SI PHI01415.009 Administration of State Supplementary Programs — District of Columbia (RTN 66 - 12/2014)

See SI 01415.010

A. Introduction

This supplement describes the District of Columbia’s optional supplementation program from January 1974 onward. Appendix II contains the District’s Certification-Decertification form used to authorize/terminate eligibility for the District’s special supplement for Adult Foster Care Home residents.

Charts containing annual payment levels and supplementation coding are found in SI PHI01415.009 Appendix I, below.

The District’s supplementation program has undergone several major changes since its inception.

1. General Supplementation

Beginning October 1, 1979, the District began paying a supplement of $15.00 to SSI eligible individuals and $30.00 to SSI eligible couples who were living in their own households (OS code C), living in their own households with an essential person (OS code E), living in the household of another (OS code D) and living in the household of another with an essential person (OS code F). “Optional supplement only” payments were provided for those persons not eligible for a Federal SSI payment, but whose Federal countable income (FCI) was within the total payment level applicable to the pertinent living arrangement.

Effective May 1995, the District eliminated state supplement payments to recipients in OS code E and reduced the state payment amount to those is OS codes C, D and F. Effective January 1997, the District eliminated state supplement payments to recipients in OS codes C, D and F.

2. Adult Foster Care

From January 1974 through March 1978, the District authorized payment of a state supplement for persons certified as eligible for Adult Foster Care. In April 1978, the District created a bi-level rate structure within its Adult Foster Care Home program and significantly increased the total payment levels for individuals/couples. The level of payment was determined by the resident capacity of the participating facility. Certified persons in facilities with 50 or fewer residents (OS code A) received a smaller payment than certified persons in a facility with 51 or more (OS code B) residents. These payment rates have increased since their inception.

The District refers to the facilities where it places individuals eligible for the Adult Foster Care Home state supplement as Certified Residential Facilities or CRFs.

3. Medicaid Facilities

Effective January 1988 SSA took over administration of the state supplement paid to residents of Title XIX facilities where Medicaid is paying more than 50% of the costs of care (OS code G). Initially this supplement amount was $30.00 for individuals and $60.00 for couples. These amounts were increased to $40.00/$80.00 effective October 1991.

B. General Description

1. Administration

SSA administers the District’s optional state supplement payments. From April 1983 through December 1987 the District administered the state supplement that it paid to residents of Title XIX facilities.

2. Variations

a. Geographic

None

b. Living Arrangements

(1) From October 1979 through December 1996 a general supplement was paid to all eligible individuals/couples who were residents of the District except for those residing in medical facilities were title XIX (Medicaid) paid more than 50% of the cost of care (Federal LA ‘D’) and those eligible for a special supplement described in (2) below.

(2) A special supplement is payable to eligible individuals/couples certified by the District to be residents of approved Adult Foster Care homes. (Subsection C of these instructions explains processing responsibilities related to this supplement.)

(3) A special supplement is payable to residents of title XIX facilities.

(4) Lien or Relative Responsibility -- None

3. Residency Requirement

An individual must be a resident of the District of Columbia to be eligible to receive an optional supplement. A resident of the District is someone who is living in the District voluntarily with the intention of making his/her home there. A temporary absence from the District does not interrupt one’s eligibility for a supplement. The instructions on residency in SI 01410.010 SI 01410.030 should be followed to insure that eligibility for an optional supplement (and Medicaid) is established correctly.

“Residency” for purposes of the special optional supplement for individuals in approved Adult Foster Care homes will be established by the District and will be conveyed to SSA via the District’s certification/decertification form. (See Appendix II) This is significant since some of the District’s certified Adult Foster Care homes may be located outside the District’s territorial boundaries.

a. Durational Residency Requirement

None

b. Additional Income Exclusions

None

c. Adjusted Payment Levels

None

d. Optional Supplement Codes

An OS code must be annotated for all cases with an assigned residence address with a state code of 09XXX.

(1) OS-A- acceptable only with Federal LA-A

(a) For 4/78 and continuing, an ‘A’ OS code designates a special supplement is payable to an Adult Foster Care Home resident in a small (50 or fewer residents) Certified Residential Facility.

(b) From 1/74 – 3/78, an ‘A’ OS code designated a special supplement was payable to an Adult Foster Care Home resident, with no differentiation for the resident capacity of the facility

(2) OS-B- acceptable only with Federal LA-A

From 4/78 on, a ‘B’ code designates a special supplement is payable to an Adult Foster Care Home resident in a large (51 or more residents) Certified Residential Facility.

