TN 33 (07-11)

SI 00520.011 Determination of Applicability of $30 Payment Limit

Citations:

Social Security Act, Section 1611(e)(1)(B);

20 CFR 416.212, 416.414

A. Residence in an institution

Residents of public institutions are ineligible for Supplemental Security Income (SSI). However, section 1611(e)(1)(B) of the Social Security Act (Act) provides an exception to that rule. Residents of medical treatment facilities that receive substantial Medicaid payments on the recipient’s behalf can be eligible for a reduced Federal SSI monthly benefit of no more than $30.

Effective with benefits payable for 12/96, the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (P.L. 104-193), extended applicability of the reduced benefit rate ($30 payment limit) to children under age 18 who reside in certain public and private medical facilities and receive payments for their care under any health insurance policy issued by a private provider.

The Balanced Budget Act of 1997 (P.L. 105-33) eliminated obsolete terminology in section 1611(e)(1) of the Act that specified particular kinds of medical facilities where the $30 reduced benefit rate could apply. Residents of any medical treatment facility may now be subject to the reduced benefit rate.

P.L. 105-33 also amended section 1611(e)(1)(G) of the Act to extend applicability of temporary institutionalization (TI) benefits to children who enter private medical treatment facilities and who otherwise would be subject to a reduced benefit because of private health insurance coverage. This provision is effective with benefits payable for 12/96.

B. Definitions for determining applicability of $30 payment limit

1. Definition of medical treatment facility for the purpose of determining when the $30 payment limit applies

A medical treatment facility is an institution, or that part of an institution, licensed or otherwise, approved by a Federal, State, or local government to provide inpatient medical care and services.

2. Definition of health insurance for the purpose of determining when the $30 payment limit applies

For purposes of this section, health insurance means benefits consisting of medical care (provided directly, through insurance or reimbursement, or otherwise and including items and services paid for as medical care) under any hospital or medical service policy or certificate, hospital or medical service plan contract, or health maintenance organization (HMO) contract offered by a health insurance provider.

Health insurance does not include benefits covered under one or any combination of the following insurances:

  • coverage only for accident, disability income insurance, or any combination thereof;

  • coverage issued as a supplement to liability insurance;

  • liability insurance, including general liability insurance, medical malpractice insurance, homeowner liability insurance, and automobile liability insurance;

  • workers' compensation or similar insurance;

  • automobile medical payment insurance;

  • credit-only insurance; or

  • other similar insurance coverage, under which benefits for medical care are secondary or incidental to other insurance benefits.

3. Definition of private provider for the purpose of determining whether the $30 payment limit applies

For purposes of this section, private provider means:

  • any commercial insurance company offering health insurance to recipients or groups;

  • any profit or nonprofit prepaid plan offering either medical services or full or partial payment for medical services (e.g., HMOs, associations such as Blue Cross and Blue Shield, church-sponsored plans); or

  • any organization administering health insurance plans for professional associations, unions, fraternal groups, employer-employee benefit plans, and any similar organization offering these payments or services, including self-insured and self-funded plans.

C. Policy for determining when the $30 payment limit applies

1. General policy for determining when the $30 payment limit applies

The Federal SSI benefit is limited to a maximum of $30 per month for an eligible recipient (or $60 per month for certain couples situations as described in this section), minus any countable income, when the recipient is a resident throughout a month in a public or private medical treatment facility, and any of the following applies:

  • Medicaid, including an HMO or other private provider on behalf of an recipient for whom Medicaid is paying the premium, pays or is expected to pay over 50 percent of the cost of care for that month; or

  • Medicare Part A pays or is expected to pay over 50 percent of the cost of care for that month, and the Part A coverage was purchased for the recipient under a State plan approved under title XIX of the Social Security Act (i.e., “State buy-in”). See example 2 in this section for additional information.

  • For children under age 18, any health insurance policy issued by a private provider pays or is expected to pay over 50 percent of the cost of care for that month; or

  • For children under age 18, a combination of Medicaid and any health insurance policy issued by a private provider pays or is expected to pay over 50 percent of the cost of care for that month. NOTE: We will refer to the term “any health insurance policy issued by a private provider” as “private health insurance.”

    IMPORTANT: The benefit rate for an eligible couple when both members are in medical treatment facilities, is $60 per month when the conditions in SI 00520.011C.1 are met and they have not separated, i.e., they intend to return to their prior living arrangement (regardless of the length of their stay in the facility).

    EXAMPLE 1-- Child with private insurance: Matthew, a disabled child, was born at Tall Oaks Multi-Care Center on 10/04/09. He remained in the hospital until 01/05/10, when he went home to live with his parents. Private health insurance paid for more than 50 percent of the cost of Matthew's care for the months of October and November. For December and January, a combination of private health insurance and Medicaid paid more than 50 percent of the cost of his care. Matthew is eligible for the $30 reduced benefit (plus any applicable state supplemental payment) for November and December. Deeming of his parents' income and resources begins in February, the month following the month he comes home from the hospital. E02 applies for October, FLA-D for November and December, FLA-A for January, and FLA-C for February. See the policy for when to deem from a parent at SI 01310.145B.

