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.