SI 01415: Elements of State Supplementary Payments

Effective Dates: 01/28/2013 - Present

TN 19 (05-00)

CALIFORNIA	NEVADA
DELAWARE	NEW JERSEY
DISTRICT OF COLUMBIA	NEW YORK
HAWAII	PENNSYLVANIA
IOWA	RHODE ISLAND
MASSACHUSETTS	UTAH
MICHIGAN	VERMONT
MONTANA	WASHINGTON

CALIFORNIA

Definitions of State Living Arrangement Variations

Code	Definition
A	Independent Living with Cooking Facilities — Eligible individual or couple who: Lives in his/her own household, as defined for Federal living arrangement “A” purposes, and has cooking and food storage facilities or is provided meals as part of the living arrangement; or 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 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; or Is a blind individual who lives in an independent living arrangement with or without cooking and food storage facilities; or Effective July 1, 1983, lives in a private medical facility licensed by the State but not certified under title XIX. (An optional supplement “A” payment based on the new instructions is payable retroactively to July 1, 1983.)
B	Nonmedical Out-of-Home Care (NMOHC) — Applies when an individual/couple needs nonmedical care or supervision in the following living arrangement situations: CHILDREN (UNDER AGE 18) Blind child residing in a State licensed NMOHC facility; or Blind child residing in the home of a relative who is not a parent and not a legal guardian; or Disabled child residing in a State licensed NMOHC facility; or Effective October 1, 1979, disabled child residing in the home of a legal guardian who is not a relative; or Effective January 1, 1984, disabled child residing in the home of a relative who is not a parent ( Major v. McMahon decision, reopening a prior decision to pay OS B under this definition may be retroactive to January 1, 1984; or A blind or disabled child in a “certified family” home approved by a licensed home-finding agency (“certified family home placement”); or For periods prior to July 1, 1983 only, a blind or disabled child placed in any home or State licensed NMOHC facility as the result of a court order; or ADULTS (AGE 18 AND OVER) Aged, blind or disabled individual/couple has been determined to be in FLA A and resides in the home of a relative, legal conservator or guardian; or Aged, blind or disabled individual/couple has been determined to be in FLA A and resides in a State licensed NMOHC facility. 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.”
C	Independent Living Without Cooking Facilities — Aged or disabled individual/couple who is neither provided any meals nor has access to adequate cooking/food storage facilities as part of a living arrangement. Transients, as defined in SI 00835.060, are also eligible for OS C. An individual/couple qualifies for OS C if any of the following situations exists: Immediate living quarters do not have cooking and food storage facilities with which the individual/couple or another person (who is responsible for preparing the individual's/couple's 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 to which they have access for preparation of 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 preparation of meals. 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 SSI applicant's/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/couple has access to: Both 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. An ice chest is not considered adequate storage.) OR 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. (Hotplates without temperature controls which are used for warming food are not considered 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 applicant/recipient applies for this supplement rate provided he/she has been without cooking and food storage facilities throughout the month. For purposes of OS C, “throughout a month” does not mean the applicant/recipient must lack adequate cooking/food storage facilities from the very first moment of the month. He/she need only lack them from some time on the first day of the month. If eligibility is based on temporary loss or nonfunctioning of an appliance, the individual should be advised of his/her responsibility to report immediately when the temporary condition has ceased. If the individual provides an expected date when the appliance will be replaced/repaired, diary the case for recontact. Eligibility for this supplement payment ceases the month following the month in which meals are provided or adequate cooking and food storage facilities are available. For a couple, comprised of an aged/disabled individual and a blind individual, whose living arrangement lacks adequate cooking and storage facilities, the couple is to receive the SSI/SSP level for a blind/aged or disabled couple plus the restaurant meals allowance for the disabled member of the couple. Force payment in this living arrangement is required.
D	Living in the Household of Another — Eligible individual/couple is living in the household of another and is receiving food and shelter from that individual. Most individuals/couples who are subject to a 1/3 reduction of their Federal SSI payments (VTR) are eligible for OS D because the criteria for this supplement level are the same as for charging the VTR. However, when the eligible individual/couple lives in the home of a relative (other than a spouse) and needs care and supervision, certification for nonmedical out-of-home care (OS F) should be obtained from the county welfare office since this is the highest categorical supplement for which an individual/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. (Until September 30, 1979, a disabled child under age 18 living with a legal guardian also fell into this category.) Effective February 1, 1982, only FLA A and C are compatible with OS E. If the VTR applies, see SI 01415.031G.
F	Nonmedical Out-of-Home Care Living in the Household of Another — Effective February 1, 1982. Applies whenever an eligible individual or couple meets the criteria for the nonmedical out-of-home care payment rate, and is determined to receive the Federal B payment for living in the household of another (SI 00835.200).
G	Disabled Child Under Age 18 Living in the Household of Another — Effective February 1, 1982. 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 B payment for living in the household of another individual (SI 00835.200).
J	Effective July 1, 1987, the State elected Federal adminstration of an optional State supplementary payment to residents of title XIX facilities. This State code is also used to supplement section 1619 cases.
Y	Optional Supplementation Waived — Individual is eligible for, but has waived his/her right to receive, an optional supplement.
Z	No Supplement Cases — Eligible individual or couple who is a patient: In a medical facility where title XIX pays more than 50 percent of the costs; or In a private medical facility which is not certified under title XIX and not licensed by the State (effective July 1, 1983). (Prior to July 1, 1983, the facility could have been licensed by the State but not certified under title XIX.) Includes residents of publicly operated emergency shelters throughout a month. California is a concurrent category State and permits SSI recipients to receive the highest categorical supplement for which they can qualify.

Federal Code	State OS Code	Category	FBR	State Supplement Level	Total Payment Levels
A	A	Aged	500.00	176.00	676.00
		Blind	500.00	232.00	732.00
		Disabled	500.00	176.00	676.00
	B	All	500.00	327.00	827.00
	C	Aged	500.00	247.00	747.00
		Disabled	500.00	247.00	747.00
	E	Disabled	500.00	79.00	579.00
	Z	All	500.00	0.00	500.00
B	D	Aged	333.34 ¹	183.66	517.00
		Blind	333.34 ¹	251.66	585.00
		Disabled	333.34 ¹	183.66	517.00
	F	All	333.34 ¹	329.66	663.00
	G	Disabled	333.34 ¹	77.66	411.00
C	A	Blind	500.00	232.00	732.00
	E	Disabled	500.00	79.00	579.00
D	J	All	30.00 ²	13.00	43.00

¹ Not an FBR; the amount represents the FBR less VTR.

² Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

Federal Code	State OS Code	Category	FBR	State Supplement Level	Total Payment Levels
A	A	Aged/Aged	751.00	450.00	1,201.00
		Blind/Blind	751.00	640.00	1,391.00
		Disabled/Disabled	751.00	450.00	1,201.00
		Aged/Blind	751.00	569.00	1,320.00
		Aged/Disabled	751.00	450.00	1,201.00
		Blind/Disabled	751.00	569.00	1,320.00
	B	All	751.00	903.00	1,654.00
	C	Aged/Aged	751.00	592.00	1,343.00
		Disabled/Disabled	751.00	592.00	1,343.00
		Aged/Disabled	751.00	592.00	1,343.00
	Z	All	751.00	0.00	751.00
B	D	Aged/Aged	500.67 ¹	482.33	983.00
		Blind/Blind	500.67 ¹	673.33	1,174.00
		Disabled/Disabled	500.67 ¹	482.33	983.00
		Aged/Blind	500.67 ¹	601.33	1,102.00
		Aged/Disabled	500.67 ¹	482.33	983.00
		Blind/Disabled	500.67 ¹	601.33	1,102.00
	F	All	500.67 ¹	863.33	1,364.00
D	J	All	60.00 ²	26.00	86.00

¹ Not an FBR; the amount represents the FBR less VTR.

² Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

DELAWARE

Definitions of State Living Arrangement Variations

Code	Definition
A	Adult Residential Care Facility — Only living arrangement variation in Delaware and includes only those recipients who are certified by the State medical unit as residents of an adult care facility.
Y	Optional Supplementation Waived — Individual is eligible for, but has waived his/her right to receive, an optional supplement.
Z	No Supplement Cases — All recipients who are not included in A or Y.
	Optional supplementation code Z is the proper code to be used with an “intervening” Federal A code. (See SM 01301.535.)

Federal Code	State OS Code	Category	FBR	State Supplement Level	Total Payment Levels
A	A	All	500.00	140.00	640.00
	Z	All	500.00	0.00	500.00
B	Z	All	333.34 ¹	0.00	333.34
C	Z	All	500.00	0.00	500.00
D	Z	All	30.00 ²	0.00	30.00

¹ Not an FBR; the amount represents the FBR less VTR.

² Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

Federal Code	State OS Code	Category	FBR	State Supplement Level	Total Payment Levels
A	A	All	751.00	448.00	1,199.00
	Z	All	751.00	0.00	751.00
B	Z	All	500.67 ¹	0.00	500.67
D	Z	All	60.00 ²	0.00	60.00

¹ Not an FBR; the amount represents the FBR less VTR.

² Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

DISTRICT OF COLUMBIA

Definitions of State Living Arrangement Variations

Code	Definition
A	Adult Foster Care Home with 50 or Fewer Residents —Recipients who are certified by the District of Columbia, Department of Human Services, 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 Human Services, as residents of an adult foster care home with more than 50 residents.
G	Effective January 1, 1988, 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 has waived his/her right to receive, an optional supplement.
Z	No Supplement Cases — All recipients who are not included in A, B, G, or Y.

Federal Code	State OS Code	Category	FBR	State Supplement Level	Total Payment Levels
A	A	All	500.00	307.00	807.00
	B	All	500.00	417.00	917.00
B	Z	All	333.34	0.00	333.34
C	Z	All	500.00	0.00	500.00
D	G	All	30.00 ²	40.00	70.00

¹ Not an FBR; the amount represents the FBR less VTR.

² Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

Federal Code	State OS Code	Category	FBR	State Supplement Level	Total Payment Levels
A	A	All	751.00	863.00	1,614.00
	B	All	751.00	1083.00	1,834.00
B	Z	All	500.67 ¹	0.00	500.67
D	G	All	60.00 ²	80.00	140.00

¹ Not an FBR; the amount represents the FBR less VTR.

² Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

Federal Code	State OS Code	Category	FBR	State Supplement Level	Total Payment Levels
A	A	All	494.00	297.00	791.00
	B	All	494.00	407.00	901.00
B	Z	All	329.34 ¹	0.00	329.34
C	Z	All	494.00	0.00	494.00
D	G	All	30.00 ²	40.00	70.00

¹ Not an FBR; the amount represents the FBR less VTR.

² Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

Federal Code	State OS Code	Category	FBR	State Supplement Level	Total Payment Levels
A	A	All	741.00	841.00	1582.00
	B	All	741.00	1061.00	1802.00
B	Z	All	494.00 ¹	0.00	494.00
D	G	All	60.00 ²	80.00	140.00

¹ Not an FBR; the amount represents the FBR less VTR.

² Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

HAWAII

Definitions of State Living Arrangement Variations

Code	Definition
A	Independent Living — Eligible individual or couple who: Lives in his/her own household as defined for Federal living arrangement A purposes. This includes living in a “half-way house,” which is a private nonmedical facility with whom the State has a purchase or services agreement for the short term care of certain needy individuals; or 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 Is a blind or disabled child under age 18 (or age 21 if the individual qualifies as a “protected child”) living in the household of a parent or parents.
	Optional supplement code A is the proper code to be used with an “intervening” Federal A code. (See SM 01301.535.) This State code is also used to supplement Section 1619 cases.
B	Living in the Household of Another — Effective July 1, 1983, a supplement is no longer payable because the combined Federal/State supplementary payment level established by the State is lower than the FBR.
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, nonmedical 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 is provided for six or more residents.
Y	Optional Supplementation Waived — Eligible for, but has waived his/her right to receive, an optional supplement.
Z	No Supplement Cases — Eligible individual (or couple) who is living in the household of another (see explanation in definition for optional supplement B) and an eligible individual (or couple) who is a patient: In a medical facility where title XIX pays more than 50 percent of the costs; or In a private medical facility which is not certified under title XIX. Also includes residents of publicly operated emergency shelters throughout a month.

Federal Code	State OS Code	Category	FBR	State Supplement Level	Total Payment Levels
A	A	All	500.00	4.90	504.90
	H	All	500.00	521.90	1,021.90
	I	All	500.00	629.90	1,129.90
B	Z	All	333.34 ¹	0.00	333.34
C	A	All	500.00	4.90	504.90
D	Z	All	30.00 ²	0.00	30.00

¹ Not an FBR; the amount represents the FBR less VTR.

² Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

Federal Code	State OS Code	Category	FBR	State Supplement Level	Total Payment Levels
A	A	All	751.00	8.80	759.80
	H	All	751.00	1,292.80	2,043.80
	I	All	751.00	1,508.80	2,259.80
B	Z	All	500.67 ¹	0.00	500.67
D	Z	All	60.00 ²	0.00	60.00

¹ Not an FBR; the amount represents the FBR less VTR.

² Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

IOWA

Definitions of State Living Arrangement Variations

Code	Definition
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 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.
	Optional supplement code A is the proper code to be used with an “intervening” Federal A code. (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/H	Living with a Dependent Person — Eligible individual or each member of an eligible couple in Federal living arrangement A, B, or C who has an ineligible spouse, parent, child, or adult child living in the home with him or her, and who is financially dependent upon the eligible individual as defined by the State Department of Human Services.
	The payment level for this variation is increased by $22 for each blind individual or blind member of a couple to reflect the categorical blind supplement.
D/I	Living in a Family Life or Boarding Home — Eligible individual or each member of an eligible couple in Federal living arrangement 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	Used 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 “throughout a month” requirement is not met at the time initial claims input is made.
Y	Optional Supplementation Waived — Individual is eligible for, but has waived his/her 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 whose Federal payments are reduced to $30/$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 two optional supplementation programs — In-Home Health Related Care and Residential Care.