    EXAMPLE 2 — State buy-in Medicare Part A pays the cost of care: Mr. Wilson entered a hospital on 11/28/10 for surgery. On 01/07/11, the doctor released him to go back home. When Mr. Wilson reported these changes to SSA, the Claims Representative (CR) contacted the hospital and determined that Medicare Part A paid for than 50% of the cost of the care at the hospital.

    Because the HI data line on the MBR indicated that Mr. Wilson’s Part A Medicare was “Premium HI,” the CR checked SM 00510.280 and SM 00510.295 and determined that Mr. Wilson’s Medicare coverage was through State buy-in. Because Mr. Wilson was in the hospital for the entire month of December, Medicare paid more than 50 percent of the cost of his care, and the State buy-in program purchased his Medicare coverage, the CR determined that the $30 dollar payment limit applied to Mr. Wilson for December.

    On the MSSICS LINS screen, the CR answers “yes” to the question, “OVER 50% MEDICAID PAYMENTS.” The CR completes a DROC to verify the admission and release dates, and document that Medicare paid over 50% of the cost of care. On the DROC, the CR also summarizes his or her determination that the $30 payment limit applies for December due to State buy-in of Medicare.

    NOTE: If the CR identifies a recipient who has Medicare Part A due to State buy-in, and was put in FLA/A instead of FLA/D, see the rules for administrative finality in SI 04070.010.

2. Policy on Medicaid Home and Community Based Services programs when determining when the $30 payment limit applies

Medicaid payments made under a home or community based services waiver (as defined by title XIX of the Social Security Act) usually do not result in imposing the $30 payment limit, even if the Medicaid payment is over 50 percent of the cost of care.

For more information on waivers in these situations, see SI 00520.510D. For information about an exception to this policy, see the second bullet of SI 00520.011C.4.

3. Policy on exceptions to “throughout a month” for the purpose of determining when the $30 payment limit applies

There are several exceptions to the requirement in SI 00520.011C.1. that residence in the facility must be throughout a month in order for the $30 payment limit to apply.

  1. The $30 payment limit applies if a recipient:

    • spends part of a month in a public institution where SSI eligibility would be precluded if there throughout a month, and

    • spends the rest of the month in a public or private medical treatment facility where the $30 payment limit would apply if there throughout a month (i.e., the Medicaid payment exceeds 50 percent of the cost of care in that facility during that month; or for children under age 18, Medicaid or private health insurance payments or both exceed 50 percent of the cost of care in that facility during that month).

    In such situations, the $30 payment limit applies regardless of:

    • the order of the types of institutionalization;

    • whether one facility is involved (e.g., different section of a multiple purpose facility, SI 00520.001B.10.);

    • whether two or more institutions of the same type are involved (e.g., two different Medicaid-certified medical treatment facilities and one public non-Medicaid facility); or

    • whether the absence from the public institution is temporary (i.e., 14 days or less).

    EXAMPLE: Mrs. Rush is a resident of Belvedere State Hospital Center, a public institution, where Medicaid does not make any payments toward the cost of her care. On 12/16/08, she entered West County Hospital for surgery. She remained at West County until 01/08/09, when she returned to the state hospital. She remained at the state hospital throughout the rest of January and continued to reside there. During Mrs. Rush's stay at West County, Medicaid paid over 50 percent of the cost of her care in that facility for both the month of December and the month of January. Therefore, she is eligible for the $30 reduced benefit (plus any applicable state supplemental payment) for December and January.

  2. Medicaid certification or decertification of a facility can result in exceptions to the throughout a month requirement, as follows:

    The $30 payment limit applies when:

    • a recipient is in a public medical treatment facility throughout a month; and

    • the facility is either certified or decertified for Medicaid during the month, and

    • the Medicaid payment exceeds 50 percent of the cost of care in the facility during that month; or

    • for children under 18, Medicaid or private insurance, or both payments exceed 50 percent of the cost of care in the facility during that month.

The $30 payment limit does not apply for the month of certification or decertification if for the balance of the month the institution is a private facility (except for cases where children are already subject to the $30 payment limit because of private health insurance payments).

For more information about Medicaid certification and decertification, and how they affect the $30 payment limit, see SI 00520.700.

4. Policy on additional situations where $30 limit applies

The $30 payment limit also applies:

  • to certain recipients who are ineligible for Medicaid payment of their institutional care because they have transferred a resource (see SI 00520.012);

  • to certain severely disabled children who are living at home and who qualify for Medicaid under a state “home care” plan and who would not be otherwise eligible for SSI under the regular parental deeming rules. (See SI 01310.201B.3.)

