TN 2 (05-95)

A. General

Policy Principle: Medical and social services are not income for purposes of the supplemental security income (SSI) program. Under the circumstances specified in this section, cash and in-kind items received in conjunction with medical and social services are also not income for SSI purposes.

When applying the guidelines in this section, be alert to the possibility that broad categories of assistance (e.g., adoption assistance, foster care, noninstitutional care of the type provided in group homes or halfway houses) may in some cases include medical and social services as part of their overall program. Therefore, when an item which is otherwise income is provided in connection with a broad category of assistance, extensive development may be required as outlined below to determine whether this section is applicable (i.e., to determine whether or not the item is income).

Assume that governmental medical and social service programs which provide cash or in-kind items are authorized to provide such items only in order to provide a medical or social service. Therefore, when an individual alleges receiving cash or in-kind items from a governmental medical or social service program, develop only for the source of the item, not its purpose.

Do not assume, however, that cash or in-kind items provided by a nongovernmental medical or social service organization can only be for medical or social service purposes. When a nongovernmental medical or social service organization is involved, develop both the source and the purpose of the cash or in-kind item. Subsections SI 00815.050B. through SI 00815.050E. explain the guidelines for determining whether or not the cash or item is income.

Do not apply the rules in this section to two kinds of payments which, although commonly associated with medical or social services, are income, regardless of the source of payment:

1. Remuneration for work or for activities performed as a participant in a program conducted by a sheltered workshop or work activities center is earned income. See SI 00820.300.

2. Incentive payments to encourage individuals to utilize specified facilities or to participate in specified medical or social service programs are unearned income, to the extent that these payments are unrestricted as to use and are not reimbursement for medical or social services already received. Accept the individual's allegation as to the purpose and the amount of the payment; however, if the person does not know this information or if there is reason to question his statement, verify the information by obtaining documentary evidence or by contacting the source of the payment.

B. Medical Services

1. General

a. Definition

Medical services are those services which are directed toward diagnostic, preventive, therapeutic, or palliative treatment of a medical condition and which are performed, directed, or supervised by a State licensed health professional. The term “medical services” also includes any room and board (i.e., food and shelter) provided during a medical confinement (SI 00815.100), as well as in-kind medical items such as prescription drugs, eyeglasses, prosthetics and their maintenance, etc. For SSI purposes, in-kind medical items also include devices intended to bring the physical abilities of a handicapped individual to a par with a nonhandicapped unaided individual (e.g., electric wheelchairs, modified scooters). Furthermore, for SSI purposes, in-kind medical items include specially trained animals (e.g., seeing eye dogs) and their maintenance (e.g., dog food). Under this definition, an automobile or van intended for street use would not be considered wholly a medical item but any modifications made to an automobile or van in order to accommodate a physically handicapped individual would be a medical item and therefore the modification would not be income upon receipt. See SI 01130.200 guidelines regarding automobiles and other vehicles used for transportation. Transportation to and from medical treatment is also considered a medical service.

b. Sources of Medical Services

Medical services may be provided directly by treatment facilities or practitioners. They may also be made available indirectly through a variety of other sources. Some examples of Federal medical services programs are Medicare and CHAMPUS (Civilian Health and Medical Plan for the Uniformed Services). However, CHAMPUS (unlike Medicare) may make payments to a vendor for an individual's domiciliary care, which may result in ISM to the individual. Therefore, do not assume that CHAMPUS payments constitute payment for medical services alone. Essentially similar medical services may be provided by or made available through other Federal programs, State and local government programs, private profit and nonprofit organizations (including charities, special funds benefiting an individual or a limited group of people, and medical insurers) and private individuals.

2. Treatment of Medical Services as Income

Medical services (which include in-kind medical items) are never income regardless of the source of the service or the source of payment for the service. This is a policy change which is effective September 1, 1983 for initial claims, and is effective with the month after the month of initiation for redeterminations initiated on or after September 1, 1983 (SI 02305.030B.). Prior to this policy change, the source of an in-kind medical item (i.e., a medical service) could be material for determining whether or not the in-kind medical item was income.

