind/Disabled

735.34¹

505.92

1241.26

F

All

735.34¹

1074.52

1809.86

D

J

All

60.00²

42.00

102.00

A

Adult residential care facility, assisted living facility, or adult foster care home

To be eligible for OS code “A,” the State must provide documentation that a recipient is a resident of a certified adult residential care facility, assisted living facility, or adult foster care home.

Y

Optional supplementation waived

Use code “Y” to indicate that a recipient is eligible for an optional supplement, but has waived his or her right to receive supplementation.

Z

No supplement cases

Use OS code “Z” for any recipient who is not included in OS categories “A” or “Y.”

Alternately, use OS code “Z” when the recipient is an “intervening” Federal code “A.”

For more information on optional State supplement codes see SM 01301.535.

A

A

All

735.00

140.00

875.00

Z

All

735.00

0.00

735.00

B

Z

All

490.00

0.00

490.00

C

Z

All

735.00

0.00

735.00

D

Z

All

30.001

0.00

30.00

A

A

All

1103.00

448.00

1551.00

Z

All

1103.00

0.00

1103.00

B

Z

All

735.34

0.00

735.34

D

Z

All

60.00¹

0.00

60.00

A

Adult foster care home with 50 or fewer residents

Use OS code “A” to indicate that you received certification from the District of Columbia, Department of Health that the recipient is a resident of an adult foster care home with 50 or fewer residents.

B

Adult foster care home with more than 50 residents

Use OS code “B” to indicate that you received certification from the District of Columbia, Department of Health that the recipient is a resident of an adult foster care home with more than 50 residents.

G

Apply OS code “G” to residents of Title XIX facilities.

Y

Optional supplementation waived

Use OS code “Y” to indicate that a recipient is eligible for an optional supplement, but has waived their right to receive such.

Z

No supplement cases

Use OS code “Z” for all recipients not included in OS codes A, B, G, or Y.

A

A

All

735.00

640.00

1375.00

B

All

735.00

750.00

1485.00

Z

All

735.00

0.00

735.00

B

Z

All

490.00¹

0.00

490.00

C

Z

All

735.00

0.00

735.00

D

G

All

30.00²

40.00

70.00

A

A

All

1103.00

1636.00

2739.00

B

All

1103.00

1856.00

2959.00

Z

All

1103.00

0.00

1103.00

B

Z

All

735.34¹

0.00

735.34

D

G

All

60.00²

80.00

140.00

B

Living in a community care or foster care home

Apply OS code “B” to recipients who are both over age 18 and live in a state approved care or foster care home.

D

Living in a certified medical facility

Use OS code “D” for an eligible recipient living in a medical treatment facility where Title XIX pays a substantial part (more than 50 percent) of the cost of care.

H

Domiciliary care I (maximum of five residents)

Use OS code “H” for an eligible recipient (including a child) or couple living in a domiciliary care facility that 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

OS code “I” is the same as code “H” except the facility provides care for six or more residents.

Y

Optional supplementation waived

Use OS code “Y” to indicate that a recipient is eligible for an optional supplement, but has waived his or her right to receive supplementation.

Z

Use OS code “Z” when the recipient is not eligible to receive Hawaii state supplement because of the following situations:

• recipient is living in the household of another;

• recipient is a patient in a private medical facility that is not certified under Title XIX; or

• recipient is residing throughout a month in a publicly operated emergency shelter.

A 

B

All

735.00

651.90

1386.90

H

All

735.00

651.90

1386.90

I

All

735.00

759.90

1494.90

Z

All

735.00

0.00

735.00

B

Z

All

490.00

0.00

490.00

D

D

All

30.00¹

20.00

50.00

 A

B

All

1103.00

1640.80

2743.80

H

All

1103.00

1640.80

2743.80

I

All

1103.00

1856.80

2959.80

Z

All

1103.00

0.00

1103.00

B

Z

All

735.34

0.00

735.34

D

D

All

60.00¹

40.00

100.00

A

Living in own household (blind only)

Only apply OS code “A” to an eligible blind recipient 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; or

• is a blind recipient living in a Title XIX facility where Medicaid pays 50 percent or less of the cost of his or her care. Optional supplement code “A” is also compatible with Federal codes “A” and “C.”