(3) OS-C -- OBSOLETE – acceptable only with Federal LA-A or LA-C

From 10/79 through 12/96, a ‘C’ code designated that a general supplement was payable.

(4) OS-D – OBSOLETE – acceptable only with Federal LA-B

From 10/79 through 4/95, a ‘D’ code designated that a general supplement was payable.

(5) OS-E – OBSOLETE – acceptable only with Federal LA-A with an Essential Person.

From 10/79 through 12/96, an ‘E’ code designated that a general supplement was payable.

(6) OS-F – OBSOLETE – acceptable only with Federal LA-B with an Essential Person.

From 10/79 through 12/96, an ‘F’ code designated that a general supplement was payable.

(7) OS-G – acceptable only with Federal LA-D

For 1/88 and continuing, OS-G indicates that a special supplement is payable to residents of Title XIX facilities.

(8) OS-Y – acceptable with any Federal LA code

This code is used in those rare cases when an individual/couple waives receipt of an optional supplement.

(9)OS-Z

This code designates a “no supplement” case. Currently, a ‘Z’ code is appropriate for DC residents in Federal LA-A (who are not certified residents of Adult Foster Care Homes), Federal LA-B and Federal LA-C.

Supplementation coding and Payment Level charts for the District of Columbia from 1991 through the present are included in Appendix I. If you need charts for periods prior to 1991, contact the SSI Program Support Team in the Philadelphia Regional Office at (215) 597-0435.

4. Special Computations for Split Couples

When one member of an eligible couple ceases to be eligible for SSI, the couple ceases to be an “eligible couple” for SSI purposes. The remaining member’s eligibility and payment are determined in accordance with the standards applicable to individuals effective with the month of the other member’s loss of eligibility. (SI 02005.030)

When one member of an eligible couple enters a Title XIX facility (LA-D), follow the instructions in SI 02005.050 to determine the SSI eligibility and payment for each member.

C. Adult Foster Care Supplementation Functional Responsibilities

SSA administers the District’s optional supplement for Adult Foster Care. Local SSA field offices and the District’s SSI Central Referral Bureau have specific functional responsibilities which must be fulfilled before any payment can be made. Placement eligibility decisions are the District’s responsibility, while income and resource eligibility decisions are SSA’s responsibility.

1. D.C.’s SSI Central Referral Bureau’s Responsibilities

  1. Furnishing SSA with an Adult Foster Care authorization/certification form which establishes that the District has determined the person eligible for placement. The form also identifies the resident capacity of the particular facility; i.e., 50 or fewer, or 51 or more.

  2. Furnishing SSA with a termination/decertification form which establishes that the District has determined the person is no longer eligible for placement/state supplement payment.

  3. Preparing and issuing all recipients notices of eligibility/ineligibility for placement/payment decisions rendered by the District. This includes appeal notices.

2. SSA Field Office Responsibilities

  1. Receiving authorization/certification forms from the District’s SSI Central Referral Bureau and pursuing initial or post-eligibility development, as appropriate.

    1. If the individual is currently receiving SSI and was a D.C. resident on the first day of the month during which he/she moved into the CRF, input change of address and OS code (‘A’ or ‘B’ as appropriate) effective with the month of placement. If he/she was not a D.C. resident on the first day of the month during which he/she moved into the D.C. CRF, the OS is not applicable until the month following the month of entry into the facility. (See SI 01410.030F. and SM 01305.535C) See SI PHI01415.009C.4.c. if the effective date of eligibility shown on the certification form is later than the month during which the individual moved into the CRF.

    2. If the individual is not receiving SSI, contact him/her to pursue an SSI application. Follow the instructions in GN 00204.010 and SI 00601.020 concerning consideration of protective filing in such cases.

  2. Receiving termination/decertification forms from the District SSI Central Referral Bureau, issuing appropriate Goldberg/Kelly notices and initiating action to change OS code ‘A’ or ‘B’ to applicable code for the new living arrangement.

  3. Notifying the District SSI Central Referral Bureau (via telephone at 202-442-5938) of any change of address reported to or identified by SSA. (SSA cannot terminate the state supplement payment without authorization from the District.) Actions to suspend the Adult Foster Care supplement should be initiated based on the phone contact if the authorized individual in the SSI Central Referral Bureau indicates that a termination/decertification form will be furnished. If the form is not received within 10 days, recontact the SSI Central Referral Bureau. If SSA takes action to suspend the state supplement payment based on the telephone conversation, all actions must be documented on a Report of Contact.