5. Policy on exceptions to $30 limit due to temporary institutionalization (TI) and 1619 cases

We discuss exceptions to the $30 payment limit in SI 00520.140, “Temporary Institutionalization Benefits,” and SI 00520.130, “Special Benefits for Institutionalized 1619 Eligibles.”

6. Policy on state supplementation for children in $30 limit cases

Children under age 18 who are subject to the $30 payment limit because of private health insurance payments (i.e., Medicaid alone does not pay over 50 percent of the cost of their care) will receive the Optional State Supplement (OSS) amount that would apply to them if they were not subject to the $30 payment limit.

D. Process used by the system in $30 limit situations

1. Automated process in $30 limit situations

In cases where the $30 payment limit applies, the system automatically computes payments. In many cases the system automatically sends notices and identifies or controls these cases.

2. Exceptions to automated process in $30 limit situations

Until full systems support is available, you need to send manual notices for institutionalized children under age 18 who are subject to the $30 payment limit because of private health insurance payments (i.e., Medicaid alone does not pay over 50 percent of the cost of care).

E. Procedure for development and documentation in $30 limit situations

1. General procedure for development and documentation in $30 limit situations

Determine if the $30 payment limit applies as follows and record the information obtained and its source on a DROC screen. Also, document the file with a copy of any manual notice required in SI 00520.011G.

  • Use reports from medical treatment facilities, representative payees, and other payment sources, as necessary, in determining expected Medicaid or private health insurance payments.

  • Reopen determinations if you receive information rebutting a determination of the applicability or inapplicability of the $30 payment limit. For example, if the original source of payment (e.g., Medicaid) later determines an overpayment or lack of liability, apply the changed facts. For rules on administrative finality, see SI 04070.010.

  • Consider the exceptions to “throughout a month” in SI 00520.011C.3.

2. Procedure for evaluating Medicaid payments in $30 limit situations

  • Consider a statement from the state Medicaid agency or its designated representative that a facility is not certified for Medicaid payments as sufficient to establish that Medicaid is not paying or expected to pay more than 50 percent of the cost of care.

  • If an institution expects to receive (or has received) payments only from Medicaid, consider those payments to be more than 50 percent of the cost of care. However, in states where the Medicaid plan will pay for only a limited number of days of the recipient’s stay in the medical treatment facility (and private insurance is not involved), apply the $30 payment limit only if the actual amount of the Medicaid payments for the month is substantial, i.e., more than 50 percent of the cost of care.

  • If Medicaid is paying more than 50 percent of the cost of care, whether or not private health insurance is involved, input FLA-D.

  • If Medicaid is not paying over 50 percent of the cost of care for an institutionalized child under age 18, determine whether private health insurance is involved.

3. Procedure for private insurance considerations (child under age 18) in $30 limit situations

  1. Determine whether private health insurance alone, or in combination with Medicaid payments, is paying over 50 percent of the cost of care.

  2. If the child's representative payee is the institution, accept the payee's allegation regarding private health insurance payments without further development.

  3. If the child's representative payee is not the institution:

    • Accept the payee's allegations regarding private health insurance without further development if the information would preclude eligibility or result in a reduction of the payment amount. For example, the payee reports that the child is in a public medical facility and neither Medicaid nor private health insurance, alone or in combination, pays more than 50 percent.

    • Obtain verification from the institution) if the information reported by the payee would be advantageous to the recipient. For example, obtain verification if the payee reports that the child is in a public medical facility and Medicaid, or private health insurance, or both, pays over 50 percent of the cost of care.

      When working KB critical birthday diaries (when the recipient attains age 18) for institutionalized children, redevelop private insurance issues that may affect payment or eligibility. Be alert to situations where a child will lose eligibility beginning with the month after the month of attainment of age 18 (i.e., in a public institution and Medicaid not paying over 50 percent), as well as situations where a child's payments will no longer be subject to the $30 limit.

    See details

    SI 02309.003 - Attainment of Age 18 - KB Diary - Supplemental Security Income (SSI)

    SI 00520.011C.1 - Determination of Applicability of $30 Payment Limit

F. Procedure for systems input for child under age 18 in $30 limit situations

When making a systems input for an institutionalized child under age 18, consider whether private health insurance payments are material to eligibility or the payment amount. Be alert to situations where a child in N02 is eligible for the $30 payment limit because private health insurance, or a combination of Medicaid and private health insurance, is paying over 50 percent of the cost of care.