OS code “A” is the proper code to use with an “intervening” Federal code “A.”

For optional State supplement codes, see SM 01301.535.

B

Living in the household of another (blind only)

OS code “B” is only for an eligible blind recipient 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

Use OS code “C” for an eligible recipient 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 recipient as defined by the State Department of Human Services.

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

D

Living in a family life or boarding home

Use OS code “D” for an eligible recipient or each member of an eligible couple in Federal living arrangement “A” 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.

H

Living with a dependent person

Use OS code “H” for an eligible recipient 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 recipient as defined by the State Department of Human Services.

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

G

Use OS code “G” to indicate 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 recipient did not meet the “throughout a month” requirement at the initial claims input.

I

Living in a family life or boarding home - eligible recipient or each member of an eligible couple in FLA “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.

Y

Optional supplementation waived

Use OS code “Y” to indicate that a recipient is eligible for an optional supplement, but waived his or her right to receive supplementation.

Z

No supplement cases

Use OS code “Z” to address:

• SSI recipients residing throughout a month in publicly operated emergency shelters;

• aged or disabled recipients living in their own households or living in the households of others;

• recipients living in medical facilities not certified under Title XIX;

• recipients whose Federal payments are reduced to $30 or $60 due to living in a Title XIX facility; or

• aged or disabled recipients whose Federal payments are not reduced but who live in a Title XIX facility where Medicaid pays 50 percent or less of the cost of care.