  4. Accepting and processing recipient appeal requests. If an appealed adverse action was the result of a District decision (a denial or termination of placement/payment eligibility,) request the District’s SSI Central Referral Bureau to review the action. If the District upholds its decision, proceed with the appeal and advise the individual of his right to appeal the District’s action through the local welfare office. If the appealed adverse action was the result of a Federal decision (a denial or suspension based on SSI categorical, income or resource factors,) pursue normal appeals procedures.

3. Certification and Decertification Forms

Appendix II contains the single form that is authorized for use by the District of Columbia for Adult Foster Care supplementation purposes. This form is a combination authorization/termination form.

4. Special Considerations for Adult Foster Care Supplementation

  1. Close coordination between SSA field offices and the District’s SSI Central Referral Bureau is essential to ensure efficient administration of the Adult Foster Care supplementation program. Any liaison or processing difficulties should be brought to the attention of the Center for Programs Support in the regional office.

  2. The District’s certification of eligibility for placement assumes that all eligibility factors are met. SSA must determine if they are actually met. The referring welfare office should be notified of all approvals and disallowances. An SSA-1610 (or other form of notification) should be furnished to the welfare office for all approvals; an SSA-1610 and the District’s certification form should be furnished to the welfare office for all denials.

  3. Eligibility for the Adult Foster Care supplement begins with the month of placement for current recipients. The “effective date” shown on the certification form should be the same as the month of placement in the facility. If it is not, the District’s SSI Central Referral Bureau should be contacted to resolve the discrepancy. (See instructions in SI PHI01415.009C.2.a.(1.) for individuals not residing in D.C. on the first day of the month during which they are placed in a CRF.)

    Eligibility for the Adult Foster Care supplement for individuals who are just filing for SSI begins with the month of effective filing of an SSI application, or the month of placement, if later than the effective filing date. As in all initial claims, SSI payment, including any state supplement, is not made for the first month of eligibility.

  4. Ineligibility for the Adult Foster Care supplement is effective with the month specified on the decertification form submitted by the District’s SSI Central Referral Bureau (see SI PHI01415.009C.1 (b.) and SI PHI01415.009C.2 (c.)). An individual may move from one certified facility to another without losing eligibility for the state supplement. The SSI Central Referral Bureau should submit a “new” certification form for each facility.

  5. Applicants/recipients who own a home will, in most cases, be ineligible for the Adult Foster Care supplement (and any Federal SSI payments) on the basis of excess resources (PSY N04). Generally, a move to an Adult Foster Care Home is not intended to be a temporary placement. Therefore, the home that he/she owns would not be the person’s principal place of residence and would not be an excludable resource. (See SI 01130.100B.5.c. and SI 01130.100D. for development.)

  6. Individuals who are candidates for Adult Residential Care placement may receive a pre-adjudicative claim decision prior to actual placement in a CRF. For institutionalized individuals whose release is contingent upon a finding that they would be eligible for an SSI payment if released from the facility, the pre-release procedures in SI 00520.900 will apply. For non-institutionalized individuals whose placement in a CRF is contingent upon a finding that they would be eligible for an SSI payment if placed in a CRF, procedures similar to the pre-release process will apply. Such individuals may file a claim and be afforded a claim evaluation—including a disability determination—on the basis of a projected living arrangement if an authorized representative from the Department of Health, the Department of Mental Health, or, Mental Health and Developmental Disabilities Administration attests that the person’s placement in a certified facility is imminent. Placement will be considered “imminent” if the one of the three agencies above indicates in writing that the person will be placed in a CRF within 30 days of the “pre-adjudicative” evaluation.

This procedure enables SSA to evaluate the claimant’s potential eligibility on the basis of the higher income limit afforded by the total payment level for an Adult Residential Care resident without the person actually being a resident. Eligibility and payment would not be established, however, until placement in the CRF is confirmed via the proscribed certification form from the SSI Central Referral Bureau.

This procedure enables SSA to evaluate the claimant’s potential eligibility on the basis of the higher income limit afforded by the total payment level for an Adult Residential Care resident without the person actually being a resident. Eligibility and payment would not be established, however, until placement in the CRF is confirmed via the proscribed certification form from the SSI Central Referral Bureau.

