TN 16 (10-01)
GN 00605.067 How To Evaluate Payee Responses About Use of Benefits
This section explains how to evaluate responses as indicators of how well the payee manages benefits. FOs must consider a change of payee or direct payment if it appears that the payee is not using the benefits properly.
The questions about use of benefits are slightly different on the SSA-623-OCR-SM than they are on the SSA-6230-OCR-SM, but the questions are designed to solicit meaningful information about how payees used the benefits sent to them.
C. EXHIBITS - USE OF BENEFITS QUESTIONS
1. SSA-623-OCR-SM Questions 3 A, B, and C (09/2001).
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2. SSA-6230-OCR-SM, Questions 3 A and B (09/2001).
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1. Payee Did Not Decide How Benefits Were Used
A conduit payee situation may indicate lack of payee interest, or it may suggest that the beneficiary is capable of managing his/her own benefits. A conduit payee does not exercise control of the funds, and cannot account accurately for how benefits were used.
Appointing a successor payee will be considered if funds are being turned over to a third party. Develop according to GN 00504.100.
Direct payment will be considered if funds are being turned over to the beneficiary. Develop according to GN 00502.050 through GN 00502.055, and GN 00502.070.
2. Care and Maintenance
The payee is primarily responsible for using benefits for the current and foreseeable needs of the beneficiary. If not needed for this or for the support of certain of the title II beneficiary's legal dependents (see GN 00602.020), the benefits must be conserved and invested for the beneficiary.
3. Personal Needs Expenditures
If a title XVI recipient is in a title XIX facility, the regulations require that the SSI standard payment amount be used only for the recipient's personal needs or saved on his behalf.
SSA policy requires that for any beneficiary who resides in any type of institution; e.g., a hospital, nursing home, etc. payees are expected to spend a minimum of $30 per month ($360 a year) for the beneficiary's personal needs unless the amount of benefits paid throughout the reporting period is less than $360. If the amount of benefits paid throughout the reporting period (TAA) is less than $360, the payee is expected to spend that amount on the beneficiary's personal needs. In rare circumstances, spending $30 per month on personal needs may not be appropriate. In these cases, the circumstances should be clearly documented by either the payee on the annual reporting form or by SSA personnel following any necessary development.
REMEMBER: A qualified organizational payee (i.e., fee-for-service) cannot collect a fee from an institutionalized beneficiary's personal needs allowance (see GN 00506.220 and GN 00506.240).
NOTE: For instructions about how to resolve questionable responses, or if the payee indicates benefits were used for any other purpose than stated in GN 00605.067D.2. and GN 00605.067D.3., see Use of Benefits, GN 00602.000.
E. PROCEDURE — TOTAL EXPENDITURES
Use the following instructions and decision factors to determine if FO development for misuse or change of payee is necessary.
NOTE: Unacceptable payee responses may indicate that the payee misused benefits.
1. Total Amount of Expenditures
Decision Factor: Add the money amount responses given by the payee and compare the total with the TAA displayed in item 3 (or on the top portion) of the form.
a. SSA-623-OCR-SM (09/2001)
Add questions 3B, 3C and 3D; compare to the TAA.
b. SSA-6230-OCR-SM (09/2001)
Add questions 3B and 3C; compare to the TAA.
2. Evaluate Total Expenditures
NOTE: If the payee indicates “ALL” (or the TAA) as a response to more than one money amount question, contact the payee for an explanation of how the TAA was used.
Decision Factor: The payee is responsible for accounting for all benefits received, spent and saved. However, because the displayed TAA may not be exact, a 10% tolerance may be used during the review process. Does the total amount of expenditures equal or exceed 90% of the amount received?
If yes, “Approve” use of benefits responses.
If no, Contact the payee to resolve the difference between the amounts. If the payee asks for examples of personal needs items refer to GN 00605.067F.
EXAMPLE: A wife accounted on an SSA-623-OCR-SM for benefits she received for her husband. The TAA is $7550. The payee showed $7420 in questions 3B, 3C and 3D. The payee accounted for more than 90% of the TAA ($7550 x .9 = $6795). Approve the use of benefits responses.
F. LIST OF PERSONAL NEEDS ITEMS
Almost all beneficiaries need some personal items regardless of their physical or mental conditions or their living arrangements. Personal needs items include (but are not limited to):
Personal articles such as cosmetics, grooming aids, etc.;
Room furnishings such as quilts, pictures, recliner, etc.;
Recreational items such as radios, musical instruments, televisions, bicycles, photo albums, cassette player, etc.;
Special medical expenses or equipment (i.e., not supplied by the care facility or by State/Federal programs) such as hearing aids, eyeglasses, special wheelchairs, etc.;
Miscellaneous items such as movies, restaurant meals, candy, magazine subscriptions, etc.
G. PROCEDURE — PERSONAL NEEDS EXPENDITURES
Decision Factor: If the beneficiary resides in any type of institution, the payee is expected to spend at least $30 per month, or $360 per yearly reporting period, on the beneficiary's personal needs. A lesser amount spent may be acceptable if the total benefits paid throughout the reporting period is less than $360. In these cases, the payee is expected to spend the TAA amount for the beneficiary's personal needs. In rare circumstances, spending $30 per month on personal needs may not be appropriate. In these cases, the circumstances should be clearly documented by either the payee on the annual reporting form or by SSA personnel following any necessary development.
If yes, Approve the use of benefits for personal needs.
If no, Contact the payee for an explanation.