TN 31 (07-11)

NL 00804.167 Exhibits of Notice Language in $30 Limit Situations

This section provides notice language for situations where the $30 payment limit applies. For the policy on when the $30 payment limit applies, please see SI 00520.011.

NOTE: If you are sending a notice to a claimant, beneficiary, or representative payee who alleges blindness or being visually impaired follow the special notice procedures in NL 01001.010.

PICM01

When used: This paragraph explains the change in the law effective 12/96 for children whose payment changes because of that provision.

New rules for children in medical facilities

Beginning December 1996, a new law changed the Supplemental Security Income (SSI) rules for some children. Under this law, SSI payments for children under age 18 are (1) for each month that:

  • a child lives in a hospital or other medical facility for the full month, and

  • Medicaid pays for, or would usually pay for, more than half the cost of the care, or

  • private health insurance or a combination of Medicaid and private health insurance pays for more than half the cost of the care.

(2)   (3) because of these new rules (4).

Fill-ins:

1. Choice 1: reduced (going from pay status)

Choice 2: changed (going from nonpay status)

2. Choice 1: (child's name—possessive) SSI payment is/was

Choice 2: (child's name—possessive) SSI payments are/were

Choice 3: Your SSI payment is/was

Choice 4: Your SSI payments are/were

3. Choice 1: reduced

Choice 2: stopped

Choice 3: changed

4. Choice 1: and your income

Choice 2: and her income

Choice 3: and his income

Choice 4: Null

PICM02

When used: This paragraph is used with paragraph PICM01 to explain the change in law. This paragraph specifically shows the facts on our record.

Our records show that:

  • (1) age (2), and

  • (3) in a medical facility, and

  • private health insurance or Medicaid or both pay for more than half the cost of (4) care.

Fill-ins:

1. Choice 1: you are

Choice 2: she is

Choice 3: he is

2. age of recipient

3. Choice 1: you live

Choice 2: she lives

Choice 3: he lives

4. Choice 1: your

Choice 2: her

Choice 3: his

PICM03

When used: A child under age 18 is eligible for TI benefits.

Based on the facts we have, (1) entered a medical facility in (2). Usually, SSI payments are reduced for each month that (3) a child under age 18, if:

  • (4) in a hospital or other medical facility for a full month, and

  • Medicaid pays for, or would usually pay for, more than half the cost of (5) care, or

  • private health insurance or a combination of Medicaid and private health insurance pays for more than half the cost of (6) care.

However, this rule does not apply for any of the first 3 full months that (7) a patient in a medical facility if:

  • (8) doctor expects (9) to stay in a medical facility for less than 91 days, and

  • (10) expenses for (11) home that (12) must continue to pay.

This means that (13) .

(14) SSI payments are meant for (15) home expenses. (16) to pay this money to the medical facility.

(17)

Fill-ins:

1. Choice 1: you

Choice 2: she

Choice 3: he

2. Month/Year

3. Choice 1: you are

Choice 2: she is

Choice 3: he is

4. Choice 1: you live

Choice 2: she lives

Choice 3: he lives

5. Choice 1: your

Choice 2: her

Choice 3: his

6. Choice 1: your

Choice 2: her

Choice 3: his

7. Choice 1: you are

Choice 2: she is

Choice 3: he is

8. Choice 1: your

Choice 2: her

Choice 3: his

9. Choice 1: you

Choice 2: her

Choice 3: him

10. Choice 1: you have

Choice 2: she has

Choice 3: he has

11. Choice 1: your

Choice 2: her

Choice 3: his

12. Choice 1: you

Choice 2: she

Choice 3: he

13. Choice 1: beginning (month/year), we are not reducing your payment because you are in a medical facility.

Choice 2: beginning (month/year), we are not reducing her payment because she is in a medical facility.

Choice 3: beginning (month/year), we are not reducing his payment because he is in a medical facility.

Choice 4: for (month/year) we did not reduce your payment because you were in a medical facility.

Choice 5: for (month/year) and (month/year) we did not reduce your payment because you were in a medical facility.

Choice 6: for (month/year) through (month/year) we did not reduce your payment because you were in a medical facility.

Choice 7: for (month/year), we did not reduce her payment because she was in a medical facility.

