A. Eligibility Criteria for OSS B

California pays OSS B when an individual/couple needs nonmedical care or supervision in the following living arrangement situations:

1. CHILDREN (Under Age 18)

   • A blind or disabled child residing in a State licensed NMOHC facility.

   • A disabled child residing in the home of a relative who is not a parent.

   • A disabled child residing in the home of a legal guardian/conservator who is not a relative.

   • A blind child residing in the home of a relative who is not a parent and not a legal guardian/conservator.

   • A blind or disabled child in a "certified family home" approved by a licensed foster family agency.

   NOTE: Youth in extended care foster care after the age of 18 (non-minor dependents) residing in a licensed/certified foster care home will remain eligible for OSS B.

2. ADULTS (Age 18 and Over)

   • An aged, blind or disabled individual/couple has been determined to be in FLA A and resides in a State licensed NMOHC facility.

   • An aged, blind, or disabled individual residing in a Family Home approved by a Family Home Agency acting on behalf of a California Regional Center.

   • An aged, blind or disabled individual/couple who has been determined to be in FLA A and resides in the home of a relative, legal conservator or guardian who provides care and supervision (see exception in SI SF01415.120B. regarding home ownership or rental liability).

   An individual/couple is also eligible for OSS B if a relative who does not live in the household provides care and supervision, i.e., the individual/couple lives with a relative, conservator or guardian, but the relative providing care and supervision resides outside the household. In the case of an eligible couple, one or both members of the couple may be eligible for OSS B. If only one member of the couple is eligible for OSS B, a variant living arrangement computation is applicable (SI 02005.030G).

   Even though the FBR is subject to the 1/3 reduction for living in the household of another (VTR), certification for NMOHC may still be appropriate. See SI SF01415.130 for instructions on OSS F – NMOHC Living in the Household of Another.

   NOTE: The State’s definition of a “State licensed NMOHC facility” includes:

   • Licensed residential care or licensed community care facility

   • Licensed foster care facility including but not limited to a foster family or group home (including youth over the age of 18 in extended foster care up to age 21 (up to age 22 with special health needs)

NOTE: For California optional supplement 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.”

Examples:

1. Martin Baker, a 10 year-old blind child, lives in his aunt and uncle's home. He pays his pro rata share of the household expenses, which places him in FLA A. Since the county has certified that he receives NMOHC from the relative, the OSS B rate is payable.

2. Ms. Smith, a disabled adult, lives with a friend of the family who has been designated her legal guardian. Mrs. Smith pays half of the household expenses and is determined to be in FLA A. When the county certifies that she receives NMOHC from the guardian, the OSS B rate is payable.

B. Exceptions to OSS B Eligibility

An SSI claimant/recipient is not eligible for OSS B if he or she is:

1. an adult who owns or has rental liability for his or her residence

2. a disabled child living with his or her parent(s)

3. a blind child (under 18, or 18 to 21 and attending school or training full-time) residing in the home of his or her parent or legal guardian (OSS A applies).

4. an individual whose ineligible spouse is living in the same household, regardless of the household/living arrangement situation. The ineligible spouse is presumed able and available to provide care and supervision as if the couple lived in their own household.

Refer individuals who are not eligible for OSS B, but need care and supervision, to the county for possible In-Home Supportive Services (IHSS). Do not use Form SSP-22 as a referral for IHSS.

Examples:

1. Robin Clark is a 3 year-old disabled child residing with her mother. Robin requires constant care and supervision. She is not eligible for OSS B because she lives with her parent. Refer for possible IHSS.

2. Mr. Saechao lives with his son and pays one-half of the household expenses. Both his and his son’s name are on the rental agreement. He needs assistance with dressing and bathing which his son provides. Mr. Saechao is not eligible for OSS B because he has rental liability. Refer for possible IHSS.

C. Development and Documentation

Use Form SSP-22 to document eligibility for NMOHC (except residence in a “Family Home” certified by a Regional Center – follow SI SF01415.120C.4) in all initial claims, FO initiated redeterminations, DOC redetermination transfers for address or living arrangement reasons, and other reports of living arrangement changes. If you are unable to access the SSP-22, download the form from the California Department of Social Services website at: On-line Forms and Publications Q - T. Store the completed SSP-22 in the electronic file. Document the Regional Center Family Home verification on a DROC or SSA-5002 stored in the electronic file.

Important: For redeterminations, a new SSP-22 for licensed facilities or reverification with the Regional Center for Family Homes is required even if the individual has not moved since the last SSP-22 verification or certification.