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

Blind recipients (either individuals or member of a couple) whose records include an EP have a supplementary payment level that includes $22 for each individual in addition to the Federal FBR and EP increment and must be force paid.

Federal Code	State OS Code	Category	FBR	State Supplement Level	Total Payment Levels
A	A	Blind	500.00	22.00	522.00
	C	Aged	500.00	251.00	751.00
		Blind	500.00	273.00	773.00
		Disabled	500.00	251.00	751.00
	D	All	500.00	62.20	562.20
	G	All	500.00	0.00	500.00
	Z	Aged	500.00	0.00	500.00
		Disabled	500.00	0.00	500.00
B	B	Blind	333.34 ¹	22.00	355.34
	H ³	Aged	333.34 ¹	251.00	584.34
		Blind	333.34 ¹	273.00	606.34
		Disabled	333.34 ¹	251.00	584.34
	I ³	All	333.34 ¹	62.20	395.54
	Z	Aged	333.34 ¹	0.00	333.34
		Disabled	333.34 ¹	0.00	333.34
C	A	Blind	500.00	22.00	522.00
	C	Blind	500.00	273.00	773.00
		Disabled	500.00	251.00	751.00
	Z	Disabled	500.00	0.00	500.00
D	Z	All	30.00 ²	0.00	30.00

¹ Not an FBR; the amount represents the FBR less VTR.

² Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

³ Old FLA/OS codes B/C and B/D were changed to B/H and B/I to make them compatible with the RMA policy computation process.

State-administered programs: For Calendar Year 1999 -

Individuals receiving “Residential Care” receive payment based on a per diem rate plus a monthly personal allowance. The proposed per diem rate for calendar year 1999 is $17.05 to $23.83. The proposed personal allowance is $71.00.
Individuals receiving “In-Home Health Care” receive a payment based on actual cost of in-home health care plus basic Federal benefits. The proposed maximum payment for care in in-home related care is $458.20.

Federal Code	State OS Code	Category	FBR	State Supplement Level	Total Payment Levels
A	A	Blind/Blind	751.00	44.00	795.00
		Blind/Aged	751.00	22.00	773.00
		Blind/Disabled	751.00	22.00	773.00
	C	Aged/Aged	751.00	251.00	1002.00
		Blind/Blind	751.00	295.00	1046.00
		Disabled/Disabled	751.00	251.00	1002.00
		Aged/Blind	751.00	273.00	1024.00
		Aged/Disabled	751.00	251.00	1002.00
		Blind/Disabled	751.00	273.00	1024.00
	D	All	751.00	413.40	1164.40
	G	All	751.00	0.00	751.00
	Z	Aged/Aged	751.00	0.00	751.00
		Disabled/Disabled	751.00	0.00	751.00
		Aged/Disabled	751.00	0.00	751.00
B	B	Blind/Blind	500.67 ¹	44.00	544.67
		Blind/Aged	500.67 ¹	22.00	522.67
		Blind/Disabled	500.67 ¹	22.00	522.67
	H³	Aged/Aged	500.67 ¹	251.00	751.67
		Blind/Blind	500.67 ¹	295.00	795.67
		Disabled/Disabled	500.67 ¹	251.00	751.67
		Aged/Blind	500.67 ¹	273.00	773.67
		Aged/Disabled	500.67 ¹	251.00	751.67
		Blind/Disabled	500.67 ¹	273.00	773.67
	I ³	All	500.67 ¹	413.40	914.07
	Z	Aged/Aged	500.67 ¹	0.00	500.67
		Disabled/Disabled	500.67 ¹	0.00	500.67
		Aged/Disabled	500.67 ¹	0.00	500.67
D	Z	All	60.00 ²	0.00	60.00

¹ Not an FBR; the amount represents the FBR less VTR.

² Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

³ Old FLA/OS codes B/C and B/D were changed to B/H and B/I to make them compatible with the RMA policy computation process.

State-administered programs: For Calendar Year 1999 -

Individuals receiving “Residential Care” receive payment based on a per diem rate plus a monthly personal allowance. The proposed per diem rate for calendar year 1999 is $17.05 to $23.83. The proposed personal allowance is $71.00.
Individuals receiving “In-Home Health Care” receive a payment based on actual cost of in-home health care plus basic Federal benefits. The proposed maximum payment for care in in-home related care is $458.20. (Members of a couple are treated as individuals.)

MASSACHUSETTS

Definitions of State Living Arrangement Variations

Code	Definition
A	Full Cost-of-Living: An individual who is in Federal living arrangement A is in State living arrangement A, if he/she is living in his/her own household¹ and is: 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, those who rent only rooms in private residences will be considered living alone provided they do not use the residential kitchen facilities for preparation of meals; or Living only with his/her eligible spouse; or Living with his/her eligible spouse and ineligible child/children ² none of whom (children) receive public income maintenance payments; ³ or Living only with his/her ineligible spouse and/or his/her ineligible child/children, none of whom (spouse and children) receive public income maintenance payments. NOTE: For purposes of a. through d. above, foster children placed with anyone other than their parents are not considered to be living with the foster parent. An individual who is in Federal living arrangement C is in State living arrangement A if none of the other people with whom he/she is living receive public income maintenance payments. An individual who is in Federal living arrangement A or C and who does not meet the criteria contained in 1. or 2. above will be in State living arrangement A if he/she pays 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 the household expenses shown in that section are to be used. An ineligible spouse's income (except any assistance based upon need) may be used 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. Optional supplement code A is the proper code to be used with an “intervening” Federal A code. (See SM 01301.535.)
B	Shared Living Expenses — An individual who is in Federal living arrangement A or C and who does not meet the criteria listed for State living arrangement A or E 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 above. Also included are 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 he/she is 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 — also is 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 that portion in which they are living is licensed by and has a provider agreement with the State. Does not include residents of a Medicaid certified portion of a rest home.
F	Effective July 1, 1987, the State elected Federal administration of an optional State supplementary payment to residents of title XIX facilities.
G	Assisted Living — Effective July 1, 1994, the State elected Federal administration of their 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 is not receiving 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 shall certify to SSA each individual who is eligible for this optional supplement living arrangement. This living arrangement was discontinued effective January 1, 1996. However, it has been restored, retroactively, to January 1, 1997.
Y	Optional Supplementation Waived — Individual is eligible for, but has waived his/her right to receive, an optional supplement.
Z	No Supplement Cases — Recipients in a title XIX facility where Medicaid pays more than 50 percent of the cost.
Massachusetts is a concurrent category State and permits SSI recipients to receive the highest categorical supplement for which they can qualify.

¹ For purposes of determining State living arrangements, a commercial boarding house, foster home, or halfway house is not considered the person's household.

² Use the SSI definition of child, SI 00501.400.

³ A public income maintenance payment is a payment from any of the following programs: Aid to Families with Dependent Children (AFDC), SSI, the Refugee Act of 1980, the Disaster Relief Act of 1974, general assistance programs of the Bureau of Indian Affairs, State or local government income maintenance programs that are based on need, or Veterans' Administration benefits based on need.