For cases where a child under age 18 is subject to the $30 payment limit because of private health insurance payments (i.e., Medicaid alone does not pay over 50 percent of the cost of care), take the following actions:

  1. Suppress the automated notice and use the Document Processing System (DPS) system to generate the SSA-L8155, SSI Notice of Planned Action in all cases involving institutionalized children under age 18 who are subject to the $30 payment limit because of private health insurance payments and in all cases where payments to those children change because of attainment of age 18. This notice is located within DPS under national documents subtitle “Post Entitlement.” For instructions on preparing the manual notices, see SI 00520.011G and NL 00804.167. Use automated notices in cases where Medicaid alone pays over 50 percent of the cost of care.

  2. Ensure that the system reflects FLA-D (the same as for cases where Medicaid pays over 50 percent of the cost of care).

  3. For non-MSSICS cases, enter the code PRIV, INSU in the Case Related Data (CG) field (see SM 01301.785).

  4. Code the Optional State Supplementation (OS) field for children in private medical treatment facilities as if they were in FLA-A rather than FLA-D. (We modified the system to ensure compatibility of the additional OS codes with FLA-D. See SI 01415.010 and regional instructions to determine the appropriate code for each supplementing state.)

NOTE: Children in public medical treatment facilities who become eligible (subject to the $30 payment limit) because of private health insurance payments will not receive state supplementation unless the state has established a rate that includes those children.

G. Procedure for notices for private health insurance cases in $30 limit situations

For private health insurance cases, use DPS as indicated in the following instructions.

1. Procedure in situations when payment is changed to the $30 limit

  1. When the child’s payment is reduced because the $30 payment limit applies, use DPS to prepare an SSA-L8155, including paragraphs PICM01 (includes caption) and PICM02 under caption 1907, “CHILD'S NAME (POSSESSIVE) Payment is Based on These Facts.”

  2. When the child’s payment increases (i.e., goes from N02 to FLA-D), prepare a manual SSA-L8151, Notice of Change of Payment, including paragraphs PICM01 and PICM02.

2. Procedure for determination of temporary institutionalization (TI) eligibility in $30 limit situations

a. Child meets TI requirements

Use the appropriate notice form (e.g., SSA-L8166, Important Information, SSA-L8155, Notice of Planned Action) and include paragraph PICM03 under caption 1907, “CHILD'S NAME (POSSESSIVE) Payment Is Based On These Facts.”

b. Child does not meet TI requirements

  • Child's payment is subject to $30 limit

Use the appropriate notice form (e.g., SSA-L8155, Notice of Planned Action) and include paragraph PICM04 under caption 1907, “CHILD'S NAME (POSSESSIVE) Payment Is Based On These Facts.”

  • Child ineligible for any SSI payment

Use either notice form SSA-L8030, Notice of Disapproved Claim (IC), or SSA-L8155, Notice of Planned Action (PE) and include paragraph PICM05. On the SSA-L8030, place the paragraph under caption 1903, “Why We Can't Pay CHILD's NAME.” On the SSA-L8155, place the paragraph under caption 1907, “CHILD'S NAME (POSSESSIVE) Payment Is Based On These Facts.”

3. Procedure when child attains age 18 in $30 limit situations

a. Child no longer eligible for SSI

Use either notice form SSA-L8030, Notice of Disapproved Claim (IC), or SSA-L8155, Notice of Planned Action (PE) and include paragraph PICM06. On the SSA-L8030, place the paragraph under caption 1903, “Why We Can't Pay CHILD'S NAME.” On the SSA-L8155, place the paragraph under caption 1904, “Why CHILD'S NAME (POSSESSIVE) Payments Changed.” Also, use paragraph PICM07 under caption 1907, “CHILD'S NAME (POSSESSIVE) Payment Is Based On These Facts.”

b. Child's payment no longer subject to $30 limit

Use the appropriate notice form (e.g., SSA-L8151, Notice of Change In Payment) and include paragraph PICM07 under caption 1907, “CHILD'S NAME (POSSESSIVE) Payment Is Based On These Facts.”

4. Procedure in overpayment situations requiring manual paragraphs for a child under age 18 in $30 limit situations

a. No withholding of overpayment — $30 payment limit

When a manual notice is required, use the following paragraphs to tell a child under age 18 (or the representative payee) that we either will not begin or will stop withholding money to recover an overpayment because the recipient is subject to the $30 payment limit:

  • paragraph PICM08 instead of automated paragraph 2455, and

  • paragraph PICM09 instead of automated paragraph (AONS) 2908.

b. Child under age 18 overpaid because of $30 payment limit

When we overpay a child under age 18 because he or she is subject to the $30 payment limit, prepare a manual overpayment notice, using paragraph PICM10 instead of automated paragraph (AONS) 2329.

NOTE: What was formerly Section H, Exhibits of Notice Language in $30 Limit Situations, is now located at NL 00804.167.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0500520011
SI 00520.011 - Determination of Applicability of $30 Payment Limit - 04/16/2013
Batch run: 04/16/2013
Rev:04/16/2013