TN 47 (07-99)

SI 00835.790 Noninstitutional Care Situations

Citations:

Regulations, 20 CFR 416.1143

If an individual is not a resident of an institution, the individual may be living in noninstitutional care. Noninstitutional care is often referred to as foster care, adult foster care, or family care.

A. Policy — ISM In Noninstitutional Care Living Arrangements

1. Noninstitutional Care

A noninstitutional care situation exists when:

  1. An individual is placed by a public or private agency under a specific program of protective placement such as foster or family care.

  2. The placement is in a private dwelling (not an institution or commercial establishment) which is licensed or otherwise approved by the State to provide foster or family care.

  3. The placing agency retains responsibility for continuing supervision of the need for such placement and of the services provided.

  4. The individual, the placing agency, or some other third party pays for the food, shelter, and protective supervision provided.

2. ISM Rules for Noninstitutional Care

  1. An individual in noninstitutional care is always considered to be living in his ownhousehold and the VTR cannot apply. ISM is valued under the PMV rule.

  2. An eligible couple placed in noninstitutional care is considered to be living in their own household separate from others living in the same residence.

  3. Any other person residing in the same dwelling is in a separate household from the individual/couple in noninstitutional care.

  4. If an individual is placed under the provisions of a State foster care plan with his/her deemor, deeming is applicable.

NOTE: Any ISM provided by a person from whom income is deemed for the month has already been taken into consideration through the deeming process, and thus, ISM would not be charged from such a deemor.

3. Care Rate and ISM Determinations

  1. The care rate established by the placing agency is the CMV of whatever food, and shelter that the care provider furnishes.

  2. If the individual pays the CMV of the food, and shelter with his/her own funds, no ISM is countable.

  3. If the individual incurs indebtedness for the CMV of the food, and shelter, no ISM is countable.

  4. Any payment by the individual is presumed to be for the food, and shelter provided.

NOTE: In general, make the presumption that any payment made by the individual to the noninstitutional care provider is a payment towards the CMV of the food and shelter. However, there may be instances (e.g., impairment-related work expenses (IRWE), plans for achieving self-support) when it might not be to the individual's advantage to apply this presumption. In such a situation, the individual's payment should be attributed in the manner that is most advantageous to the individual (SI 00835.790B., Example 2).

4. Care Provider Receives No Foster Care Payment

In some cases, State foster care agencies make noninstitutional care placements in which the care provider does not receive a foster care payment or other reimbursement. Typically, this occurs when the child is placed with a relative who agrees to care for the child without being reimbursed.

  1. If the placement meets the requirements in SI 00835.790A.1. (except for the payment requirement in SI 00835.790A.1.d.), the individual is considered to be in noninstitutional care.

  2. Because this individual is considered to be in noninstitutional care, he /she is considered to be living in his own household.

  3. Because the individual is living in his own household, the one-third reduction rule (VTR) does not apply. ISM is determined using the PMV rule.

  4. The food, and shelter supplied by the care provider is countable ISM unless the individual pays the provider for it. See SI 00835.790B.4. for the procedures for determining ISM.

B. Procedure — Computing ISM For Noninstitutional Care

1. Individual Pays

  1. Contact the provider or the placing agency to determine the care rate (the CMV of the food and shelter).

  2. Document the care rate with:

    • a copy of the placing agency's agreement; or

    • the pertinent information from the agreement recorded on the evidence screen (EVID); or

    • a DROC screen on MSSICS.

  3. Determine the actual value (AV) of the ISM by subtracting the individual's payment from the care rate.

  4. Determine that there is no countable ISM if the individual's payment equals or exceeds the care rate.

  5. If the individual's payment is less than the care rate, and a third party is paying, see SI 00835.790B.2.

2. Third Party Pays

  1. If a third party is paying towards the care rate, follow the instructions in SI 00835.706C. to determine whether the third party payments are countable as ISM or are excludable. Be alert to the possibility that the placing agency may not use its own funds to pay for the individual's care, but may be acting as an agent to collect funds from other programs.

  2. If the third party payments are:

    • excludable they do not result in countable ISM;

    • not excludable they result in countable ISM capped at the PMV.

3. Both Individual and Third Party Pay

  1. Subtract the individual's payment from the care rate.

  2. Then, subtract from the remainder any third party payment that is not countable as ISM (SI 00835.706C.).

  3. If part of the care rate is still unpaid, this remainder is countable as ISM capped at the PMV.

NOTE: If the source of the third party payments for the care is federally funded income based on need (e.g., foster care under title IV-E), the total payment is counted ascashincome to the individual and the SSI payment is reduced dollar for dollar. Such a payment is considered the individual's own payment toward the care rate and does not result in countable ISM (SI 00830.170).

EXAMPLE 1: Both Individual and Third Parties Pay

The County Department of Social Services places Lucille Green, a disabled child, in Mrs. Smith's home which is licensed to provide foster care. The care rate is $500 per month. For 05/99, Lucille's father, Mr. James Green, pays $300 to Mrs. Smith for his daughter's care. The County pays $200 from its protective services program which is funded by the State. The CR determines that the County's payment is assistance based on need
(SI 00830.175). Thus, the County's $200 payment does not result in ISM.