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

1. In-home health related care;

2. Residential care; and

3. Supplement for Medicare and Medicaid Eligible.

A

A

Blind

735.00

22.00

757.00

C

Aged

735.00

379.00

1114.00

Blind

735.00

401.00

1136.00

Disabled

735.00

379.00

1114.00

D

Aged

735.00

142.00

877.00

Blind

735.00

164.00

899.00

Disabled

735.00

142.00

877.00

Z

All

735.00

0.00

735.00

B

B

Blind

490.00¹

22.00

512.00

H

Aged

490.00¹

379.00

869.00

Blind

490.00¹

401.00

891.00

Disabled

490.00¹

379.00

869.00

I

Aged

490.00¹

142.00

632.00

I

Disabled

490.00¹

142.00

632.00

I

Blind

490.00¹

164.00

654.00

Z

All

490.00¹

0.00

490.00

C

A

Blind

735.00

22.00

757.00

C

Blind

735.00

401.00

1136.00

Disabled

735.00

379.00

1114.00

Z

Disabled

735.00

0.00

735.00

D

Z

All

30.00²

0.00

30.00

A

A

Blind/Blind

1103.00

44.00

1147.00

Blind/Aged

1103.00

44.00

1147.00

Blind/Disabled

1103.00

44.00

1147.00

C

Aged/Aged

1103.00

379.00

1482.00

Blind/Blind

1103.00

423.00

1526.00

Disabled/Disabled

1103.00

379.00

1482.00

Aged/Blind

1103.00

423.00

1526.00

Aged/Disabled

1103.00

379.00

1482.00

Blind/Disabled

1103.00

423.00

1526.00

D

Aged/Aged

1103.00

671.00

1774.00

Blind/Blind

1103.00

715.00

1818.00

Disabled/Disabled

1103.00

671.00

1774.00

Aged/Blind

1103.00

715.00

1818.00

Aged/Disabled

1103.00

671.00

1774.00

Blind/Disabled

1103.00

715.00

1818.00

Z

Aged/Aged

1103.00

0.00

1103.00

Disabled/Disabled

1103.00

0.00

1103.00

Aged/Disabled

1103.00

0.00

1103.00

B

B

Blind/Blind

735.34¹

44.00

779.34

Blind/Aged

735.34¹

44.00

779.34

Blind/Disabled

735.34¹

44.00

779.34

H

Aged/Aged

735.34¹

379.00

1114.34

Blind/Blind

735.34¹

423.00

1158.34

Disabled/Disabled

735.34¹

379.00

1114.34

Aged/Blind

735.34¹

423.00

1158.34

Aged/Disabled

735.34¹

379.00

1114.34

Blind/Disabled

735.34¹

423.00

1158.34

I

Aged/Aged

735.34¹

671.00

1406.34

Blind/Blind

735.34¹

715.00

1450.34

Disabled/Disabled

735.34¹

671.00

1406.34

Aged/Blind

735.34¹

715.00

1450.34

Aged/Disabled

735.34¹

671.00

1406.34

Blind/Disabled

735.34¹

715.00

1450.34

Z

Aged/Aged

735.34¹

0.00

735.34

Disabled/Disabled

735.34¹

0.00

735.34

Aged/Disabled

735.34¹

0.00

735.34

D

Z

All

60.00²

0.00

60.00

D

Domiciliary care

Use OS code “D” for recipients residing in licensed non-medical facilities that provide room, board, and supervision. The State provides a list of these facilities and certifies recipients who are residents requiring this level of care.

E

Personal care

Apply OS code “E” to recipients residing in licensed non-medical facilities that provide general supervision, physical care, and assistance to residents as they carry out the basic activities of daily living. The State provides a list of these facilities and certifies the recipients who 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

Apply OS code “F” for residents in homes for the aged. The State provides SSA with a list of these non-medical facilities for the aged and certifies the recipients who are residents that require this level of care.

G

Independent living with an EP

OS code “G” applies to recipients with an essential person who are not living in the household of another. Exclude from this category children under age 18.

H

Living in the household of another with an EP OS code “H” applies to recipients with an EP who are living in the household of another for Federal purposes. Exclude from this category children under age 18.

I

Effective January 1, 1988, OS code “I” applies to the State elected Federal administration of an optional State supplementary payment to residents of Title XIX facilities.

Y

Optional supplementation waived

Use OS code “Y” to indicate that a recipient is eligible for an optional supplement, but has waived his or her right to receive supplementation.

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

735.00

87.00

822.00

E

All

735.00

157.50

892.50

F

All

735.00

179.30

914.30

G

All

1103.00¹

14.00

1117.00

B

H

All

7

735.34²

9.33

744.67

D

I

All

30.00³

7.00

37.00

Z

All

30.00

0.00

30.00

A

D

All

1103.00

541.00

1644.00

E

All

1103.00

682.00

1785.00

F

All

1103.00

725.60

1828.60

G

All

1471.001

21.00

1492.00

B

H

All

980.66

14.00

994.66

D

I

All

60.002

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 – Use this code to indicate that a recipient is eligible for an optional supplement but waived his or her right to receive supplementation.

Z

No supplement cases – Includes all recipients and couples not certified in State codes G, H, I, J, or K.

A

G

All

735.00

94.00

829.00

H

All

735.00

94.00

829.00

I

All

735.00

94.00

829.00

J

All

735.00

52.75

787.75

K

All

735.00

26.00

761.00

Z

All

735.00

0.00

735.00

B

Z

All

490.00¹

0.00

490.00

C

Z

All

735.00

0.00

735.00

D

Z

All

30.00²

0.00

30.00

A

G

All

1103.00

193.00

1296.00

H

All

1103.00

193.00

1296.00

I

All

1103.00

193.00

1296.00

J

All

1103.00

110.50

1213.50

K

All

1103.00

57.00

1160.00

Z

All

1103.00

0.00

1103.00

B

Z

All

735.34¹

0.00

735.34

D

Z

All

60.00²

0.00

60.00

A

Independent living or living in parental household

Use OS code “A” for an aged or blind eligible recipient who meets one of the following situations:

1. Lives in his or her 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 recipients 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

Use OS code “B” for aged or blind recipient who is living in the household of another and receiving food and shelter from that person. Aged or blind recipients who are subject to a one-third reduction (VTR) of his or her 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

Apply OS code “C” to aged or blind recipients who the State has certified to live in a private non-medical facility or, a residential facility serving 16 or fewer persons that provides personal care and services to aged, infirm, or handicapped adult persons who are unrelated to the proprietor.