1. Licensed NMOHC facility

• Verify the licensure through the California Community Care Licensing Division (CCLD) website. If not listed, then contact the Community Care Licensing Division Program Office. Do not verify licensure by contact with the facility.

• If not completed previously, use the Seattle SSA-8045 Facility Determination site to create and store a SSA-8045 (See SI 00520.800 Facility Determinations).

• If the recipient lives in a NMOHC facility for drug addicts or alcoholics, then contact Department of Health Care Services, Substance Use Disorder Services Division at (916) 322-2911. Do not verify licensure by contact with the facility.

• When an individual resides in an NMOHC facility, enter the facility's current license number in Part II of the SSP-22.

• Authorize OSS B only for residents of facilities that are shown as "Licensed." Facilities whose license is shown as "Pending" are unlicensed facilities and OSS B should not be authorized for residents in such facilities. *

  Exceptions to this rule are possible only in the following situations:

  1. The facility was not issued a license at the time it was eligible due to an administrative error by the California Care Licensing Division (CCLD). In this situation, the FO should document this was verified via contact with CCLD.

  2. A licensed facility changes ownership and the new owner's license is "Pending" (provided there is no change in the facility's location). In such a case, recipients who were residents of the licensed facility prior to the change of ownership should continue to receive OSS B without interruption. New residents, however, should receive only OSS A until the new license is issued. When the license is issued, retroactive payment should be made to the date of admission to the facility if the recipient was already eligible or the application date, whichever is applicable.

• A "licensed" facility has either a permanent, provisional, or probationary license. Probational or provisional licenses are valid for less than 12 months. The FO should tickle the case for the expiration date in order to determine whether a permanent license has been issued. If a permanent license has been issued, the case remains in OSS B. If a permanent license has not been issued, OSS B can no longer be paid. If a permanent license is not issued at the end of the probational or provisional period, the facility will no longer appear on the CCL website. Clearly annotate the SSA-8045 with the dates the facility was licensed for NMOHC and when that license expired.

• When licensure is verified by telephone contact, check the block in Part II.B on the SSP-22 titled "Telephone contact with" and enter the name and title of the licensing official contacted.

• The effective date for the certification is the month in which the individual changed his/her residence to the licensed facility. (See SI 00835.040 to determine whether federal temporary absence rules apply). Throughout the month residency is not required. Contact the facility to determine the date the individual entered the facility. Document the file to show that contact was made by completing Part II.A of the SSP-22.

NOTE: The State provides a breakout of standard charges each year for NMOHC facilities (shown at the bottom of the SSI/SSP Payment Rates for California). The charges are broken out by board and room, care and supervision, and personal and incidental expenses. However, a recipient’s written admission agreement may include additional charges if a resident chooses a private room when a double room is available and/or for special food services or products. The facility should be able to provide the actual charges for room and board as specified in the written agreement. In addition, a recipient with income other than SSI/SSP (e.g., Title II benefits) may have up to an additional $20 available for his or her cost of care due to the basic $20 SSI income exclusion. Therefore, the facility may charge this additional amount up to $20.

If a recipient’s payment to a facility does not equal or exceed the board and room charge specified in the admission agreement and a third party pays the difference directly to the facility, in-kind support and maintenance may be chargeable. Third-party payments to the facility for charges other than the shortfall for room and board are not countable as ISM. Payments made directly to the recipient are charged as cash income regardless of the intended purpose

2. Children in foster care (including those in extended foster care after the age of 18 – “non-minor dependents”)

Whether a foster home is considered a “licensed” home or “certified” home depends upon whether the home is licensed by the State or County or certified by a foster family agency.

1. There are various types of foster care placements including but not limited to:

   • A foster family home is a State or County licensed home (see Foster Family Home Program Directory for the contact information for applicable counties who contract with the State’s Community Care Licensing Division).

   • A certified family home is a family residence certified by a licensed foster family agency (FFA) and issued a certificate of approval by that agency as meeting licensing standards, and used only by that foster family agency for placements. Obtain verification of certified homes from the FFA. To search for a FFA, please see the CCLD website: Social Services - Community Care Facility search or contact the CCLD program office: Statewide Children's Residential Program Office.

   • A group home is a licensed facility that provides 24-hour care and supervision to children, provides specified services to a specific client group, and maintains a structured environment, with such services provided at least in part by staff employed by the licensee. Verify group homes via the CCLD website: Social Services - Community Care Facility search or contact the CCLD program office: Statewide Children's Residential Program Office.

2. In all foster care placements, complete an SSP-22 by phone or send an SSP-22 to the appropriate agency for verification.

