TN 30 (07-08)
SI 00520.800 Facility Determinations
A. Background — Use of Electronic Form SSA-8045
When an SSI applicant or beneficiary resides in an institution, SSA must determine what kind of institution it is. For example, is it public or private, a medical treatment facility, a publicly operated community residence (POCR), etc?
Until recently, SSI facility determinations were made using a paper Form SSA-8045 and saved in the field office (FO) precedent file. With SSA’s move toward a paperless office, the Seattle website SEANET 8045 is now the preferred way to establish a precedent. The purpose of the SSI Facility Information and Determination Form is to document and record the status of any facility in which a current SSI claimant or recipient resides in order to determine the federal living arrangements (FLA) and in-kind support and maintenance (ISM) status. Use the determination as a precedent and apply it in any future claim or post entitlement actions.
SEANET 8045 is essentially an electronic version of Form SSA-8045. The paper Form SSA-8045 is no longer printed or stocked in the supply warehouse although a printer friendly version is maintained in (SI 00520.820).
B. Policy — Duration of Precedent
A facility determination serves as a precedent for case actions until:
there is information regarding a change in the facility which affects its status; or
3 years have elapsed from the effective date of the precedent and there is a case which requires current information.
C. Policy — When to Establish or Revise a Precedent
The FO must establish a new facility determination precedent:
When a precedent already exists, prepare a revised precedent upon becoming aware of a material change in the facility’s:
administrative or fiscal control;
capacity, if the change is sufficient to affect the facility's status; or
programs, if the change will affect the facility's status.
NOTE: The RO may choose to review revised determinations prior to effectuation. FOs should check with their respective Regional Office (RO) for specific instructions.
NOTE: When a precedent is started on Seanet 8045 it must be completed within 30 days. Any new determinations in “Pending Completion” status will be permanently removed from the database if they are not completed within 30 days from the date they are established.
D. Procedure — Determining Facility Status
1. Provision of Treatment or Services
Determine the type of treatment or services a facility provides by examining copies of:
If the type of treatment or services the facility offers is not obvious, record clarifying information including, if necessary to resolve this issue, a statement from an officer of the facility on an SSA-795 or a Report of Contact.
2. Verification of Private Status
When an institution's claim to private status is unclear, verify the status by applying the principles covered in “Residence in an Institution” (SI 00520.001C.2.).
E. Procedure — Documentation Requirements
1. Contents of Precedent
The precedent should:
describe the facility's total program and potential variations for individual residents;
explain how the residents who are in one type of program are distinguished from those in another; and
Note in the remarks section other pertinent information, including allegations from the facility on controversial issues.
2. Documenting Claims File
Use the MSSICS Report of Contact (DROC) screen to document the claims file when there is already a precedent for the facility on the SEANET 8045 website.
F. Procedure — Field Office Responsibilities
1. Establishing Precedents
Base decisions in the precedent on evidence obtained:
Obtain RO approval before implementing an FO decision when:
Advise the facility's management in writing of the initial precedent determination.
2. Revising Precedents
When revising a precedent:
advise facility management in writing of the change;
identify affected claimants (e.g., denials, suspensions, payment changes, or new eligibles);
obtain needed applications; and
advise the RO of the changes and the estimated number of cases affected before taking any adverse case action.
3. Maintaining and Using Precedents
Maintain all precedents on SEANET 8045 .
Use the established precedent for individuals residing in a facility to process:
initial claims; and
Update precedents that are more than 3 years old before processing a claim or post entitlement action.
NOTE: When conducting an onsite facility determination, use a
printed Form SSA-8045 from (SI 00520.820) to record the information for later input to SEANET 8045 .
G. Procedure — Hearings, Appeals Council, and Court Decisions
When a request for a hearing is filed or a reversal is ordered on an issue determined by use of a facility precedent, follow these instructions.
1. Request for Hearing
When a request for a hearing is filed, the field office:
prepares a certified photocopy or printout of the original precedent, if available, and the most recent precedent including attachments;
records on a SSA-5002 the dates of revisions or other pertinent information;
forwards these copies along with the file to the hearing office.
a. All Levels of Appeal
When a hearing, Appeals Council (AC), or court decision reverses a prior determination or results in a new decision:
implement it immediately for the specifically named individual or class unless a protest or appeal will be pursued; and
document the decision on SEANET 8045 if it involves a living arrangement (LA) determination.
b. Hearing or AC Decision
A reversal through a hearing or AC decision is not a precedent (i.e., do not apply the decision to other residents of the facility). Submit the following to the RO as quickly as possible after any hearing or AC decision:
a link to the LA determination on the website;
a copy of the decision which reverses the facility determination; and
an estimate of the number of facility residents who would be affected if the decision were applied to all residents; and
the FO's recommendation regarding full implementation of the decision. (The RO will decide if the decision should be questioned and will advise the FO on full-scale implementation with respect to other individuals in the facility.)
c. District Court Decisions
A reversal by a U.S. District Court order may or may not be a precedent. If the FO receives notification prior to being officially advised by the RO, consult the RO before taking any action.
H. Procedure — Completion of the Precedent
FO personnel should use SEANET 8045 to establish and maintain the precedent file. On the first screen, enter:
2. Section A., Blocks 1- 5 Field Office Identification
Enter the zip code. The name, address, phone number, and area director’s area designation code of the servicing FO are propagated based on the zip code of the facility.
3. Section B. Facility Identification
To identify the facility enter the following information:
Complete name without abbreviations and the telephone number, including the area code.