The State licenses these facilities for direct payment. The State provides SSA with listings of these facilities.

Y

Optional supplementation waived

Use OS code “Y” to indicate that a recipient is eligible for an optional supplement but has waived his or her right to receive supplementation.

Z

Apply “No Supplement” code “Y” to the following recipients:

• disabled eligible recipient or disabled member of eligible couple;

• eligible recipient or member of eligible couple in a medical facility where Title XIX pays more than 50 percent of the cost;

• eligible recipient or member of eligible couple who is a patient in a private medical facility, which is not certified under Title XIX; or

• recipients who are residing throughout a month in publicly operated emergency shelters.

A

A

Aged

735.00

36.40

771.40

Blind

735.00

109.30

844.30

C

Aged

735.00

391.00

1126.00

Blind

735.00

391.00

1126.00

Z

Disabled

735.00

0.00

735.00

B

B

Aged

490.00¹

24.27

514.27

Blind

490.00

213.96

703.96

Z

Disabled

490.00

0.00

490.00

C

A

Blind

735.00

109.30

844.30

Z

Disabled

735.00

0.00

735.00

D

Z

All

30.00²

0.00

30.00

A

A

Aged/Aged

1103.00

74.46

1177.46

Blind/Blind

1103.00

374.60

1477.60

Aged/Blind

1103.00

374.60

1477.60

Aged/

Disabled

1103.00

74.46

1177.46

Blind/

Disabled

1103.00

374.60

1477.60

C

Aged/Aged

1103.00

881.00

1984.00

Blind/Blind

1103.00

881.00

1984.00

Aged/Blind

1103.00

881.00

1984.00

Aged/

Disabled

1103.00

881.00

1984.00

Blind/

Disabled

1103.00

881.00

1984.00

Z

Disabled

1103.00

0.00

1103.00

B

B

Aged/Aged

735.34

49.64

784.98

Blind/Blind

735.34

531.94

1267.28

Aged/Blind

735.34

531.94

1267.28

Aged/

Disabled

735.34

49.64

784.98

Blind/

Disabled

735.34

531.94

1267.28

Z

Disabled

735.34

0.00

735.34

D

Z

All

60.00²

0.00

60.00

A

Congregate care

Apply OS code “A” to recipients in Federal living arrangement “A.” The living arrangement includes:

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

• children and adults in residential facilities (both inside and outside of NJ) who are 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); and

• recipients living in assisted living residences or comprehensive personal care homes (CPCH) licensed by the Department of Health and Senior Services.

B

Living alone or with others

Use OS code “B” for recipients whose Federal living arrangements are “A” or “C” and who do not meet the requirements defined in other supplementation categories.

You must consider any eligible recipient who meets the requirement for a Federal code “A” to be in optional supplement “B” unless they are residing in a residential health care facility or living alone with an ineligible spouse.

Likewise, any child meeting the criteria for a Federal code “C” is automatically entitled to optional supplement “B.”

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

1. Living physically alone;

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

3. Placed in a transitional residency program by the Division of Mental Health and Hospitals, Department of Human Services.

Optional supplement code “B” is the proper code to use with an “intervening” Federal code “A.” For State supplement codes, see SM 01301.535.

Use OS code “B” to address Section 1619 cases.

C

Living alone with an ineligible spouse

Use OS code “C” when a recipient lives with ONLY his or her ineligible spouse and NO other persons are part of the household. Use Federal criteria to determine an ineligible spouse for State supplementation purposes (i.e., a spouse, either by marriage or holding out as spouses) who is either not eligible for SSI or who chooses not to apply. If other persons, even minor children, are present in the household, you cannot apply this OS code.

It is possible that a claimant and the 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, you may consider an optional supplement “C” as long as no other person is considered part of the “household.” There is no couple counterpart in this category.

