TN 7 (03-02)
GN 00602.010 Current Maintenance Needs for Institutionalized Beneficiaries
404.2035 - 404.2045, 416.635 - 416.645
Payees must keep informed of the beneficiary's total needs. Current needs should never be sacrificed to pay other expenses, to conserve or invest, or to accumulate for a future purpose.
1. Non-Medicaid Institution
If a beneficiary is receiving care in a State, Federal, or private institution not receiving Medicaid funds on behalf of the beneficiary, the payee should give highest priority to the beneficiary's current maintenance. Current maintenance is not limited to the usual institutional charges but includes expenditures for items that will aid in the beneficiary's recovery or release from the institution or improve the beneficiary's condition while in the institution. Any benefits remaining should be conserved or invested except as they may be otherwise properly used. This includes temporarily maintaining the beneficiary's residence outside the institution unless a physician certifies the beneficiary is unlikely to return home.
2. Medicaid Institution
If a title XVI beneficiary is in a facility receiving substantial Medicaid payments on the beneficiary's behalf for the cost of care, the title XVI reduced rate must be used only for personal needs. The benefit may not be used for current maintenance.
1. Customary Charges
When a beneficiary resides in an institution, advise the payee to allot a reasonable share of benefits for the institution's customary charges. An institution's customary charges and the beneficiary's other current needs should be taken into account. A payee should not pay an amount for current maintenance in excess of the legal maximum charge established by the State. If the care-providing facility complains that the payee is not contributing toward the cost of care, contact the payee for an explanation. If the payee's handling of the charges adversely affects the beneficiary, consider a change of payee action. Develop fully and follow the rules for payee selection (see GN 00504.100).
2. Personal Needs Expenditures
SSA has extended the policy of using the title XVI reduced rate payable to title XVI beneficiaries residing in title XIX facilities only for personal needs to any beneficiary residing in any type of facility, e.g., hospitals, nursing homes, etc. Payees should set aside a minimum of $30 per month to be used for the beneficiary's personal needs or saved on his/her behalf.
SSA encourages payees to use good judgment in determining appropriate personal expenditures. All purchases should reflect a personal evaluation of the beneficiary's situation and needs, and should help the beneficiary keep contact with the outside world and preserve his/her sense of individuality. Payees should not use benefits to purchase items normally provided by the facility or covered under a State or Federal program.
3. Examples of Personal Needs Expenditures
Some examples of acceptable personal needs expenditures are:
Athletic shoes, bathing suits and caps, boots, disability-related adaptive clothing, gloves, hats, scarves, seasonal garments, shoes, slippers, etc.
b. Convenience Items
Cassette/CD players, clocks, clothes hamper, radios, stationery, TVs, wristwatches, etc.
c. Health and Hygiene Items
Bath scale, brushes, combs, cosmetics, cosmetic surgery, dermatology treatments, elective or cosmetic dental treatments, hairdresser/barber costs, soaps, toilet articles, etc.
d. Hobby and Craft Items
Art supplies, cameras, film, cassette tapes, photo albums, videocassettes, etc.
e. Living Area Furnishings
Bedspreads, blankets, carpets, curtains, lockable chest/trunk, mirrors, pictures, pillows, posters, quilts, recliner, rocking chair, etc.
f. Miscellaneous Items
Magazine subscriptions, reasonably priced holiday presents for family/friends, restaurant meals, telephone expenses for calls to or from out of town relatives, etc.
g. Staff Travel Items
Using the beneficiary's funds to pay the expenses incurred by staff accompanying the beneficiary on an outing or vacation may be an acceptable use provided:
a correlation exists between the expense incurred and a direct benefit to the beneficiary,
the beneficiary does not have unmet needs or foreseeable needs,
the expense must be reasonable in relation to the beneficiary's conserved funds, and
the staff member's travel expense (e.g., food, transportation, lodging, admission ticket) is not paid for by the payee organization or from another source. Beneficiary funds should never be used to pay for a staff member's salary/hourly wage or to compensate the payee for these costs.
NOTE: A payee must obtain SSA approval prior to using benefits for staff travel items.
h. Therapeutic Equipment
If recommended by a doctor or appropriate therapist, and not covered by any other source: book holders, crawlers, electric wheelchairs, feeding aids, hearing aids, orthopedic shoes, shower and bathroom chairs, toilet aids, walkers, etc.
i. Transportation Expenses
Trips to visit family or for relatives to visit patient in special cases, trips to amusement parks, State fairs, summer camps, etc.
SSA has no authority to compel a payee to spend benefits in a preferred manner. However, while the payee has judgment in spending funds, SSA has the right and responsibility to identify any situation or practice which may work to the disadvantage of a beneficiary and to take corrective action which will be in the interests of the beneficiary and improve payee performance.