When cash or an in-kind item (other than a medical item, as defined above) is received by an individual in conjunction with a medical service, see SI 00815.050D. and SI 00815.050E. in order to determine whether the item is income.

NOTE: Payments by a third party of an individual's medical insurance premiums are not considered a medical service; however, these payments are not income per SI 00815.400. Also, items which do not qualify as a medical service may qualify as items received in conjunction with a social service and may not be income. See SI 00815.050D. and SI 00815.050E.

C. Social Services

1. General

There are differing opinions among acknowledged experts in the field, in both governmental and nongovernmental agencies, as to what constitutes a social service. For SSI purposes, use the following definition: A social service is any service (other than medical) which is intended to assist a handicapped or socially disadvantaged individual to function in society on a level comparable to that of an individual who does not have such a handicap or disadvantage.

Note that unlike the definition of medical services in SI 00815.050B., no in-kind items are expressly identified as social services. Use the criteria in E. below to determine whether in-kind items received in conjunction with social services are income.

2. Several Examples of Frequently Encountered Social Services Programs

1. Title XX of the Social Security Act provides services directed at the following goals:

   1. Achieving or maintaining economic self-support to prevent, reduce, or eliminate dependency;

   2. Achieving or maintaining self-sufficiency, including reduction or prevention of dependency;

   3. Preventing or remedying neglect, abuse, or exploitation of children and adults unable to protect their own interests; or preserving, rehabilitating, or reuniting families;

   4. Preventing or reducing inappropriate institutional care by providing for community-based care, home-based care, or other forms of less intensive care; and

   5. Securing referral or admission for institutional care when other forms of care are not appropriate, or providing services to individuals for institutions.

2. Title IV-B of the Social Security Act, Child Welfare Services, provides for:

   1. Public social services which supplement, or substitute for, parental care and supervision for the purpose of preventing, remedying, or assisting in the solution of problems which may result in the neglect, abuse, exploitation, or delinquency of children;

   2. Protecting and caring for homeless, dependent, or neglected children;

   3. Protecting and promoting the welfare of children of working mothers; and

   4. Otherwise protecting and promoting the welfare of children.

3. Title V of the Social Security Act, Maternal and Child Health and Crippled Children's Services, provides:

   1. Services for reducing infant mortality and otherwise promoting the health of mothers and children;

   2. Medical, surgical, corrective, and other services; and

   3. Care and facilities for diagnosis, hospitalization, and aftercare to children who are crippled or who are suffering from conditions leading to crippling.

4. The Rehabilitation Act of 1973 provides:

   1. Vocational rehabilitation services to handicapped individuals;

   2. Services that may improve their ability to live with greater independence by self-sufficiency;

   3. Services to the handicapped individuals who are homebound or institutionalized; and

   4. Services to promote and expand employment opportunities in the public or private sectors for handicapped individuals and to place such individuals in employment.

5. Some examples of governmental programs which may provide medical and social services in combination are: programs under the Lanterman Developmental Disabilities Services Act of 1976 (California), Texas State Mental Health and Mental Retardation Programs, programs under the Pennsylvania Juvenile Act, and State alcoholism programs. Typical of nongovernmental organizations that may provide medical and social services in combination are the Salvation Army and the American Red Cross. The above is not an all-inclusive list. There are social services similar to those described above that are provided by, or made available through, other Federal, State, and local government programs, private profit and nonprofit organizations (including charities) and private individuals.

3. Several Examples of What Is Not a Social Service

1. Education such as that provided by the public schools (and essentially similar programs provided by private and parochial schools) is generally accepted to be in a category of its own and is not considered to be a social service.

2. Training for a specific job skill or trade (vocational training) is not a social service. Do not confuse vocational training with vocational rehabilitation. Vocational rehabilitation refers to a set of social services (not income) that is directed at bringing the abilities of the handicapped up to par with those of the nonhandicapped. However, if part of the vocational rehabilitation includes vocational training, treat both as a social service (i.e., not income).