The excludable County payment is subtracted from $500 care rate which leaves an unpaid balance of $300. The father's $300 payment pays this balance. However, a one-third exclusion is applied to payments made by an absent parent (SI 00830.420). Therefore, his $300 payment is counted as $200 for 05/99. Since this $200 payment still exceeds the PMV ($186.66) Lucille is charged with the PMV.

For 06/99, Mr. Green pays only $150 and the County protective services program pays $350. The excludable $350 County payment is subtracted from the care rate of $500. This leaves an unpaid balance of $150 that is not excludable and may be counted as ISM. Mr. Green pays the $150 balance. However, since one-third of Mr. Green's payment as an absent parent is excluded, only $100 is counted as ISM for Lucille.

In 07/99, Lucille's SSI benefits start. Her SSI benefits are used to pay the $500 to Mrs. Smith. Since Lucille pays the entire care rate from her own funds, no ISM is counted for July.

EXAMPLE 2: Computing ISM in Most Advantageous Way for the Individual

Mr. Arthur, who resides in a foster care home, files for SSI disability in 7/99 (he is ineligible for title II benefits). The placing agency advises that the care rate for the home is $400 per month. The home's monthly charge is $700. The DO learns that the additional $300 is for attendant care services. Mr. Arthur pays the provider $300 per month from his monthly earnings of $400. His brother pays the balance of $400 to the home, with none of his money earmarked for any particular expense.

At first, the CR determines that Mr. Arthur is getting countable ISM of $100 ($400 care rate minus his own payment of $300). However, the CR identifies IRWE when evaluating Mr. Arthur's wages because he is required to pay the cost of the attendant care services ($300) provided by the home. The CR calculates the IRWE to be $300 because all of the attendant care services are provided to enable Mr. Arthur to work.

The CR uses the IRWE and attributes Mr. Arthur's payment to the home as follows: $300 towards attendant care; and $0 towards the care rate. By using this apportionment of his payment, the actual value of ISM Mr. Arthur receives is $400 (capped at the PMV — $186.66). The CR deducts the $300 IRWE from Mr. Arthur's $400 wages when the claim is adjudicated because this yields a higher SSI payment than the benefit that would be paid if we assume that Mr. Arthur's $300 monthly payment to the home is for the care rate.

4. Care Provider Receives No Payment

If the individual has been determined to be in noninstitutional care based on SI 00835.790A.1., and there is an indication that no foster care payments are received by the care provider, it is necessary to determine whether the individual receives countable ISM.

  1. Contact the placing agency and verify that no foster care payments or other reimbursement are made to the provider.

  2. Document the file with a Report of Contact (paper RC or DROC screen on MSSICS).

  3. Contact the provider for an estimate of the CMV of the food, clothing, and shelter being provided, and the amount contributed towards the CMV by the eligible individual.

  4. Document the provider contact with the provider's signed statement or a Report of Contact (paper RC or DROC screen).

  5. Compute the ISM by subtracting the eligible individual's contribution from the CMV of the food, clothing, and shelter.

NOTE: In this type of case, the eligible individual is not a member of the care provider's household. This is true even if the individual is related to the provider. Therefore, the VTR rule should not be used to determine the ISM.

EXAMPLE: Child in Noninstitutional Care — No Foster Care Payment

The county foster care agency places Thomas Smith, age 8, in the home of his uncle, Frank Johnson. The agency approved Mr. Johnson's home for foster placement and will retain responsibility for supervising Thomas's placement. Mr. Johnson has agreed to care for Thomas without receiving foster care payments.

The CR verifies this information by contacting the agency and documents the contact on the DROC screen on MSSICS. Based on this contact, the CR also determines that Thomas is in noninstitutional care. Then, the CR contacts Mr. Johnson for an estimate of the CMV of the food, clothing, and shelter that he provides to Thomas. Mr. Johnson states that the food, clothing, and shelter is worth $250 per month and that Thomas contributes $150 per month from his SSI check. The CR documents this contact on the DROC screen and determines, applying the PMV rule, that Thomas receives $100 of ISM.

On MSSICS this case is processed as follows:

On the LRES screen, the CR indicates that the residence type is “noninstitutional care.” This puts the LNON screen in the screenpath. On LNON, the CR records the placing agency information. In the field titled “CURRENT MARKET VALUE OF MONTHLY CARE” the CR enters $250 which is the CMV of the food, clothing, and shelter provided by Mr. Johnson. The CR enters “no” in the CLAIMANT PAYS ENTIRE CMV FROM OWN FUNDS field. And, the CR enters $150 in the AMOUNT PAID BY CLAIMANT field. MSSICS prefills a “yes”on the LIID screen and prefills $100 of ISM on the LISM screen in the ISM MONTHLY VALUE field. On LISM, the CR records the uncle's name and address as the source of ISM.

C. References