Choice 8: for (month/year) and (month/year) we did not reduce her payment because she was in a medical facility.

Choice 9: for (month/year) through (month/year) we did not reduce her payment because she was in a medical facility.

Choice 10: for (month/year), we did not reduce his payment because he was in a medical facility.

Choice 11: for (month/year) and (month/year) we did not reduce his payment because he was in a medical facility.

Choice 12: for (month/year) through (month/year) we did not reduce his payment because he was in a medical facility.

14. Choice 1: Your

Choice 2: Her

Choice 3: His

15. Choice 1: your

Choice 2: her

Choice 3: his

16. Choice 1: You do not have

Choice 2: She does not have

Choice 3: He does not have

17. Choice 1: Please tell us as soon as you know when you will be leaving the medical facility, so we can continue to pay you correctly.

Choice 2: Please tell us as soon as you know when she will be leaving the medical facility, so we can continue to pay her correctly.

Choice 3: Please tell us as soon as you know when he will be leaving the medical facility, so we can continue to pay him correctly.

Choice 4: Null

PICM04

When used: A child under age 18 is not eligible for TI benefits, but is eligible for the $30 reduced benefit.

Based on the facts we have, (1) entered a medical facility in (2) . Our records show that (3) in this facility for (4). Usually, SSI payments are reduced for each month that (5) a child under age 18 if:

  • (6) in a hospital or other medical facility for a full month, and

  • Medicaid pays for, or would usually pay for, more than half the cost of (7) care, or

  • private health insurance or a combination of Medicaid and private health insurance pays for more than half the cost of (8) care.

(9) could be eligible for continued payments for any of the first 3 full months that (10) a patient in a medical facility if:

  • we would have reduced (11) SSI payments for any of these months, and

  • (12) eligible for an SSI payment in the month before we would have reduced (13) SSI payment, and

  • (14) us proof that (15) home expenses that (16) to continue to pay, and

  • we have proof that (17) doctor expects (18) to stay in a medical facility for less than 91 days.

The proofs must be received or postmarked by the 90th day of (19) stay in the medical facility or the day of (20) release, if earlier.

(21) all of these requirements because (22).

Fill-ins:

1. Choice 1: you

Choice 2: she

Choice 3: he

2. month/year

3. Choice 1: you will be

Choice 2: she will be

Choice 3: he will be

Choice 4: you were

Choice 5: she was

Choice 6: he was

4. Choice 1: the full month of (month/year)

Choice 2: each full month (month/year) through (month/year)

Choice 3: each full month (month/ year) on

5. Choice 1: you are

Choice 2: she is

Choice 3: he is

6. Choice 1: you live

Choice 2: she lives

Choice 3: he lives

7. Choice 1: your

Choice 2: her

Choice 3: his

8. Choice 1: your

Choice 2: her

Choice 3: his

9. Choice 1: You

Choice 2: She

Choice 3: He

10. Choice 1: you are

Choice 2: she is

Choice 3: he is

11. Choice 1: your

Choice 2: her

Choice 3: his

12. Choice 1: you are

Choice 2: she is

Choice 3: he is

13. Choice 1: your

Choice 2: her

Choice 3: his

14. Choice 1: you give

Choice 2: she gives

Choice 3: he gives

15. Choice 1: you have

Choice 2: she has

Choice 3: he has

16. Choice 1: you have

Choice 2: she has

Choice 3: he has

17. Choice 1: your

Choice 2: her

Choice 3: his

18. Choice 1: you

Choice 2: her

Choice 3: him

19. Choice 1: your

Choice 2: her

Choice 3: his

20. Choice 1: your

Choice 2: her

Choice 3: his

21. Choice 1: You do not meet

Choice 2: She does not meet

Choice 3: He does not meet

22. Choice 1: you do not have expenses for your home which you must continue to pay

Choice 2: she does not have expenses for her home which she must continue to pay

Choice 3: he does not have expenses for his home which he must continue to pay

Choice 4: the proof about your home expenses was not received

Choice 5: the proof about her home expenses was not received

Choice 6: the proof about his home expenses was not received

Choice 7: the proof about your home expenses was not received or postmarked by (month/day/year)

Choice 8: the proof about her home expenses was not received or postmarked by (month/day/year)

