TN 7 (03-02)
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
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.
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.
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
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.
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.
Cassette/CD players, clocks, clothes hamper, radios, stationery, TVs, wristwatches,
Bath scale, brushes, combs, cosmetics, cosmetic surgery, dermatology treatments, elective
or cosmetic dental treatments, hairdresser/barber costs, soaps, toilet articles, etc.
Art supplies, cameras, film, cassette tapes, photo albums, videocassettes, etc.
Bedspreads, blankets, carpets, curtains, lockable chest/trunk, mirrors, pictures,
pillows, posters, quilts, recliner, rocking chair, etc.
Magazine subscriptions, reasonably priced holiday presents for family/friends, restaurant
meals, telephone expenses for calls to or from out of town relatives, etc.
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.
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.
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.