  

(DC), Appendix I — Chart 44 (RTN 66– 12/2014)
SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2015 -12/2015 )

Living Arrangement

L/A Code

O/S Code

O/S Amount

Federal Payment Amount

Total Payment Level

INDIVIDUALS 1/

In Own Household

     

No EP

A

Z

 

$733.00

$733.00

1 EP

A

Z

 

$1100.00

$1100.00

In Certified Adult

A

A

$585.00

$733.00

$1,318.00

Foster Care Home 2/

A

B

$695.00

$733.00

$1,428.00

In Another's Household

     

No EP

B

Z

 

$488.67

$488.67

1 EP

B

Z

 

$733.34

$733.34

In Parental Household

C

Z

 

$733.00

$733.00

Medicaid Facility

D

G

$40.00

$30.00

$70.00

COUPLES 1/

In Own Household

     

No EP

A

Z

 

$1100.00

$1100.00

1 EP

A

Z

 

$1467.00

$1467.00

In Certified Adult

A

A

$1536.00

$1100.00

$2636.00

Foster Care Home 2/

A

B

$1756.00

$1100.00

$2856.00

In Another's Household

     

No EP

B

Z

 

$733.34

$733.34

1 EP

B

Z

 

$978.00

$978.00

Medicaid Facility

D

G

$80.00

$60.00

$140.00

1/ For individuals/couples whose FCI precludes a Federal payment, the amounts in the "O/S Amount" column will vary depending on income. See SI 02005.001, which discusses situations of this kind.

OS-A applies to recipients in Adult Foster Care Homes with 50 or fewer residents

OS-B applies to recipients in Adult Foster Care Homes with 51 or more residents.

     

(DC), Appendix I — Chart 43 (RTN 65 – 11/2014)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2014 – 12/2014)

Living Arrangement

L/A Code

O/S Code

O/S Amount

Federal Payment Amount

Total Payment Level

INDIVIDUALS 1/

In Own Household

     

No EP

A

Z

 

$721.00

$721.00

1 EP

A

Z

 

$1082.00

$1082.00

In Certified Adult

A

A

$615.00

$721.00

$1,336.00

Foster Care Home 2/

A

B

$725.00

$721.00

$1,446.00

In Another's Household

     

No EP

B

Z

 

$480.67

$480.67

1 EP

B

Z

 

$721.34

$721.34

In Parental Household

C

Z

 

$721.00

$721.00

Medicaid Facility

D

G

$40.00

$30.00

$70.00

COUPLES 1/

In Own Household

     

No EP

A

Z

 

$1082.00

$1082.00

1 EP

A

Z

 

$1443.00

$1443.00

In Certified Adult

A

A

$1590.00

$1082.00

$2672.00

Foster Care Home 2/

A

B

$1810.00

$1082.00

$2892.00

In Another's Household

     

No EP

B

Z

 

$721.34

$721.34

1 EP

B

Z

 

$962.01

$962.01

Medicaid Facility

D

G

$80.00

$60.00

$140.00

State Supplement amounts for calendar year 2014 were temporarily increased in November 2014, retroactive to January 2014.

1/ For individuals/couples whose FCI precludes a Federal payment, the amounts in the "O/S Amount" column will vary depending on income. See SI 02005.001, which discusses situations of this kind.

2/ OS-A applies to recipients in Adult Foster Care Homes with 50 or fewer residents.

OS-B applies to recipients in Adult Foster Care Homes with 51 or more residents.

  

(DC), Appendix I — Chart 42 (RTN 64 – 01/2014)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2014 – 12/2014)

Living Arrangement

L/A Code

O/S Code

O/S Amount

Federal Payment Amount

Total Payment Level

INDIVIDUALS 1/

In Own Household

     

No EP

A

Z

 

$721.00

$721.00

1 EP

A

Z

 

$1082.00

$1082.00

In Certified Adult

A

A

$585.00

$721.00

$1,306.00

Foster Care Home 2/

A

B

$695.00

$721.00

$1,416.00

In Another's Household

     

No EP

B

Z

 

$480.67

$480.67

1 EP

B

Z

 

$721.34

$721.34

In Parental Household

C

Z

 

$721.00

$721.00

Medicaid Facility

D

G

$40.00

$30.00

$70.00

COUPLES 1/

In Own Household

     

No EP

A

Z

 

$1082.00

$1082.00

1 EP

A

Z

 

$1443.00

$1443.00

In Certified Adult

A

A

$1530.00

$1082.00

$2612.00

Foster Care Home 2/

A

B

$1750.00

$1082.00

$2832.00

In Another's Household

     

No EP

B

Z

 

$721.34

$721.34

1 EP

B

Z

 

$1082.34

$1082.34

Medicaid Facility

D

G

$80.00

$60.00

$140.00

1/ For individuals/couples whose FCI precludes a Federal payment, the amounts in the "O/S Amount" column will vary depending on income. See SI 02005.001, which discusses situations of this kind.