Choice 9: the proof about his home expenses was not received or postmarked by (month/day/year)

Choice 10: your doctor expects you to stay 91 days or more

Choice 11: her doctor expects her to stay 91 days or more

Choice 12: his doctor expects him to stay 91 days or more

Choice 13: the proof of how long your doctor expects you to stay in a medical facility was not received or postmarked by (month/year)

Choice 14: the proof of how long her doctor expects her to stay in a medical facility was not received or postmarked by (month/year)

Choice 15: the proof of how long his doctor expects him to stay in a medical facility was not received or postmarked by (month/year)

Choice 16: the proof of how long your doctor expects you to stay in a medical facility was not received

Choice 17: the proof of how long her doctor expects her to stay in a medical facility was not received

Choice 18: the proof of how long his doctor expects him to stay in a medical facility was not received

Choice 19: you were not eligible for an SSI payment in (month/year)

Choice 20: she was not eligible for an SSI payment in (month/year)

Choice 21: he was not eligible for an SSI payment in (month/year)

Choice 22: you do not have expenses for your home which you must continue to pay. Also, the proof of how long your doctor expects you to stay in a medical facility was not received or postmarked by (month/day/year)

Choice 23: she does not have expenses for her home which she must continue to pay. Also, the proof of how long her doctor expects her to stay in a medical facility was not received or postmarked by (month/day/year)

Choice 24: he does not have expenses for his home which he must continue to pay. Also, the proof of how long his doctor expects him to stay in a medical facility was not received or postmarked by (month/day/year)

Choice 25: the proof about your home expenses was not received. Also, the proof of how long your doctor expects you to stay in a medical facility was not received or postmarked by (month/day/year)

Choice 26: the proof about her home expenses was not received. Also, the proof of how long her doctor expects her to stay in a medical facility was not received or postmarked by (month/day/year)

Choice 27: the proof about his home expenses was not received. Also, the proof of how long his doctor expects him to stay in a medical facility was not received or postmarked by (month/day/year)

Choice 28: the proof about your home expenses was not received or postmarked by (month/day/year). Also, the proof of how long your doctor expects you to stay in a medical facility was not received or postmarked by (month/day/year)

Choice 29: the proof about her home expenses was not received or postmarked by (month/day/year). Also, the proof of how long her doctor expects her to stay in a medical facility was not received or postmarked by (month/day/year)

Choice 30: the proof about his home expenses was not received or postmarked by (month/day/year). Also, the proof of how long his doctor expects him to stay in a medical facility was not received or postmarked by (month/day/year)

Choice 31: your doctor expects you to stay 91 days or more and the proof of how long your doctor expects you to stay in a medical facility was not received or postmarked by (month/day/year)

Choice 32: her doctor expects her to stay 91 days or more and the proof of how long her doctor expects her to stay in a medical facility was not received or postmarked by (month/day/year)

Choice 33: his doctor expects him to stay 91 days or more and the proof of how long his doctor expects him to stay in a medical facility was not received or postmarked by (month/day/year)

Choice 34: you were not eligible for an SSI payment in (month/year). Also, the proof of how long your doctor expects you to stay in a medical facility was not received or postmarked by (month/day/year)

Choice 35: she was not eligible for an SSI payment in (month/year). Also, the proof of how long her doctor expects her to stay in a medical facility was not received or postmarked by (month/day/year)

Choice 36: he was not eligible for an SSI payment in (month/year). Also, the proof of how long his doctor expects him to stay in a medical facility was not received or postmarked by (month/day/year)

Choice 37: we did not reduce your SSI payment for all of the first 3 full months you were a patient. We can pay continued payments only for those first 3 months.

Choice 38: we did not reduce her SSI payment for all of the first 3 full months she was a patient. We can pay continued payments only for those first 3 months.

Choice 39: we did not reduce his SSI payment for all of the first 3 full months he was a patient. We can pay continued payments only for those first 3 months.

PICM05

When used: A child under age 18 is in a public facility and is not eligible for TI benefits or for the $30 reduced benefit.

Based on the facts we have, (1) entered a public (2) facility in (3). Our records show that (4) in this facility for (5). Usually, SSI payments are stopped for each month that (6) a child under age 18 if:

  • (7) in a hospital or other medical facility for a full month, and

  • Medicaid, private health insurance, or a combination of Medicaid and private health insurance does not pay for more than half the cost of (8) care.