Federal Code	State OS Code	Category	FBR	State Supplement Level	Total Payment Levels
A	A	Aged	500.00	128.82	628.82
		Blind	500.00	149.74	649.74
		Disabled	500.00	114.39	614.39
	B	Aged	500.00	39.26	539.26
		Blind	500.00	149.74	649.74
		Disabled	500.00	30.40	530.40
	E	Aged	500.00	293.00	793.00
		Blind	500.00	149.74	649.74
		Disabled	500.00	293.00	793.00
	G	Aged	500.00	454.00	954.00
		Blind	500.00	454.00	954.00
		Disabled	500.00	454.00	954.00
B	C	Aged	333.34 ¹	104.36	437.70
		Blind	333.34 ¹	316.40	649.74
		Disabled	333.34 ¹	87.58	420.92
C	A	Blind	500.00	149.74	649.74
		Disabled	500.00	114.39	614.39
	B	Blind	500.00	149.74	649.74
		Disabled	500.00	30.40	530.40
D	F	All	30.00 ²	35.00	65.00

¹ Not an FBR; the amount represents the FBR less VTR.

² Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

Federal Code	State OS Code	Category	FBR	State Supplement Level	Total Payment Levels
A	A	Aged/Aged	751.00	201.72	952.72
		Blind/Blind	751.00	548.48	1,299.48
		Disabled/Disabled	751.00	180.06	931.06
		Aged/Blind	751.00	375.10	1,126.10
		Aged/Disabled	751.00	190.89	941.89
		Blind/Disabled	751.00	364.27	1,115.27
	B	Aged/Aged	751.00	201.72	952.72
		Blind/Blind	751.00	548.48	1,299.48
		Disabled/Disabled	751.00	180.06	931.06
		Aged/Blind	751.00	375.10	1,126.10
		Aged/Disabled	751.00	190.89	941.89
		Blind/Disabled	751.00	364.27	1,115.27
	E	Aged/Aged	751.00	835.00	1,586.00
		Blind/Blind	751.00	548.48	1,299.48
		Disabled/Disabled	751.00	835.00	1,586.00
		Aged/Blind	751.00	691.74	1,442.74
		Aged/Disabled	751.00	835.00	1,586.00
		Blind/Disabled	751.00	691.74	1,442.74
	G	Aged/Aged	751.00	681.00	1,432.00
		Blind/Blind	751.00	681.00	1,432.00
		Disabled/Disabled	751.00	681.00	1,432.00
		Aged/Blind	751.00	681.00	1,432.00
		Aged/Disabled	751.00	681.00	1,432.00
		Blind/Disabled	751.00	681.00	1,432.00
B	C	Aged/Aged	500.67 ¹	215.80	716.47
		Blind/Blind	500.67 ¹	798.81	1,299.48
		Disabled/Disabled	500.67 ¹	194.18	694.85
		Aged/Blind	500.67 ¹	507.31	1007.98
		Aged/Disabled	500.67 ¹	204.99	705.66
		Blind/Disabled	500.67 ¹	496.50	997.17
D	F	All	60.00 ²	70.00	130.00

¹ Not an FBR; the amount represents the FBR less VTR.

² Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

MICHIGAN

Definitions of State Living Arrangement Variations

Code	Definition
D	Domiciliary Care — Recipients residing in licensed nonmedical facilities which 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 nonmedical facilities which 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 nonmedical facility for the aged. The State provides SSA with a list of these facilities and certified 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. (Children under 18 are excluded.)
H	Living in the Household of Another with an EP —Recipients with an EP and living in the household of another for Federal purposes. (Children under 18 are excluded.)
I	Effective January 1, 1988, 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 has waived his/her 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.

Federal Code	State OS Code	Category	FBR	State Supplement Level	Total Payment Levels
A	D	All	500.00	87.00	587.00
	E	All	500.00	157.50	657.50
	F	All	500.00	179.30	679.30
	G	All	750.00 ²	14.00	764.00
B	H	All	500.00 ¹	9.33	509.33
D	I	All	30.00 ³	7.00	37.00

¹ Not an FBR; the amount represents the FBR plus EP increment less VTR.

² Not an FBR; the amount represents the FBR plus EP increment.

³ Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

Federal Code	State OS Code	Category	FBR	State Supplement Level	Total Payment Levels
A	D	All	751.00	423.00	1,174.00
	E	All	751.00	564.00	1,315.00
	F	All	751.00	607.60	1,358.60
	G	All	1001.00 ²	21.00	1,022.00
B	H	All	667.34 ¹	14.00	681.34
D	I	All	60.00 ³	14.00	74.00

¹ Not an FBR; the amount represents the FBR plus EP increment less VTR.

² Not an FBR; the amount represents the FBR plus EP increment.

³ Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

MONTANA

Definitions of State Living Arrangement Variations

Code	Definition
G	State-Certified Personal Care
H	State-Certified Residence in Community Home for Mentally Disabled
I	State-Certified Residence in Community Home for Physically or Developmentally Disabled
J	State-Certified Residence for Child and Adult Foster Care
K	State-Certified Semi-Independent Care
Y	Optional Supplementation Waived — Individual is eligible for, but has waived his/her 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.

Federal Code	State OS Code	Category	FBR	State Supplement Level	Total Payment Levels
A	G	All	500.00	94.00	594.00
	H	All	500.00	94.00	594.00
	I	All	500.00	94.00	594.00
	J	All	500.00	52.75	552.75
	K	All	500.00	26.00	526.00
	Z	All	500.00	0.00	500.00
B	Z	All	333.34 ¹	0.00	333.34
C	Z	All	500.00	0.00	500.00
D	Z	All	30.00 ²	0.00	30.00

¹ Not an FBR; the amount represents the FBR less VTR.

² Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

Federal Code	State OS Code	Category	FBR	State Supplement Level	Total Payment Levels
A	G	All	751.00	193.00	944.00
	H	All	751.00	193.00	944.00
	I	All	751.00	193.00	944.00
	J	All	751.00	110.50	861.50
	K	All	751.00	57.00	808.00
	Z	All	751.00	0.00	751.00
B	Z	All	500.67 ¹	0.00	500.67
D	Z	All	60.00 ²	0.00	60.00

¹ Not an FBR; the amount represents the FBR less VTR.

² Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

NEVADA

Definitions of State Living Arrangement Variations

Code	Definition
A	Independent Living or Living in Parental Household — Aged or blind eligible individual or couple who: Lives in his/her own household as defined for Federal living arrangement A purposes; or 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 Is a blind child under age 18 (age 21 for individuals who qualify as a “protected child”) living in a parent's household. Used with an “intervening” Federal A code. (See SM 01301.535.)
B	Living in the Household of Another — Aged or blind eligible individual or couple who is living in the household of another individual and receiving food and shelter from that individual. Aged or blind individuals or couples, who are subject to a one-third reduction 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 individual or couple who lives in a private nonmedical facility or, as of October 1976, 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.
	These facilities are licensed or authorized to receive payment by the State. The State provides SSA with listings of these facilities.
Y	Optional Supplementation Waived — Individual is eligible for, but has waived his/her right to receive, an optional supplement.
Z	No Supplement Cases — No supplement cases include:

	Disabled eligible individuals or disabled members of eligible couples; or Eligible individuals or members of eligible couples in a medical facility where title XIX pays more than 50 percent of the cost; or Eligible individuals or members of eligible couples who are patients in a private medical facility which is not certified under title XIX; or Residents of publicly operated emergency shelters throughout a month.