3. Governmental income maintenance programs are not considered social services programs (e.g., Aid to Families with Dependent Children, Bureau of Indian Affairs General Assistance and/or Child Welfare Assistance, State general assistance, and Veterans Administration compensation or pension benefits).

4. Provision of food, shelter, laundry and recreational facilities in any combination is not by itself a social service.

D. Cash Received In Conjunction With Medical or Social Services

Cash received from a medical or social services program or organization is not income under the conditions described below.

1. Governmental Medical or Social Services Program

a. Rule

Any cash (other than remuneration for sheltered employment and incentive payments) provided by a governmental medical or social services program is not income. To be considered “governmental” in this context, the program must be authorized by Federal, State or local law to make payments for medical or social service purposes. Payment from a governmental program, which is disbursed by a nongovernmental agency, is considered a payment from a governmental program for purposes of this section.

b. Development

Document the file per GN 00301.285 through GN 00301.289 that the source of the cash is a governmental medical or social services program. Obtain evidence from the individual that the source of the cash is a governmental medical or social services program (e.g., program identification card, notice, or award letter). If the individual has no evidence available, contact the agency or organization alleged to be providing the cash and verify it is the source of the cash.

However, if the field office has established that the program's fundamental purpose is medical or social services through a precedent, regional supplement, etc., and the program agency or organization furnishes little or no documentary evidence to the claimant, then it is not necessary to contact the agency or organization. In these circumstances, obtain the individual's statement either signed or recorded on a DROC indicating the source and amount of payments or in-kind items.

When it is not obvious that the governmental program is a medical or social services program (e.g., when medical and/or social services are provided in conjunction with other assistance or unrelated activities), look to the stated fundamental purpose of the program which is the direct provider of the cash as stated in its authorizing law, statute, or ordinance. (For the purposes of this section, an intervening vendor is not considered the direct provider of the cash.) If the fundamental purpose of the governmental program is to provide medical or social service assistance, the cash is not income.

If you are unable to determine the fundamental purpose of the governmental program (e.g., the authorizing statute provides more than one purpose, one of which is not medical or social services, and it does not identify which one is the fundamental purpose), make your determination based on the particular case facts and circumstances involved. If unable to make such a determination, refer the case facts to the Assistance Programs Branch for a decision.

2. Nongovernmental Medical or Social Services Organization

a. Cash Provided for Medical or Social Services Already Received

1. Rule

Any cash provided by a nongovernmental medical or social services organization (including medical and liability insurers) for medical or social services already received by the individual and approved by the organization is not income. However, if the individual alleges (or evidence indicates) the receipt of amounts in excess of the medical or social services expenses incurred, charge the cash received in excess of the expenses as unearned income.

2. Development

Document the file per GN 00301.285 through GN 00301.289 that the source of cash is a nongovernmental medical or social services organization. Look to the fundamental purpose of the organization in its articles of incorporation or certification as a nonprofit organization under section 501(c) of the Internal Revenue Code.

Also obtain the organization's statement either signed or recorded on a DROC as to the purpose of providing the cash. If you verify the source of the cash is a nongovernmental medical or social services organization and the purpose of the cash is to provide a medical or social service, the cash is not income.

b. Cash Provided as a Payment Restricted to Future Use

1. Rule

Any cash provided by a nongovernmental medical or social services organization (including medical and liability insurers) as a payment restricted to the future purchase of a medical or social service, or related excludable in-kind items, is not income.

2. Development

Document the file per GN 00301.285 through GN 00301.289 with the following:

• that the cash is provided by a nongovernmental organization in accordance with the guidelines in a.2) above;

• the purpose of the cash (i.e., it is a payment restricted to the future purchase of a medical or social service); and

• that the providing program requires followup to verify that the funds were spent for the purpose given (e.g., the provider contacts the vendor or requests a receipt).

c. Flat Rate Benefit Payments from an Insurance Policy

1. Rule

   Cash from any insurance policy which pays a flat rate benefit to the recipient without regard to the actual charges or expenses incurred is income. Examples of these types of insurance policies are per diem hospitalization or disability insurance, or cancer or dismemberment policies.