(9) could be eligible for continued payments for any of the first 3 full months that (10) a patient in a medical facility if:

  • we would have stopped (11) SSI payments for any of these months, and

  • (12) eligible for an SSI payment in the month before we would have stopped (13) SSI payment, and

  • (14) us proof that (15) home expenses that (16) to continue to pay, and

  • we have proof that (17) doctor expects (18) to stay in a medical facility for less than 91 days.

The proofs must be received or postmarked by the 90th day of (19) stay in the (20) facility or the day of (21) release, if earlier.  (22) all of these requirements because (23).

Fill-ins:

1. Choice 1: you

Choice 2: she

Choice 3: he

2. Choice 1: medical

Choice 2: null

3. month/year

4. Choice 1: you will be

Choice 2: she will be

Choice 3: he will be

Choice 4: you were

Choice 5: she was

Choice 6: he was

5. Choice 1: the full month of (month/year)

Choice 2: each full month (month/year) through (month/year)

Choice 3: each full month (month/ year) on

6. Choice 1: you are

Choice 2: she is

Choice 3: he is

7. Choice 1: you live

Choice 2: she lives

Choice 3: he lives

8. Choice 1: your

Choice 2: her

Choice 3: his

9. Choice 1: You

Choice 2: She

Choice 3: He

10. Choice 1: you are

Choice 2: she is

Choice 3: he is

11. Choice 1: your

Choice 2: her

Choice 3: his

12. Choice 1: you are

Choice 2: she is

Choice 3: he is

13. Choice 1: your

Choice 2: her

Choice 3: his

14. Choice 1: you give

Choice 2: she gives

Choice 3: he gives

15. Choice 1: you have

Choice 2: she has

Choice 3: he has

16. Choice 1: you have

Choice 2: she has

Choice 3: he has

17. Choice 1: your

Choice 2: her

Choice 3: his

18. Choice 1: you

Choice 2: her

Choice 3: him

19. Choice 1: your

Choice 2: her

Choice 3: his

20. Choice 1: medical

Choice 2: null

21. Choice 1: your

Choice 2: her

Choice 3: his

22. Choice 1: You do not meet

Choice 2: She does not meet

Choice 3: He does not meet

23. Choice 1: you do not have expenses for your home which you must continue to pay

Choice 2: she does not have expenses for her home which she must continue to pay

Choice 3: he does not have expenses for his home which he must continue to pay

Choice 4: the proof about your home expenses was not received

Choice 5: the proof about her home expenses was not received

Choice 6: the proof about his home expenses was not received

Choice 7: the proof about your home expenses was not received or postmarked by (month/day/year)

Choice 8: the proof about her home expenses was not received or postmarked by (month/day/year)

Choice 9: the proof about his home expenses was not received or postmarked by (month/day/year)

Choice 10: your doctor expects you to stay 91 days or more

Choice 11: her doctor expects her to stay 91 days or more

Choice 12: his doctor expects him to stay 91 days or more

Choice 13: the proof of how long your doctor expects you to stay in a medical facility was not received or postmarked by (month/year)

Choice 14: the proof of how long her doctor expects her to stay in a medical facility was not received or postmarked by (month/year)

Choice 15: the proof of how long his doctor expects him to stay in a medical facility was not received or postmarked by (month/year)

Choice 16: the proof of how long your doctor expects you to stay in a medical facility was not received

Choice 17: the proof of how long her doctor expects her to stay in a medical facility was not received

Choice 18: the proof of how long his doctor expects him to stay in a medical facility was not received

Choice 19: you were not eligible for an SSI payment in (month/year)

Choice 20: she was not eligible for an SSI payment in (month/year)

Choice 21: he was not eligible for an SSI payment in (month/year)

Choice 22: you are not in a medical facility

Choice 23: she is not in a medical facility

Choice 24: he is not in a medical facility

Choice 25: you were not in a medical facility

Choice 26: she was not in a medical facility

Choice 27: he was not in a medical facility

Choice 28: you do not have expenses for your home which you must continue to pay. Also, the proof of how long your doctor expects you to stay in a medical facility was not received or postmarked by (month/day/year)

