SSA - POMS: SI NY01415.025 - New Jersey Payments (RTS 398 - 06/2006)

A. Introduction

Since the beginning of the SSI Program, SSA has administered Optional State Supplement (OSS) payments on behalf of New Jersey.

B. OSS Codes

Code	Definition
A	Congregate Care - This variation includes an eligible individual/child/couple in Federal living arrangement (FLA) A. The living arrangement includes the following: 1. Recipients in residential facilities both inside and outside New Jersey who are under the supervision and/or placement of the Department of Human Services Division of Developmental Disabilities (DDD) or Department of Children and Families (DCF.) (Most claims are filed through the Trenton Field Office.) 2. Authorization to make this payment is based on the recipient's residence at a facility listed in the New Jersey Congregate Care Directory. Recipients in Assisted Living Residences (ALR) and in Comprehensive Personal Care Homes (CPCH) licensed by the Department of Health and Senior Services. Authorization to make this payment is based on the recipient's residence at a facility listed in the New Jersey Congregate Care Directory. 3. Prior to 1/1/06 recipients in Residential Health Care Facilities (RHCF) licensed by the Department of Health and Senior Services. The New Jersey Congregate Care Directory lists all certified RHCFs (code “I” effective 1/1/06, see below) and Multi-Purpose Facilities (MPF). MPFs have residential and nursing home (NH) units and may be either OS “A” or “I” (effective 1/1/06) or D/G if in a NH. MPFs must always be contacted to determine whether the recipient is in long term care. NOTE - When a couple enters a Level 2 facility, they will usually get the couple FBR and couple OSS D for the month of change only. After that, they are treated as two individuals, since couple status can exist only in households, not institutions, per SI 00501.154. However, while Level 2 facilities usually meet the Federal definition of institution, this is not always the case (e.g., facility serves fewer than four people). In such small scale "household" (i.e., non-institutional) Level 2 facilities, couple status can continue.
B	Living Alone or With Others This variation includes an eligible individual/student/child/couple in a FLA A or C and who do not meet the criteria for State living arrangement A or C. The living arrangement also includes the following: 1. Transitional residences which are certified by the NJ Department of Human Services, Division of Mental Health and Hospitals; or 2. Rooming/Boarding Houses licensed by the New Jersey Department of Community Affairs; or 3. Recipients who qualify under the special provision of the Social Security Act at 1611(e) (1) (E). 4. Intervening OSS for month of change.
C	Living Alone with an Ineligible Spouse Used when an individual lives with the individual's 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 ineligible for SSI or who chooses not to apply. Once other persons, even minor children, are present in the household, this supplementary payment variation cannot exist. However, it is possible that a claimant and the claimant's 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 OSS C is permissible as long as no other person is in their household. There is no couple counterpart in this category. The state determination of eating all meals out or separate purchase and preparation of food must be documented on the Optional State Supplement page. A transient individual who co-exists only with an ineligible spouse will also qualify for the OSS C rate. An individual living alone only with an ineligible spouse and foster child(ren) will also qualify for the OSS C rate (effective 7/1/90).
D	Living in the Household of Another This variation consists of recipients determined under Federal rules to be living in the household of another (FLA B).
G	Title XIX (Medicaid certified) Institution Effective September 1, 1988, the State elected Federal administration of an OSS payment to residents of an FLA D.
I	Licensed Residential Health Care Facilities (either attached to a: nursing home; Assisted Living Residence; Comprehensive Personal Care Home; or “free standing”). Prior to January 1, 2006 residents of these facilities were paid at the OS “A” rate. Authorization to make this payment is based on the recipient's residence at a facility listed in the New Jersey Congregate Care Directory. Only the RHCF section of a multipurpose facility is eligible for the OS “I” rate. Residents of the ALR or CPCH section of a multipurpose facility are paid at the OS “A” rate. Nursing home residents are D/G if Medicaid pays more than 50% of the cost of care. NOTE - When a couple enters a Level 2 facility, they will usually get the couple FBR and couple OSS D for the month of change only. After that, they are treated as two individuals, since couple status can exist only in households, not institutions, per SI 00501.154. However, while Level 2 facilities usually meet the Federal definition of institution, this is not always the case (e.g., facility serves fewer than four people). In such small scale "household" (i.e., non-institutional) Level 2 facilities, couple status can continue.
Y	Optional Supplement Waived This code designates that an individual is eligible for, but has waived the individual's right to receive an OSS.
Z	No Supplement Cases This variation includes an eligible individual or couple in an FLA A or B who are: 1. Recipients in licensed medical facilities where Medicaid is paying less than 50% of the cost of care; or 2. Recipients in publicly operated community residences which serve 16 or fewer residents. 3. Residents of publicly operated emergency shelters throughout a month. It also includes cases that were FLA D prior to January 1988 or effective 12/1/96 children under age 18 residing in certain public or private facilities receiving payment for their care under any health insurance policy issued by a private provider (SI 00520.011).

C. Intrastate Changes

Follow SI 01410.040.

D. Temporary Absence

Follow SI 01410.030 which discusses residency for OSS and Medicaid purposes. Note - Do not confuse this with the concept of temporary absence for FLA and ISM purposes in SI 00835.040. Temporary absences for OSS/Medicaid can be longer term.

E. Placement in NJ by an Agency of Another State

An individual placed by an agency of another State will generally remain a resident of the placing State. Use the guidelines in SI 01410.030 to make this determination.

F. Placements by NJ to an out of State Facility

Generally, these individuals remain residents of NJ per the guidelines in SI 01410.030. However, NJ does not certify or exercise control over out-of-state facilities. Therefore, the NJ OSS A is rarely appropriate for NJ residents physically located in other states. The non-congregate care NJ OSS corresponding as closely as possible to the individual's actual living arrangement is appropriate. In the majority of cases, this would be an OSS B for adults and for children (see SI 01410.030D.1.).

Requests for payment of a NJ congregate care rate by individuals residing in out-of-state facilities should be brought to the attention of the Center for Programs Support.

Document the out of State placement and include the name and telephone number of the State contact. In the Consolidated Claims Experience (CCE), enter the information on one of the following pages: the Remarks attached to the Optional State Supplement page, the Remarks attached to the Residence Address and Jurisdiction page, or a Report of Contact page. If using a Report of Contact page, lock the Report of Contact page after recording the information.

Social Security

Program Operations Manual System (POMS)

SI NY01415.025 New Jersey Payments (RTS 398 - 06/2006)