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

Federal Code	State OS Code	Category	FBR	State Supplement Level	Total Payment Levels
A	A	Aged	500.00	36.40	536.40
		Blind	500.00	109.30	609.30
	C	Aged	500.00	329.66	829.66
		Blind	500.00	329.66	829.66
	Z	Disabled	500.00	0.00	500.00
B	B	Aged	333.34 ¹	24.27	357.61
		Blind	333.34 ¹	213.96	547.30
	Z	Disabled	333.34 ¹	0.00	333.34
C	A	Blind	500.00	109.30	609.30
	Z	Disabled	500.00	0.00	500.00
D	Z	All	30.00 ²	0.00	30.00

¹ Not an FBR; the amount represents the FBR less VTR.

² Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

Federal Code	State OS Code	Category	FBR	State Supplement Level	Total Payment Levels
A	A	Aged/Aged	751.00	74.46	825.46
		Blind/Blind	751.00	374.60	1,125.60
		Aged/Blind	751.00	224.53	975.53
		Aged/Disabled	751.00	37.23	788.23
		Blind/Disabled	751.00	187.30	938.30
	C	Aged/Aged	751.00	829.98	1,580.98
		Blind/Blind	751.00	829.98	1,580.98
		Aged/Blind	751.00	829.98	1,580.98
		Aged/Disabled	751.00	414.99	1,165.99
		Blind/Disabled	751.00	414.99	1,165.99
	Z	Disabled	751.00	0.00	751.00
B	B	Aged/Aged	500.67 ¹	49.64	550.31
		Blind/Blind	500.67 ¹	531.94	1,032.61
		Aged/Blind	500.67 ¹	290.79	791.46
		Aged/Disabled	500.67 ¹	24.82	525.49
		Blind/Disabled	500.67 ¹	265.97	766.64
	Z	Disabled	500.67 ¹	0.00	500.67
D	Z	All	60.00 ²	0.00	60.00

¹ Not an FBR; the amount represents the FBR less VTR.

² Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

NEW JERSEY

Definitions of State Living Arrangement Variations

Code	Definition
A	Licensed Residential Health Care Facilities and Certain Licensed Residential Facilities — The State provides New Jersey District Offices with lists of approved facilities. Mentally retarded individuals must be placed and supervised by either the State Department of Youth and Family Services or the State Division of Mental Retardation.
B	Living Alone or with Others — Eligible individuals (including children) or eligible couples whose Federal living arrangements are A or C and who do not meet the requirements defined in other supplementation categories.
	Therefore, effective August 1, 1981, any eligible adult/couple who meets the requirement for a Federal A will be in optional supplement B unless 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 will automatically be entitled to optional supplement B. This category includes, but is not limited to, those eligible adults/couples who are: Living physically alone; or Living with others in a private dwelling, but meeting some criteria for Federal living arrangement A; or
	Living in the Transitional Residency Program when the placement is through the Division of Mental Health and Hospitals, Department of Human Services Optional supplement code B is the proper code to be used with an “intervening” Federal A code. (See SM 01301.535.) This State code is also used to supplement Section 1619 cases.
C	Living Alone with an Ineligible Spouse — Used when an individual lives with his/her ineligible spouse and there are no other persons who are part of the household. An ineligible spouse for State supplementation purposes is determined 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. The State uses this category to ensure that an individual with an ineligible spouse will receive the same total payment as an eligible couple or an individual with an EP. 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 his/her 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 their “household.” There is no couple counterpart in this category.
	Parent(s) with minor children are always considered 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 will also qualify for the O/S - C rate.
D	Living in the Household of Another — Persons who are “living in the household of another” for Federal purposes.
G	Effective September 1, 1988, 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 has waived his/her right to receive, an optional supplement.
Z	No Supplement Cases — Individuals and couples in licensed medical facilities where Medicaid is paying more than 50 percent of the cost of care, individuals and couples in publicly operated community residences having 16 or less residents, and residents of publicly operated emergency shelters throughout a month.

Federal Code	State OS Code	Category	FBR	State Supplement Level	Total Payment Levels
A	A	All	500.00	150.05	650.05
	B	All	500.00	31.25	531.25
	C	Individual	500.00	276.36	776.36
		w/EP	750.00 ²	26.36	776.36
	Z	All	500.00	0.00	500.00
B	D	All	333.34 ¹	44.31	377.65
C	B	All	500.00	31.25	531.25
D	G	All	30.00 ³	10.00	40.00

¹ Not an FBR; the amount represents the FBR less VTR.

² Not an FBR; the amount represents the FBR plus EP increment.

³ Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

Federal Code	State OS Code	Category	FBR	State Supplement Level	Total Payment Levels
A	A	All	751.00	530.36	1,281.36
	B	All	751.00	25.36	776.36
	Z	All	751.00	0.00	751.00
B	D	All	500.67 ¹	93.09	593.76
D	G	All	60.00 ²	20.00	80.00

¹ Not an FBR; the amount represents the FBR less VTR.

² Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

NEW YORK

Definitions of State Living Arrangement Variations

Code	Definition
A	Living Alone — Eligible individuals or eligible couples living physically alone, or living with only a foster child(ren), or a homemaker authorized by the local Department of Social Services (DSS), or a family care recipient(s) placed by the Office of Mental Health (OMH) or Office of Mental Retardation and Developmentally Disabled (OMRDD) or local DSS, or individuals living with others but paying a “flat fee for room and board,” or living with others but taking all his/her meals outside the dwelling unit, or living with others in a dwelling but separately preparing food, or having his/her food separately prepared for him/her.
B	Living with Others — Individual/child/couple who resides in a dwelling with others and prepares food in common with at least one other person in the dwelling, or is a member of a religious community, or child in any living arrangement other than a family care home (Level I) or community residence (Level II) certified by OMRDD or OMH.
C	Congregate Care Level I — Family type homes and family care homes. Family type homes are facilities operated for the purpose of providing long-term residential care for adults and are certified by the New York State DSS and supervised by local departments of social services. Family care homes are private households which provide care for mentally disabled persons.
D	Congregate Care Level II — Residential facilities for adults and certain children with mental disabilities.
E	Congregate Care Level III — Privately operated non-medical residential facilities. Although Level III facilities are often called schools, these facilities may not meet the Federal definition of school. Operated for the purpose of providing treatment, training and education for mentally retarded or developmentally disabled individuals, these facilities are certified by OMRDD in accordance with State regulations.
F	Living in the Household of Another — Same as Federal definition. The State supplement payment for the individual/child/couple whose Federal benefit rate is subject to the one-third reduction is the “living with others” rate but for systems purposes is coded F.
G	Effective January 1, 1988, 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 has waived his/her right to receive, an optional supplement.
Z	No Supplement Cases — Recipients in licensed medical facilities where Medicaid is paying more than 50 percent of the cost of care, recipients in publicly operated community residences which serve 16 or fewer residents, and residents of publicly operated emergency shelters throughout a month.