Choice 29: she does not have expenses for her home which she must continue to pay. Also, the proof of how long her doctor expects her to stay in a medical facility was not received or postmarked by (month/day/year)

Choice 30: he does not have expenses for his home which he must continue to pay. Also, the proof of how long his doctor expects him to stay in a medical facility was not received or postmarked by (month/day/year)

Choice 31: the proof about your home expenses was not received. Also, the proof of how long your doctor expects you to stay in a medical facility was not received or postmarked by (month/day/year)

Choice 32: the proof about her home expenses was not received. Also, the proof of how long her doctor expects her to stay in a medical facility was not received or postmarked by (month/day/year)

Choice 33: the proof about his home expenses was not received. Also, the proof of how long his doctor expects him to stay in a medical facility was not received or postmarked by (month/day/year)

Choice 34: the proof about your home expenses was not received or postmarked by (month/day/year). Also, the proof of how long your doctor expects you to stay in a medical facility was not received or postmarked by (month/day/year)

Choice 35: the proof about her home expenses was not received or postmarked by (month/day/year). Also, the proof of how long her doctor expects her to stay in a medical facility was not received or postmarked by (month/day/year)

Choice 36: the proof about his home expenses was not received or postmarked by (month/day/year). Also, the proof of how long his doctor expects him to stay in a medical facility was not received or postmarked by (month/day/year)

Choice 37: your doctor expects you to stay 91 days or more and the proof of how long your doctor expects you to stay in a medical facility was not received or postmarked by (month/day/year)

Choice 38: her doctor expects her to stay 91 days or more and the proof of how long her doctor expects her to stay in a medical facility was not received or postmarked by (month/day/year)

Choice 39: his doctor expects him to stay 91 days or more and the proof of how long his doctor expects him to stay in a medical facility was not received or postmarked by (month/day/year)

Choice 40: you were not eligible for an SSI payment in (month/year). Also, the proof of how long your doctor expects you to stay in a medical facility was not received or postmarked by (month/day/year)

Choice 41: she was not eligible for an SSI payment in (month/year). Also, the proof of how long her doctor expects her to stay in a medical facility was not received or postmarked by (month/day/year)

Choice 42: he was not eligible for an SSI payment in (month/year). Also, the proof of how long his doctor expects him to stay in a medical facility was not received or postmarked by (month/day/year)

Choice 43: we did not reduce your SSI payment for all of the first 3 full months you were a patient. We can pay continued payments only for those first 3 months.

Choice 44: we did not reduce her SSI payment for all of the first 3 full months she was a patient. We can pay continued payments only for those first 3 months.

Choice 45: we did not reduce his SSI payment for all of the first 3 full months he was a patient. We can pay continued payments only for those first 3 months.

PICM06

When used: This paragraph is used with PICM07 to explain that the recipient with private health insurance is no longer eligible for the $30 reduced benefit, because he or she attained age 18 and is living in a public institution where Medicaid does not pay over 50 percent of the cost of care.

We cannot pay (1) any SSI beginning (2) because (3) age 18 or older, (4) in a public institution, and Medicaid does not pay for more than half the cost of (5) care.

Fill-ins:

1. Choice 1: you

Choice 2: her

Choice 3: him

2. Month/Year

3. Choice 1: you are

Choice 2: she is

Choice 3: he is

4. Choice 1: live

Choice 2: lives

5. Choice 1: your

Choice 2: her

Choice 3: his

PICM07

When used: This paragraph is used to give the facts that show the recipient is no longer eligible for the $30 reduced benefit because he or she attained age 18.

Our records show:

  • (1) became age 18 on (2),

  • (3) in a (4) for (5), and

  • Medicaid (6) not pay for more than half the cost of (7) care.

Fill-ins:

1. Choice 1: you

Choice 2: she

Choice 3: he

2. Month/Day/Year

3. Choice 1: you live

Choice 2: she lives

Choice 3: he lives

Choice 4: you lived

Choice 5: she lived

Choice 6: he lived

4. Choice 1: medical facility

Choice 2: public institution

5. Choice 1: Month/Year on

Choice 2: Month/Year

Choice 3: Month /Year through Month/Year

6. Choice 1: does

Choice 2: did

7. Choice 1: your

Choice 2: her

Choice 3: his

PICM08

When used: This paragraph is used to explain that we either will not begin or will stop withholding money to recover an overpayment because the recipient's payment is subject to the $30 limit.