3. Living in the home of a relative, legal conservator or guardian

• Send an SSP-22 to the county (this certification cannot be completed by phone). Show the name and relationship of the relative providing the care in Part 1.A of the SSP-22. The county will make its certification in Part 1.B of the SSP-22. The effective date of certification is established by the county. Throughout-the-month residency is not required. The effective date of OSS B is subject to administrative finality. On deferred development cases, send the SSP-22 to the county when the PERC is initiated.

• When the county cannot obtain material evidence that the individual needed and was receiving care in the living arrangement continuously from an earlier date, the county will have the client complete the statement on the reverse side of the SSP-22. These are county instructions only. FOs are not to complete, nor have the individual sign, the Client Statement for Retroactive Certifications on the SSP-22.

• If an individual appears to meet the eligibility requirements for the OSS B payment and is currently receiving In-Home Supportive Services (IHSS), do not forward an SSP-22. An individual cannot receive both IHSS and an OSS B payment. Accept the individual's allegation as to the receipt of IHSS without further verification. Record the allegation in the "Remarks" section of the application, or redetermination form, on an SSA-795, or on an SSA-5002. If an individual appears to meet the eligibility requirements for the OSS B payment and an application for IHSS is pending, send the SSP-22 to the county.

  NOTE: If you discover the recipient is receiving both OSS B and IHSS, the recipient must choose which he wishes to receive. If he/she decides to receive IHSS rather than OSS B, terminate OSS B in the month following the month of discovery that he or she is receiving benefits from both programs. If he or she decides to receive OSS B rather than IHSS, notify the County IHSS office.

• If all other factors of SSI eligibility are met, adjudicate the case with the lower applicable OSS category while awaiting the return of the SSP-22. (SI 01410.001C). The OSS payment level determination can be reopened when the SSP-22 certification is subsequently received. Document the DW01 or MDW to show the SSP-22 has been sent for NMOHC certification and control for receipt

• When the SSP-22 is received, fax it into the electronic file.

  NOTE: If the county does not certify that NMOHC is required, that is an initial determination for which the recipient must receive proper notification, including appeal rights . If the determination will not result in an automated notice (i.e., a new allegation for NMOHC is not certified by the county, so payment amount will not be changed), a manual notice must be prepared. See SI SF01415.190, Exhibit 4 for an example of the notice language to include.

  Reconsideration requests should be handled by the FO, with another SSP-22 sent to the county explaining the recipient’s reason for the appeal.

• Counties are to respond to SSP-22 certification requests within 13 working days of receipt. If the SSP-22 is not received, send a follow-up request to the county and diary the case for an additional 13 working days. If the SSP-22 is still not received, contact the Center for Programs Support in the Regional Office via vHelp.

• It is not necessary to obtain a new SSP-22 certified by the county during a redetermination when there has been no change in the living arrangement since the county's last SSP-22 certification. If the recipient alleges he or she no longer requires assistance, accept the allegation, document the file and input the living arrangement change. The date of change is the month following the month in which the recipient alleges that he or she no longer required assistance.

4. Developmentally disabled adults placed in a Family Home

• February 1996, the California Department of Developmental Services (CDDS) issued regulations that established a type of facility called a Family Home (FH). SSI recipients living in FHs are eligible for the nonmedical-out-of-home-care (NMOHC) optional state supplement (OSS) "B." FHs are exempt from State licensing requirements and are not under the jurisdiction of the Community Care Licensing Division of the California Department of Social Services (CDSS). Do not confuse these Family Homes with CDSS’ Foster Family Homes.

• Each FH may house no more than two developmentally disabled adults. The FH meets the State criteria for the NMOHC rate assuming two things: (1) the provider is not a spouse of the recipient and (2) the residence is clearly not the recipient's own home, i.e., not owned or rented by the recipient. Similar to other NMOHC facilities, the FH provides room, board, personalized care and supervision to its residents.

• FHs are certified by Family Home Agencies (FHAs) that are authorized through a contract with a Regional Center to recruit, approve, and monitor FHs. The FHA performs a function similar to what the Foster Family Agencies currently provide for foster care homes, except that a CDDS FH is for adults only and is not related to foster care. The CDDS, through the Regional Centers and FHAs, are responsible for approving the FH is providing the necessary services.

• FOs can verify FH approval by contacting the FH’s local Regional Center. Document the contact with a Record of Contact (DROC or SSA-5002). FOs can find a list of Regional Centers and jurisdictions at Regional Centers. Do not contact the local Community Care Licensing Office or County Welfare Office for verification.