2/ OS-A applies to recipients in Adult Foster Care Homes with 50 or fewer residents.

OS-B applies to recipients in Adult Foster Care Homes with 51 or more residents.

  

(DC), Appendix I — Chart 41 (RTN 63 – 04/2013)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2013 – 12/2013)

Living Arrangement

L/A Code

O/S Code

O/S Amount

Federal Payment Amount

Total Payment Level

INDIVIDUALS 1/

In Own Household

     

No EP

A

Z

 

$710.00

$710.00

1 EP

A

Z

 

$1066.00

$1066.00

In Certified Adult

A

A

$585.00

$710.00

$1,195.00

Foster Care Home 2/

A

B

$695.00

$710.00

$1,305.00

In Another's Household

     

No EP

B

Z

 

$473.34

$473.34

1 EP

B

Z

 

$710.67

$710.67

In Parental Household

C

Z

 

$710.00

$710.00

Medicaid Facility

D

G

$40.00

$30.00

$70.00

COUPLES 1/

In Own Household

     

No EP

A

Z

 

$1066.00

$1066.00

1 EP

A

Z

 

$1422.00

$1442.00

In Certified Adult

A

A

$1524.00

$1066.00

$2390.00

Foster Care Home 2/

A

B

$1744.00

$1066.00

$2610.00

In Another's Household

     

No EP

B

Z

 

$710.67

$710.67

1 EP

B

Z

 

$948.00

$948.00

Medicaid Facility

D

G

$80.00

$60.00

$140.00

State Supplement amounts for calendar year 2013 were temporarily increased in April 2013, retroactive to January 2013.

1/ For individuals/couples whose FCI precludes a Federal payment, the amounts in the "O/S Amount" column will vary depending on income. See SI 02005.001, which discusses situations of this kind.

2/ OS-A applies to recipients in Adult Foster Care Homes with 50 or fewer residents.

OS-B applies to recipients in Adult Foster Care Homes with 51 or more residents.

(DC), Appendix I — Chart 40 (RTN 62 – 01/2013)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2013 – 12/2013)

Living Arrangement

L/A Code

O/S Code

O/S Amount

Federal Payment Amount

Total Payment Level

INDIVIDUALS 1/

In Own Household

     

No EP

A

Z

 

$710.00

$710.00

1 EP

A

Z

 

$1066.00

$1066.00

In Certified Adult

A

A

$485.00

$710.00

$1,195.00

Foster Care Home 2/

A

B

$595.00

$710.00

$1,305.00

In Another's Household

     

No EP

B

Z

 

$473.34

$473.34

1 EP

B

Z

 

$710.67

$710.67

In Parental Household

C

Z

 

$710.00

$710.00

Medicaid Facility

D

G

$40.00

$30.00

$70.00

COUPLES 1/

In Own Household

     

No EP

A

Z

 

$1066.00

$1066.00

1 EP

A

Z

 

$1422.00

$1442.00

In Certified Adult

A

A

$1324.00

$1066.00

$2390.00

Foster Care Home 2/

A

B

$1544.00

$1066.00

$2610.00

In Another's Household

     

No EP

B

Z

 

$710.67

$710.67

1 EP

B

Z

 

$948.00

$948.00

Medicaid Facility

D

G

$80.00

$60.00

$140.00

1/ For individuals/couples whose FCI precludes a Federal payment, the amounts in the "O/S Amount" column will vary depending on income. See SI 02005.001, which discusses situations of this kind.

2/ OS-A applies to recipients in Adult Foster Care Homes with 50 or fewer residents.

OS-B applies to recipients in Adult Foster Care Homes with 51 or more residents.

   

(DC), Appendix I — Chart 39 (RTN 61 – 12/2011)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2012)

Living Arrangement

L/A Code

O/S Code

O/S Amount

Federal Payment Amount

Total Payment Level

INDIVIDUALS 1/

In Own Household

     

No EP

A

Z

 

$698.00

$698.00

1 EP

A

Z

 

$1048.00

$1048.00

In Certified Adult

A

A

$485.00

$698.00

$1,183.00

Foster Care Home 2/

A

B

$595.00

$698.00

$1,293.00

In Another's Household

     

No EP

B

Z

 

$465.34

$465.34

1 EP

B

Z

 

$698.67

$698.67

In Parental Household

C

Z

 