A transient recipient who co-exists only with an ineligible spouse also qualifies as OS code “C.”

Always consider parent(s) with minor children to be in the same household and code the case OS code “B.”

D

Living in the of another

Apply OS code D to recipients who are “living in the household of another” for Federal purposes.

I

Licensed residential health care facilities (RHCF)

Apply OS code “I” to recipients living in:

• attached nursing homes;

• assisted living residence;

• CPCH; or

• “free-standing” licensed residential health care facilities. We paid residents of these facilities the OS “A” rate prior to January 1, 2006.

We must base our authorization for this payment on the recipient's verified 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 code “I” rate. Pay residents of the assisted living resident (ALR or CPCH section of a multipurpose facility) at the OS code “A” rate. Nursing home residents are in living arrangement (“D” or “G”) if Medicaid pays more than 50 percent of the cost of care.

G

Apply OS code “G” effective September 1, 1988, when the State elected Federal administration of an optional State supplementary payment to residents of Title XIX facilities.

Y

Optional supplementation waived

Use OS code “Y” to indicate that a recipient is eligible for an optional supplement but waived his or her right to receive supplementation.

Z

No supplement cases

Apply OS code “Z” to recipients:

• in licensed medical facilities where Medicaid is paying less than 50 percent of the cost of care;

• in publicly operated community residences having 16 or less residents; and

• residing throughout a month in publicly operated emergency shelters.

You can also apply OS code “Z” to cases that were FLA “D” prior to January 1988, or effective December 1, 1996, to children residing in public or private facilities where private health insurance paid for their care. For determination of applicability of $30 payment limit, see SI 00520.011.

A

A

All

735.00

150.05

885.05

B

All

735.00

31.25

766.25

C

Individual

735.00

153.00

888.00

w/EP

1103.00¹

25.36

1128.36

I

All

735.00

210.05

945.05

Z

All

735.00

0.00

735.00

B

D

All

490.00²

44.31

534.31

C

B

All

735.00

31.25

766.25

D

G

All

30.00³

10.00

40.00

Z

All

30.00

0.00

30.00

A

A

All

1103.00

618.36

1721.36

B

All

1103.00

25.36

1128.36

I

All

1103.00

738.36

1841.36

Z

All

1103.00

0.00

1103.00

B

D

All

735.34¹

93.09

828.43

D

G

All

60.00²

20.00

80.00

C

Living with an essential person (EP)

Apply OS code “C” to 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

Apply OS code “D” to 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

Apply OS code “G” to adult persons (age 18 and over) certified by the State to reside in non-medical residential care facilities.

H

Living in a personal care boarding home (PCBH)

Apply OS code “H” to adult persons (age 18 and over) certified by the State to reside in non-medical residential care facilities.

Y

Optional supplementation waived

Use code “Y” to indicate that a recipient is eligible for an optional supplement, but waived his or her right to receive supplementation.

Z

No supplement cases

OS code “Z” includes all recipients who are residing in a medical facility that Title XIX pays more than 50 percent of the cost of care and recipients in FLA “A” or FLA “B” who receive a State-administered supplement.

A

C

All

1103.00¹

43.70

1146.70

G

All

735.00

434.30

1169.30

H

All

735.00

439.30

1174.30

Z

All

735.00

0.00

735.00

B

Z

All

490.00²

0.00

490.00

D

All

735.34³

43.70

779.04

C

Z

All

735.00

0.00

735.00

D

Z

All

30.00⁴

0.00

30.00

 A

C

All

1471.00¹

68.05

1539.05

G

All

1103.00

947.40

2050.40

H

All

1103.00

957.40

2060.40

Z

All

1103.00

0.00

1103.00

B 

D

All

980.66²

68.05

1048.71

B

Z

All

735.34³

0.00

735.34

D

Z

All

60.00⁴

0.00

60.00

D

Residential care or assisted living

Apply OS code “D” only to recipients living in residential care or assisted living facilities as certified by the Rhode Island Department of Human Services.

