Mr. Daily files an SSI application on January 10, 1999. He has been in Rowlett Community
Hospital, a public institution in Texas, since December 25, 1998. He expects to be
in the hospital until February 5, 1999.
Part I of the SS-RVI-306 is completed from information on the SSA-8045.
Part II is completed with information obtained from the Rowlett Community Hospital.
Since this is a medical facility, the last sentence in the language in B. above would
be ". . ., would you expect Medicaid to pay over 50 percent of the cost of care you
are providing Mr. Daily during the entire month of January and for those days in February
until his anticipated release on February 5?" This information will be used to determine
if the Medicaid exception to ineligibility in a public institution is met (SI 00520.001C.1.).
Part III is reviewed to determine if any of the listed provisions apply to Mr. Daily
which can affect eligibility and payment amount.
Part IV is used to document the living arrangement during the period of confinement
for Mr. Daily.
RECORD OF INSTITUTIONALIZATION
Name of Applicant/Recipient: ________________________________________
SSN: ___________________ DOB: _____________________________
Part I Information about the Facility from the SSA-8045 (SSI Facility Information
and Determination Form):
Name of Facility: _____________________________________
Telephone: ______________________ Public or Private?: _______________
Type of Facility: (e.g., Penal; _______________________________
Educational; Medicaid Certified) _______________________________
Part II Information about the SSI Applicant/Recipient Obtained from the Facility:
A. Admission Information
1. Date Admitted: __________________
2. Expected/Actual Date of Release: __________
3. Was the individual admitted from another facility?
______ No _____ Yes
Complete multiple SS-RVI-306s if multiple admissions to the same facility occurred, or if admitted from a different facility, during the month of filing or later.
B. Payment for Care Information
Period covered by SSI Application/Redetermination and Confinement:
From: _________ To: __________
NOTE: If the facility is a medical facility, use the language provided in SI DAL00520.001B. to obtain Medicaid information to 1 and 2 below.
1. Is Medicaid expected to pay or has it paid over 50 percent of the cost of care
during some or all of the specified period?
_____ Yes (Continue to 2.) _______ No (Continue to 3.)
2. If yes, list each month Medicaid is expected to pay or has paid over 50 percent of the cost of care:
If not all months in the specified period are covered by Medicaid, continue to 3.
3. Medicaid is not expected to pay for part or all of the period or the facility is not Medicaid certified, list the expected source of payment for months
not covered by Medicaid (e.g., insurance, Medicare, etc.):
4. Source of Part II Information
Name: ______________ Title: _______________________
Date: ______________ Phone: ______________________
Part III Special Conditions to Consider
Check all provisions pertinent to the SSI applicant/recipient:
___ Child under 18 in public or private institution receiving payments for care from
privately provided health insurance. (SI 00520.011)
___ Levings vs. Califano Eighth Judicial Circuit (e.g., Ark, N. Dakota, S. Dakota) - Voluntary resident of
a public institution paying for cost of care (SI 00520.120)
___ Continuation of benefits for recipients temporarily institutionalized applicable
___ Penal confinement, but outside traditional correctional facility (SI 00520.009)
___ Recipient was section 1619 eligible in the month preceding the first full month
List months of full payment: ____________ (SI 00520.130)
___ Transfer of resources for less than fair market value
—LA-D applies even if no Medicaid payments (SI 00520.012)
___ Medicaid provided under a Home and Community Based Services Waiver program (SI 00520.011C.2)
Part IV Case Determination Living Arrangement: _________________
Effective from _______ thru ________. Amount of ISM: ____________________
Decision by: __________________ Date:
SS-RVI-306 (Revised 02/01)