Employer identification number, if known. (This number is not mandatory for a facility determination, but is used for representative payee purposes.)
Mailing address, if different from the street address.
“N/A” in the Parent Office field unless the facility is a branch of another facility or a subsidiary of another corporation. Otherwise, enter the name and mailing address of the parent facility or corporation, and enter the name and code for the FO servicing the parent office.
Principal contacts, including name, title, phone number, and what information the contact can supply (e.g., admissions).
Since the determination of whether a branch or subsidiary is a public institution must be consistent with that for the parent facility or corporation, check with the FO servicing the parent facility, if necessary, to guarantee this consistency.
4. Section C. Determination of Institutional Status
Use this section to record and document the status of the facility or institution. Enter the information in each field as it is presented in the application path. Based on the answers to each question, the application will follow the correct sequence to complete the facility determination. If the facility is determined not to be an institution, pertinent information about the facility can be retained by attaching an electronic Report of Contact to the determination.
5. Block C.2. Determination of Public or Private Status
When making the determination on public/private status, field offices should consider:
both direct and indirect control of the facility (SI 00520.001C.2.a.).
whether all of the staff and management are governmental employees; who has the authority to hire and fire; who prepares the budget, approves the budget, controls expenditures of funds (including salaries and administrative expenses); and who receives payments (if any) from residents.
whether there are public funds appropriated and then allocated to the facility. (This does not include reimbursement for services from programs such as Medicaid.)
6. Block C.3.A. Public Emergency Shelter for the Homeless (PESH)
Click “Yes” if the requirements are met (SI 00520.600).
7. Block C.3.B. Publicly Operated Community Residence (POCR)
Click “Yes” if the requirements are met (SI 00520.500).
8. Block C.3.C. Educational/Vocational Training
Click “Yes” if the institution provides educational/vocational training to any of its residents (SI 00520.400).
9. Block C.3.D. Medicaid
Click the applicable radio button to indicate the type of Medicaid payments received. If button 2 is checked, indicating that Medicaid certification is pending, a follow-up is necessary, Information about Medicaid certification is found in “Conversion of Facilities to Medicaid” (SI 00520.700).
10. Block C.4. Medical Services
If the facility provides medical services, check all applicable boxes indicating the types of services.
11. Block C.5. For Profit or Private Nonprofit Status of Private Facility
If a facility is “for profit”, check “No.”
If a facility is “nonprofit”, check “Yes” and click the appropriate radio button to indicate tax exemption status. If item “B” is checked, a follow-up is necessary.
Instructions for determining nonprofit status are found in “In-Kind Support and Maintenance Provided Residents of Private Nonprofit Residential Care Institutions” (SI 00835.710).
12. Block C.6. Facility's Policies on Charges
An institution's policies on charges for its residents affect eligibility and payments (see SI 00835.704).
a. Items “A” through “E” identify a facility as one which:
does not charge any resident (either directly, or indirectly by billing a third party) for what the facility provides; or
charges all its residents and uses the same rate for the same accommodations; or
falls somewhere in between these extremes. For example, if a facility bills Medicaid or some other State program, the answer to “A” is “Yes”. The terms “bills” or “billing” include situations where the resident is expected to pay a set amount each month even if no written bill is prepared.
b. Facility is a nonprofit retirement home or similar nonprofit institution.
If the facility is a nonprofit retirement home or similar nonprofit institution, consider whether the exclusion of ISM applies to some or all residents of the facility. See (SI 00835.712) for a discussion of when ISM is excluded for residents of non profit institutions.
c. Value of ISM is not excluded for all residents.
Block C.6.E. applies only if the value of ISM is not excluded for all residents. This block does not apply to an institution which:
has only inpatients (i.e., individuals in medical confinement); or
is a private nonprofit institution which has an express obligation to provide all of the food and shelter for every resident. (See SI 00835.712B.)
d. If block C.6.E. applies:
determine the monthly charge for a resident; and
determine the portion of this charge that is attributable to food and shelter.
if the above information is not available, accept the institution's best estimate of the current market value (CMV) of food and shelter.
13. Section D Prerelease
Document whether a facility has been contacted regarding a prerelease agreement and whether a formal or informal agreement exists with the facility. When updating a precedent and a prior precedent shows the facility unable or unwilling to develop prerelease procedures, recontact the facility on this issue.
14. Section E Special Provision Related to 1619 Eligibility
Document whether the facility has agreed to allow all non-Medicaid individuals to retain additional SSI benefits authorized under section SI 00520.130.
Click “Yes” only if a facility-wide agreement exists.
Click “N/A” for institutions where the special payments are not available to any resident (e.g., penal, private, non-Medicaid).
If no facility-wide agreement exists, click “No” and complete block E.2.
Enter additional notes regarding the facility determination in the space provided. Any information you add will be appended to a DROC and attached to this facility determination.
15. Submit for Final Review
Click the “Submit for Final Review” button. This will allow you to review and edit a draft of the determination.
When the determination is complete, select “Sign Off,” and the application generates an automatic e-mail message to the FO mailbox for management review and sign-off.
When the SSA-8045 is approved by management, the names and titles of both the preparer and the management reviewer, along with the date the determination was prepared, propagate to the signature block in Section F based on the user PINs.
16. Section G Individual Case Determinations (Optional)
Only use this section to record individual case information. Do not include such information on the precedent form itself. When the institution is multipurpose, use this space to document which program(s) apply to the individual.