Federal Code	State OS Code	Category	FBR	State Supplement Level	Total Payment Levels
A, C	A	All	500.00	87.00	587.00
	B	All	500.00	23.00	523.00
	C	NY City	500.00	266.48	766.48
		Nassau County⁴	500.00	266.48	766.48
		All other counties	500.00	228.48	728.48
	D	NY City	500.00	435.00	935.00
		Nassau County⁴	500.00	435.00	935.00
		All other counties	500.00	405.00	905.00
	E	NY City	500.00	482.96	982.96
		Nassau County⁴	500.00	458.96	958.96
		All other counties	500.00	458.96	958.96
	Z	All	500.00	0.00	500.00
B	F	All	333.34 ¹	23.00	356.34
D	G	All	30.00 ²	5.00 ³	35.00

¹ Not an FBR; the amount represents the FBR less VTR.

² Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

³ New York administers a supplement of $20 to some recipients in a title XIX institution.

⁴ Includes and applies to: Nassau, Suffolk, and Westchester counties effective 7/1/85.

Federal Code	State OS Code	Category	FBR	State Supplement Level	Total Payment Levels
A, C	A	All	751.00	104.00	855.00
	B	All	751.00	46.00	797.00
	C	NY City	751.00	781.96	1,532.96
		Nassau County⁴	751.00	781.96	1,532.96
		All other counties	751.00	705.96	1,456.96
	D	NY City	751.00	1,119.00	1,870.00
		Nassau County⁴	751.00	1,119.00	1,870.00
		All other counties	751.00	1,059.00	1,810.00
	E	NY City	751.00	1,214.92	1,965.92
		Nassau County⁴	751.00	1,166.92	1,917.92
		All other counties	751.00	1,166.92	1,917.92
	Z	All	751.00	0.00	751.00
B	F	All	500.67 ¹	46.00	546.67
D	G	All	60.00 ²	10.00³	70.00

¹ Not an FBR; the amount represents the FBR less VTR.

² Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

³ New York administers a supplement of $40 to recipients in a title XIX institution.

⁴ Includes and applies to: Nassau, Suffolk and Westchester counties effective 7/1/85.

PENNSYLVANIA

Definitions of State Living Arrangement Variations

Code	Definition
A	Living Alone — Recipients in private medical facilities (nursing homes, hospitals, intermediate care facilities) where title XIX is not paying more than 50 percent of the cost of care, residents of publicly operated emergency shelters throughout a month, and all other individuals and couples in Federal codes A and C not meeting the definition of another variation.
	Used with an “intervening” Federal A code. (See SM 01301.535.)
	This State code is also used to supplement Section 1619 cases.
B	Living in the Household of Another — Recipients who do not have an EP and who live in the household of another and receive support and maintenance for Federal purposes.
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; i.e., Public Law 93-66.
D	Living in the Household of Another with an EP —Recipients who live in the household of another and who have one or more EP's as defined under the Federal rules; i.e., Public Law 93-66.
G	Living in a Domiciliary Care Facility — Adult persons (18 and over) certified by the State to be residing in nonmedical residential care facilities.
H	Living in a Personal Care Boarding Home — Adult Persons (18 and Over) certified by the State to be residing in nonmedical residential care facilities (Effective 07/01/89).
Y	Optional Supplementation Waived — Individual is eligible for, but has waived his/her right to receive, an optional supplement.
Z	No Supplement Cases — Includes all recipients who are residing in a medical facility in which title XIX is paying more than 50 percent of the cost of care.

Federal Code	State OS Code	Category	FBR	State Supplement Level	Total Payment Levels
A	A	All	500.00	27.40	527.40
	C	All	750.00 ³	43.70	793.70
	G	All	500.00	329.30	829.30
	H	All	500.00	334.30	834.30
B	B	All	333.34 ¹	27.40	360.74
	D	All	500.00 ²	43.70	543.70
C	A	All	500.00	27.40	527.40
D	Z	All	30.00 ⁴	0.00	30.00

¹ Not an FBR; the amount represents the FBR less VTR.

² Not an FBR; the amount represents the FBR plus EP increment less VTR.

³ Not an FBR; the amount represents the FBR plus EP increment.

⁴ Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

Federal Code	State OS Code	Category	FBR	State Supplement Level	Total Payment Levels
A	A	All	751.00	43.70	794.70
	C	All	1001.00 ³	68.05	1,069.05
	G	All	751.00	737.40	1,488.40
	H	All	751.00	747.40	1,498.40
B	B	All	500.67 ¹	43.70	544.37
	D	All	750.67 ²	68.05	818.72
D	Z	All	60.00 ⁴	0.00	60.00

¹ Not an FBR; the amount represents the FBR less VTR.

² Not an FBR; the amount represents the FBR plus EP increment less VTR.

³ Not an FBR; the amount represents the FBR plus EP increment.

⁴ Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

RHODE ISLAND

Definitions of State Living Arrangement Variations

Code	Definition
A	Living Alone — Recipients who are in Federal codes A and C.
	Used to supplement Section 1619 cases.
B	Living in the Household of Another — Recipients who are living in the household of another and receiving support and maintenance in-kind. This variation applies only when the one-third reduction to the Federal benefit is applied.
D	Living in a Shelter Care Facility (Effective 10/01/90). Revised to: Residential Care/Assisted Living - Adult Individuals Only (Effective 10/01/98).
E	The State elected Federal Administration of an optional State Supplementary payment to residents of Title XIX Facilities (Effective 03/01/91).
Y	Optional Supplementation Waived — Individual is eligible for, but has waived his/her right to receive, an optional supplement.
Z	No Supplement Cases — Residents of publicly operated emergency shelters throughout a month and recipients who are subject to the $30 per month SSI payment limit because they are inpatients in medical facilities receiving more than 50 percent of the cost of care from the State's Medicaid program.

Federal Code	State OS Code	Category	FBR	State Supplement Level	Total Payment Levels
A	A ¹	All	500.00	64.35	564.35
	D	All	500.00	582.00	1082.00
B	B ¹	All	333.34 ²	74.60	407.94
C	A ¹	All	500.00	64.35	564.35
D	E	All	30.00 ³	20.00	50.00

¹ Code is systems generated from the Federal code.

² Not an FBR; the amount represents the FBR less VTR.

³ Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

Federal Code	State OS Code	Category	FBR	State Supplement Level	Total Payment Levels
A	A ¹	All	751.00	120.50	871.50
B	B ¹	All	500.67 ²	136.50	637.17
D	E	All	60.00 ³	40.00	100.00

¹ Code is systems generated from the Federal code.

² Not an FBR; the amount represents the FBR less VTR.

³ Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

Federal Code	State OS Code	Category	FBR	State Supplement Level	Total Payment Levels
A	A ¹	All	500.00	64.35	564.35
	D	All	500.00	582.00	1082.00
B	B ¹	All	333.34 ²	74.60	407.94
C	A ¹	All	500.00	64.35	564.35
D	E	All	30.00 ³	10.00	40.00

¹ Code is systems generated from the Federal code.

² Not an FBR; the amount represents the FBR less VTR.

³ Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

Federal Code	State OS Code	Category	FBR	State Supplement Level	Total Payment Levels
A	A ¹	All	751.00	120.50	871.50
B	B ¹	All	500.67 ²	136.50	637.17
D	E	All	60.00 ³	20.00	80.00

¹ Code is systems generated from the Federal code.

² Not an FBR; the amount represents the FBR less VTR.

³ Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

UTAH

Definitions of State Living Arrangement Variations

Code	Definition
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 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.

Federal Code	State OS Code	Category	FBR	State Supplement Level	Total Payment Levels
A,C	Z	All	500.00	0.00	500.00
B	B	All	333.34 ²	3.13	336.47
D	Z	All	30.00 ¹	None	30.00

¹ Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

² Not an FBR, the amount represents the FBR less VTR.

Federal Code	State OS Code	Category	FBR	State Supplement Level	Total Payment Levels
A,C	A	All	751.00	4.60	755.60
B	B	All	500.67 ²	9.73	510.40
D	Z	All	60.00 ¹	0.00	60.00

¹ Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

² Not an FBR, the amount represents the FBR less VTR.

VERMONT

Definitions of State Living Arrangement Variations

Code	Definition
A	Independent Living (except Chittenden County) — Recipients not living in the household of another, not in a custodial care situation, and not otherwise excepted from supplementation. 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.
	Effective May 1, 1983, an individual or eligible couple residing in a publicly operated emergency shelter throughout a month.
	Optional supplement code A is the proper code to be used with an “intervening” Federal A code (except Chittenden County).
B	Independent Living in Chittenden County — Same as A above except restricted to residents of Chittenden County.
	Effective May 1, 1983, an individual or eligible couple residing in a publicly operated emergency shelter throughout a month.
	Optional supplement code B is the proper code to be used with an “intervening” Federal A code (Chittenden County only). (See SM 01301.535.)
C	Level III assistive community care: Recipients living in Level III facilities identified by the State. (Effective July 1, 1999)
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), and not otherwise excepted from supplementation.
F	Custodial Care: Licensed Home with Limited Nursing Care — Recipients living in Level III Community Homes identified by the State. State administration effective July 1, 1999.
G	Custodial Care: Licensed Community Care Home — Recipients living in Level IV Community Homes identified by the State.
H	Custodial Care: Family Home — Recipients living in another's home in such a manner that the individual or couple is paying room and board and is receiving one or more of the services outlined under the custodial care definition. The individual or couple must also receive the room and board and custodial care in the home in which he/she (they) reside. 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 addition to the above individuals, the Vermont Community Mental Health Agency and Department of Mental Health have established outplacement programs which provide a family home setting to no more than two persons in need of custodial care or supervision. The individuals placed in this setting are eligible for this arrangement only if a third party resides with the individual and provides the custodial care.
	Custodial care means providing basic room and board, plus personal services such as: help with feeding, dressing, bathing, moving about under normal circumstances, occasional tray service (tray service 2-3 times a week) and/or supervision for the recipients'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 is receiving custodial care.
	The change in this arrangement is effective for initial claims filed on or after January 1, 1984. For redeterminations the change is effective with the month after the month in which the first redetermination on or after January 1, 1984, is initiated.
	This arrangement does not cover: Institutional Living — Regardless of whether custodial care is needed in addition to the medical, training, rehabilitation, educational or similar services as the primary function of the institution. A person whose Federal living arrangement is based on home ownership or rental liability. (A flat fee for room and board per SI 00835.120B. is not considered as rental liability for this arrangement.) A child under l8 years of age not placed by a Vermont Community Mental Health Agency or the Vermont Department of Mental Health. Custodial care or supervision provided by a spouse (as defined by Federal regulations). Any home or boarding arrangement which does not meet the Federal (SSI) definition of independent living, Federal code A.
I	Effective July 1, 1987, the State elected Federal administration of an optional State supplementary payment to residents in title XIX facilities.
Y	Optional Supplementation Waived — Individual is eligible for, but has waived his/her 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 the care.

When a person has a room in one facility/household and receives board or custodial care in another facility/household, the custodial rate (F, G, or H) is based on the facility/household where the person sleeps.

Federal Code	State OS Code	Category	FBR	State Supplement Level	Total Payment Levels
A	A	All (Except Chittenden County)	500.00	57.66	557.66
	B	All (Restricted to Chittenden County)	500.00	57.66	557.66
	C ³	All	500.00	47.25	547.25
	F ⁴	All	500.00	0.00	500.00
	G	All	500.00	218.69	718.69
	H	All	500.00	96.38	596.38
B	E	All	333.34 ¹	38.38	371.72
C	A	All (Except Chittenden County)	500.00	57.66	557.66
	B	All (Restricted to Chittenden County)	500.00	57.66	557.66
D	I	All	30.00 ²	17.25	47.25

¹ Not an FBR; the amount represents the FBR less VTR.

² Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

³ New State living arrangement effective July 1, 1999.

⁴ State administration effective July 1, 1999.

Federal Code	State OS Code	Category	FBR	State Supplement Level	Total Payment Levels
A	A	All (Except Chittenden County)	751.00	108.28	859.28
	B	All (Restricted to Chittenden County)	751.00	108.28	859.28
	C ³	All	751.00	94.50	845.50
	F ⁴	All	751.00	0.00	751.00
	G	All	751.00	548.89	1,299.89
	H	All	751.00	325.02	1,076.02
B	E	All	500.67 ¹	47.18	547.85
D	I	All	60.00 ²	34.50	94.50

¹ Not an FBR; the amount represents the FBR less VTR.

² Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

³ New State living arrangement effective July 1, 1999.

⁴ State administration effective July 1, 1999.

Federal Code	State OS Code	Category	FBR	State Supplement Level	Total Payment Levels
A	A	All (Except Chittenden County)	500.00	54.91	554.91
	B	All (Restricted to Chittenden County)	500.00	54.91	554.91
	C ³	All	500.00	45.00	545.00
	F ⁴	All	500.00	0.00	500.00
	G	All	500.00	208.28	708.28
	H	All	500.00	91.79	591.79
B	E	All	333.34 ¹	36.55	369.89
C	A	All (Except Chittenden County)	500.00	54.91	554.91
	B	All (Restricted to Chittenden County)	500.00	54.91	554.91
D	I	All	30.00 ²	15.00	45.00

¹ Not an FBR; the amount represents the FBR less VTR.

² Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

³ New State living arrangement effective July 1, 1999.

⁴ State administration effective July 1, 1999.

Federal Code	State OS Code	Category	FBR	State Supplement Level	Total Payment Levels
A	A	All (Except Chittenden County)	751.00	103.12	854.12
	B	All (Restricted to Chittenden County)	751.00	103.12	854.12
	C³	All	751.00	90.00	841.00
	F⁴	All	751.00	0.00	751.00
	G	All	751.00	522.75	1,273.75
	H	All	751.00	309.54	1,060.54
B	E	All	500.67¹	44.93	545.60
D	I	All	60.00²	30.00	90.00

¹ Not an FBR; the amount represents the FBR less VTR.

² Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

³ New State living arrangement effective July 1, 1999.

⁴ State administration effective July 1, 1999.