2. Development

   When a claimant/recipient receives cash from a flat rate benefit insurance policy document the file per GN 00301.285 through GN 00301.289 as to the source and amount of the cash.

E. In-Kind Items Received In Conjunction With Medical or Social Services

1. Governmental Medical or Social Services Program

a. Rule

Any in-kind items (including food, or shelter) provided by a governmental medical or social services program (e.g., recreational equipment, magazines, toiletries) are not income unless provided as remuneration for sheltered employment or as incentive payments. Note that in-kind medical items are never income regardless of their source (see B. above).

To be considered “governmental” in this context, the program must be authorized by Federal, State, or local law, statute, or ordinance to provide medical or social services.

b. Development

Unless an in-kind medical item is involved, follow the general guidelines in SI 00815.050D.1.b., and document the file per GN 00301.285 through GN 00301.289 that the purpose of the governmental program involved is to provide medical or social services. Do not count as income any in-kind items provided by the governmental medical or social services program. It is not necessary to develop for the reason the in-kind items are provided when a governmental medical or social services program is involved. It is necessary only to develop the source.

In-kind medical items are not income regardless of their source. If an item meets the definition of an in-kind medical item as defined in SI 00815.050B., no further development is needed.

2. Nongovernmental Medical or Social Services Organization

a. Rules

1. In-kind items (other than food, or shelter) provided by a nongovernmental medical or social services program (e.g., recreational equipment, magazines, toiletries) for medical or social services purposes are not income.

2. Food, or shelter provided by a nongovernmental medical or social services program is income unless excluded under some other section of the POMS (e.g., the food provided during a medical confinement is not income, SI 00815.100).

b. Development

1. In-kind medical items are not income regardless of their source. If an item meets the definition of an in-kind medical item as defined in B. above, no further development is needed. When other in-kind items (not including food, or shelter) are alleged to be received in conjunction with a medical or social service, document the file per GN 00301.285 through GN 00301.289 that the item is provided by a nongovernmental medical or social services organization for medical or social service purposes in accordance with the guidelines in SI 00815.050D.2.a.2.) above. If you verify the source of the cash is a nongovernmental medical or social services organization and the purpose of the item is to provide a medical or social service, the item is not income.

2. Because food, and/or shelter provided by a nongovernmental medical or social services organization and which is not excluded under some other section of the POMS is unearned income (i.e., in-kind support and maintenance (ISM)), develop and document the value of the ISM in accordance with the rules in SI 00835.300 ff.

F. Summary of Rules On Cash and In-Kind Items Received In Conjunction With Medical or Social Services

What follows is a summary of the rules provided in this section for cash and in-kind items received in conjunction with medical or social services.

1. Cash Received in Conjunction With Medical or Social Services

1. Any cash provided by a governmental medical or social services program is not income.

2. Any cash from a nongovernmental medical or social services organization is not income when:

   1. The cash is for medical or social services already received by the individual and approved by the organization; or

   2. The cash is a payment restricted to the future purchase of a medical or social service.

3. Cash from any insurance policy which pays a flat rate benefit to the recipient without regard to the actual charges or expenses incurred is income.

2. In-Kind Items Received in Conjunction With Medical or Social Services

1. In-kind items which meet the definition of medical services in SI 00815.050B. are not income regardless of their source.

2. Room and board provided during a medical confinement (SI 00815.100) is not income.

3. Any in-kind items (including food, or shelter) provided by a governmental medical or social services program are not income.

4. In-kind items (other than food, or shelter) provided by a nongovernmental medical or social services organization for medical or social services purposes are not income.

5. Food, or shelter or other in-kind income provided by a nongovernmental medical or social services organization is income unless excluded under some other section of the POMS (e.g., the food is provided during a medical confinement and consequently is not income).