(1)   (2) in an institution where:

Medicaid pays for, or would usually pay for, more than half the cost of (3) care, or

private health insurance or a combination of Medicaid and private health insurance pays for more than half the cost of (4) care, we will not withhold money to get back money overpaid.

Fill-ins:

1. Choice 1: While (Use when we will not begin withholding an overpayment.)

Choice 2: You/She/He will get an SSI check for (money amount) about the first day of the month beginning (Month/Year). We were withholding money from your/her/his check to get back money you were/he was/she was overpaid. Now, while, (Use when we will stop withholding an overpayment.)

2. Choice 1: you are

Choice 2: she is

Choice 3: he is

3. Choice 1: your

Choice 2: her

Choice 3: his

4. Choice 1: your

Choice 2: her

Choice 3: his

PICM09

When used: This paragraph is used to explain that we will not withhold money to recover an overpayment because the recipient's payment is subject to the $30 limit.

We will not reduce (1) SSI check

Usually when a person is getting an SSI check, we withhold money from the check to repay an overpayment. But we will not do this while (2)

  • in a medical facility,

  AND

  • Medicaid is paying for, or would usually pay for, more than half the cost of (3) care, or

  • private health insurance or Medicaid or both is paying for more than half the cost of (4) care.

If any of the above things change, and (5) still (6) an overpayment, we will send you a notice about withholding money from (7) SSI check.

Fill-ins:

1. Choice 1: Your

Choice 2: Her

Choice 3: His

2. Choice 1: you are

Choice 2: she is

Choice 3: he is

3. Choice 1: your

Choice 2: her

Choice 3: his

4. Choice 1: your

Choice 2: her

Choice 3: his

5. Choice 1: you

Choice 2: she

Choice 3: he

6. Choice 1: have

Choice 2: has

7. Choice 1: your

Choice 2: her

Choice 3: his

PICM10

When used: This paragraph is used to explain why the recipient is overpaid.

(1) could not get more than $30 while:

  • (2) in a medical care facility, like a hospital or a nursing home, for a full month, and

  • Medicaid paid for, or would usually pay for, more than half the cost of (3) care, or

  • private health insurance or Medicaid or both paid for more than half the cost of (4) care.

Also, if there was income on (5) record other than SSI, (6) might get less than $30. As a result, (7) overpaid for (8).

Fill-ins:

1. Choice 1: You

Choice 2: She

Choice 3: He

2. Choice 1: You were

Choice 2: She was

Choice 3: He was

3. Choice 1: your

Choice 2: her

Choice 3: his

4. Choice 1: your

Choice 2: her

Choice 3: his

5. Choice 1: your

Choice 2: her

Choice 3: his

6. Choice 1: you

Choice 2: she

Choice 3: he

7. Choice 1: you were

Choice 2: she was

Choice 3: he was

8. Choice 1: Month/Year

Choice 2: Month/Year through Month/Year

(Repeat choices for fill-in 8 as often as needed to cover overpayment periods.)

References

  • SI 00520.012, Payment Limit Due to Medicaid Transfer of Resources penalty,

  • SI 00520.130, Special Benefits for Institutionalized 1619 Eligibles

  • SI 00520.140, Temporary Institutionalization (TI) Benefits

  • SI 00520.700, Conversion of Facilities to Medicaid

  • SI 00520.720, Decertification of Medicaid Facilities

  • SI 01310.207, Waiver of Parental Deeming

  • SI 01415.010, Administration of State Supplementary Program

  • SI 02309.003, Attainment of Age 18 - KB Diary - SSI

  • SM 01301.785, Case Related Data (CG)

  • NL 00801.000, General Notice Instructions

  • NL 00802.000, Initial Claims Notices

  • NL 00803.000, Posteligibility Notices

  • NL 00804.000, Stock Notice Paragraphs

  • SM 01301.675, Notice Suppression

  • SM 01305.515, Notice Suppression for a SSA-L8155


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900804167
NL 00804.167 - Exhibits of Notice Language in $30 Limit Situations - 07/13/2011
Batch run: 09/27/2024
Rev:07/13/2011