F

Advanced Care

Apply OS code “F” only to recipients living in a licensed adult community supportive living residence and receiving advanced care as certified by the Rhode Island Executive Office of Health and Human Services.

Y

Optional supplementation waived

Use OS code “Y” to indicate that a recipient is eligible for an optional supplement, but waived his or her right to receive supplementation.

Z

No state supplement payable

Use OS code “Z” when the State of Rhode Island does not pay a supplement unless the recipient resides in a licensed adult care facility described in category “D” or “F”.

A

D

F

All

All

735.00

735.00

332.00

797.00

1067.00

1532.00

Z

All

735.00

0.00

735.00

A

Independent living (except Chittenden County)

Apply OS code “A” to several situations including recipients who:

• are not living in the household of another;

• are not in a residential or custodial care situation;

• are under age 18 and live with a parent;

• reside in a private Title XIX facility where Medicaid is not paying more than 50 percent of the cost of care;

• are under age 18 in a private medical facility where private health insurance is paying more than 50 percent of their care;

• are under age 18 in a private medical facility where a combination of Medicaid and a private health insurance policy pays or is expected to pay over 50 percent of the cost of their care. For information regarding the $30 payment limit, see in SI 00520.011C.1.; and

• reside throughout a month in a publicly operated emergency shelter.

B

Independent living in Chittenden County

Apply OS code “B” to all recipients living in situations described in “A” above except restricted to residents of Chittenden County.

C

Licensed residential care home or assisted living residence with assistive community care services (Level III)

Apply OS code “C” to recipients residing in Level III facilities identified by the State. To determine if the facility meets the requirements for OS code “C,” refer to the Division of Licensing and Protection for Vermont State. Use this website link: http://www.dlp.vermont.gov/resident-list.

E

Living in the household of another

Apply OS code “E” to recipients who live in the household of another and receive support and maintenance from them (subject to the Federal one-third reduction provisions).

G

Licensed residential care home or therapeutic community residence (Level IV)

Apply OS code “G” to recipients residing in Level IV facilities identified by the State. Apply OS code “G” to recipients residing in Level IV facilities identified by the State. To determine if a facility meets the requirements for OS code “G,” refer to the Division of Licensing and Protection for Vermont State. Use this website link: http://www.dlp.vermont.gov/resident-list

H

Custodial care: family home

Apply OS code “H” to recipients who:

• live in another's home,

• pay room and board to that home owner, and

• receive one or more of the services outlined under the custodial care definition.

To qualify as a home under this arrangement, a resident of the home must provide the services to two persons or less.

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

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

• help with feeding,

• dressing,

• bathing,

• moving about under normal circumstances, or

• 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 recipients.

A person who receives one or more of these personal services is receiving custodial care.

I

Apply OS code “I” effective July 1, 1987, when 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 is expected to pay, over 50 percent of the cost of care for that month.

Y

Optional supplementation waived

Use this OS code “Y” to indicate that a recipient is eligible for an optional supplement, but waived his or her right to receive supplementation.

A

A

All (Except Chittenden County)

735.00

52.04

787.04

B

All (Restricted to Chittenden County)

735.00

52.04

787.04

C

All

735.00

48.38

783.38

G

All

735.00

223.94

958.94

H

All

735.00

98.69

833.69

B

E

All

490.00

39.30

529.30

C

A

All (Except Chittenden County)

735.00

52.04

787.04

B

All (Restricted to Chittenden County)

735.00

52.04

787.04

D

A or B²

Children Private Insurance

30.00¹

52.04

82.04

I

All

30.00²

17.66

47.66

A

A

All(Except Chittenden County)

1103.00

98.88

1201.88

B

All (Restricted to Chittenden County)

1103.00

98.88

1201.88

C

All

1103.00

96.77

1199.77

G

All

1103.00

562.06

1665.06

H

All

1103.00

332.82

1435.82

B

E

All

735.34¹

48.31

783.65

D

I

All

60.00²

35.33

95.33