WASHINGTON

Definitions of State Living Arrangement Variations

Code	Definition
A	Living Alone — Recipients who are “living in own household” under title XVI. If an eligible individual/couple is determined to be living in own household (Federal living arrangement A) for title XVI, the eligible individual /couple will usually be in a living alone arrangement for State supplementation purposes. This variation includes: Eligible individuals or eligible couples living in private households, whether they are renting, buying, own their home, or have an interest in the home (e.g., a life estate). The household may be in a house, room, college dormitory, apartment, hotel, motel, etc.
	Eligible individuals or eligible couples living in board and room situations. This includes commercial, benevolent, religious, or fraternal board and room accommodations. Eligible individuals or eligible couples residing in homes approved as congregate care facilities (group homes).
	Eligible individuals or eligible couples residing in publicly operated community-based residences of 16 or fewer beds. Eligible individuals and eligible couples residing in adult family homes. Adult family homes are homes that provide board, room, laundry. They may also provide necessary supervision, personal and social services, and, when appropriate, a minimum of nursing care, and are approved for payment and licensed by the State Department of Social and Health Services.
	An eligible individual living with an ineligible spouse when natural, step, adoptive or foster children under age 18 whose needs are included in determining an AFDC grant are residing in the same household. In these cases we assume that the ineligible spouse's income has been considered in determining the AFDC payment unless the couple is living in a holding-out relationship. (Where the holding-out spouse has income, the local Department of Social and Health Services office must be contacted to determine whether that income has been considered in an AFDC payment.) This variation does not include an eligible individual living with an ineligible spouse and grandchildren under age 18 whose needs are included in determining an AFDC grant.
	A child in a Federal code A or C living arrangement. Optional supplement code A is the proper code to be used with an “intervening” Federal A code. (See SM 01301.535.) Exceptions Optional supplement A is not paid when: An individual is living in a medical care facility throughout an entire calendar month;
	An eligible individual has more than one EP; An eligible couple has one or more EP's; and An eligible individual or couple is residing in a public emergency shelter for the homeless (effective 5/83).
B	Living Alone with an Ineligible Spouse — Eligible individual who is the head of the household and who lives alone as described in A above and is living with an ineligible spouse. An ineligible spouse is a spouse who has either not applied for SSI benefits, has been denied or terminated, or has withdrawn his/ her application. It is not material whether the ineligible spouse is aged, blind, or disabled. An ineligible spouse includes: Legally married and common law spouses; “Holding-out” spouses; Alien spouses not lawfully admitted to the U.S., and Refugee spouses receiving payments.
	NOTE: Refugee payments are not deemable to the eligible individual. In determining whether an ineligible spouse is a member of the household for the purpose of paying the optional supplement B to the eligible individual, use the same rules for making Federal determinations. If an eligible individual marries, or a separated spouse returns home, the ineligible spouse supplement is paid beginning with the month after the month of the arrival of the ineligible spouse in the household.
	Exceptions Optional supplement B is not paid when: (1) an individual with an ineligible spouse also has child(ren) under the age of 18 whose needs are considered in determining an AFDC grant. Rather, the optional supplement A is paid. This is true whether or not the ineligible spouse is actually included on the AFDC grant; (2) an eligible individual resides in a public emergency shelter for the homeless (effective 5/83). In this case, use optional supplementation code Z.
C	Living in the Household of Another — Applies to most cases which meet the Federal definition of living in the household of another (Federal code B).
	Exceptions
	Not paid when: (1) an individual lives in the household of another with more than one EP; or (2) a couple lives in the household of another with one or more EP's. In both of these cases the optional supplementation code is Z.
F	Living in the Household of Another with an Ineligible Spouse — Individuals living in the household of another (Federal code B) who have an ineligible spouse or an EP.
	Exceptions
	Individuals with more than one EP are not eligible for an optional supplement.
G	Living with an Essential Person — Applies to an eligible individual who is the head of the household and who lives alone as described in A above and was converted from the December 1973 State rolls with an EP who has continued to live in the household. The system will pay the optional supplement for an EP. If an eligible individual has more than one EP use optional supplementation code Z.
H	Living in the Household of Another with an EP — Applies to individuals living in the household of another who have an EP. Individuals with more than one EP are not eligible for an optional supplement.
Y	Optional Supplementation Waived — Individual is eligible for, but has waived his/her right to receive, an optional supplement.
Z	No Supplement Cases — The following groups are ineligible for a federally administered optional supplement:
	An individual with more than one EP. A couple with one or more EP's. Individuals residing in a medical facility throughout a month, regardless of whether private or public, or if Medicaid is involved in reimbursement for the cost of the care. (If only one member of an eligible couple is in a medical facility, determine the optional supplement variation that applies to the other member separately.) The term “medical facility” includes hospitals, nursing homes, and extended care facilities, but does not include boarding schools, congregate care facilities, and half-way houses. Residents of publicly operated emergency shelters throughout a month, effective May 1983.

Federal Code	State OS Code	Category	FBR	State Supplement Level	Total Payment Levels
A	A	King, Kitsap, Pierce, Snohomish, Thurston Counties	500.00	27.00	527.00
		All other counties	500.00	6.55	506.55
	B	King, Kitsap, Pierce, Snohomish, Thurston Counties	500.00	167.20	667.20
		All other counties	500.00	137.25	637.25
	G	Individual with one EP King, Kitsap, Pierce, Snohomish, Thurston Counties	750.00	21.00	771.00
		Individual with one EP All other counties	750.00	0.00	750.00
	Z	All	500.00³	0.00	500.00
B	C	All	333.34¹	4.81	338.15
	F	Individual w/Ineligible Spouse	333.34¹	102.76	436.10
	H	Individual living with one EP	500.00²	5.30	505.30
	Z	Individual living with more than one EP	333.34³	0.00	333.34
C	A	King, Kitsap, Pierce, Snohomish, Thurston Counties	500.00	27.00	527.00
		All other counties	500.00	6.55	506.55
D	Z	All	30.00⁵	0.00⁴	30.00

¹ Not an FBR; the amount represents the FBR less VTR.

² Not an FBR; the amount represents the FBR plus EP increment less VTR.

³ Plus increment for each EP, if appropriate.

⁴ Individuals/each member of a couple with income of $45.00 or less will receive a $11.62 State-administered supplement. Individuals/each member of a couple with income making them ineligible for SSI payments will be allowed to keep $36.62/month for personal expenses.

⁵ Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

Federal Code	State OS Code	Category	FBR	State Supplement Level	Total Payment Levels
A	A	King, Kitsap, Pierce, Snohomish, Thurston Counties	751.00	21.00	772.00
		All other counties	751.00	0.00	751.00
	Z	All	751.00²	0.00	751.00
B	C	All	500.67¹	5.30	505.97
	Z	All	500.67²	0.00	500.67
D	Z	All	60.00⁴	0.00³	60.00

¹ Not an FBR; the amount represents the FBR less VTR.

² Plus increment for each EP, if appropriate.

³ Individuals/each member of a couple with income of $45.00 or less will each receive a $11.62 State-administered supplement. Individuals/each member of a couple with income making them ineligible for SSI payments will be allowed to keep $36.62/month for personal expenses.

⁴ Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

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