$698.00

$698.00

Medicaid Facility

D

G

40.00

$30.00

$70.00

COUPLES 1/

In Own Household

     

No EP

A

Z

 

$1048.00

$1048.00

1 EP

A

Z

 

$1398.00

$1398.00

In Certified Adult

A

A

$1318.00

$1048.00

$2366.00

Foster Care Home 2/

A

B

$1538.00

$1048.00

$2586.00

In Another's Household

     

No EP

B

Z

 

$698.67

$698.67

1 EP

B

Z

 

$932.00

$932.00

Medicaid Facility

D

G

$80.00

$60.00

$140.00

1/ For individuals/couples whose FCI precludes a Federal payment, the amounts in the "O/S Amount" column will vary depending on income. See SI 02005.001, which discusses situations of this kind.

2/ OS-A applies to recipients in Adult Foster Care Homes with 50 or fewer residents.

OS-B applies to recipients in Adult Foster Care Homes with 51 or more residents.

(DC), Appendix I — Chart 38 (RTN 60 – 12/2010)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2011 - 12/2011)

Living Arrangement

L/A Code

O/S Code

O/S Amount

Federal Payment Amount

Total Payment Level

INDIVIDUALS 1/

In Own Household

 

 

 

 

 

No EP

A

Z

$674.00

$674.00

1 EP

A

Z

$1012.00

$1012.00

In Certified Adult

A

A

$485.00

$674.00

$1,159.00

Foster Care Home 2/

A

B

$595.00

$674.00

$1,269.00

In Another's Household

 

 

 

 

 

No EP

B

Z

$449.34

$449.34

1 EP

B

Z

$674.67

$674.67

In Parental Household

C

Z

$674.00

$674.00

Medicaid Facility

D

G

40.00

$30.00

$70.00

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

Z

$1011.00

$1011.00

1 EP

A

Z

$1349.00

$1349.00

In Certified Adult

A

A

$1307.00

$1011.00

$2318.00

Foster Care Home 2/

A

B

$1527.00

$1011.00

$2538.00

In Another's Household

 

 

 

 

 

No EP

B

Z

$674.00

$674.00

1 EP

B

Z

$899.34

$899.34

Medicaid Facility

D

G

$80.00

$60.00

$140.00

1/ For individuals/couples whose FCI precludes a Federal payment, the amounts in the "O/S Amount" column will vary depending on income. See SI 02005.001, which discusses situations of this kind.

2/ OS-A applies to recipients in Adult Foster Care Homes with 50 or fewer residents.

OS-B applies to recipients in Adult Foster Care Homes with 51 or more residents.

    

(DC), Appendix I — Chart 37 (RTN 59 – 11/2010)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2010 - 12/2010)

Living Arrangement

L/A Code

O/S Code

O/S Amount

Federal Payment Amount

Total Payment Level

INDIVIDUALS 1/

In Own Household

 

 

 

 

 

No EP

A

Z

$674.00

$674.00

1 EP

A

Z

$1012.00

$1012.00

In Certified Adult

A

A

$510.00

$674.00

$1,184.00

Foster Care Home 2/

A

B

$620.00

$674.00

$1,294.00

In Another's Household

 

 

 

 

 

No EP

B

Z

$449.34

$449.34

1 EP

B

Z

$674.67

$674.67

In Parental Household

C

Z

$674.00

$674.00

Medicaid Facility

D

G

40.00

$30.00

$70.00

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

Z

$1011.00

$1011.00

1 EP

A

Z

$1349.00

$1349.00

In Certified Adult

A

A

$1357.00

$1011.00

$2368.00

Foster Care Home 2/

A

B

$1577.00

$1011.00

$2588.00

In Another's Household

 

 

 

 

 

No EP

B

Z

$674.00

$674.00

1 EP

B

Z

$899.34

$899.34

Medicaid Facility

D

G

$80.00

$60.00

$140.00

State Supplement amounts for calendar year 2010 were temporarily increased in December 2010, retroactive to January 2010.

1/ For individuals/couples whose FCI precludes a Federal payment, the amounts in the "O/S Amount" column will vary depending on income. See SI 02005.001, which discusses situations of this kind.

OS-A applies to recipients in Adult Foster Care Homes with 50 or fewer residents.
OS-B applies to recipients in Adult Foster Care Homes with 51 or more residents.

    

(DC), Appendix I — Chart 36 (RTN 58 – 12/2008)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2009 - 12/2009)

Living Arrangement

L/A Code

O/S Code

O/S Amount

Federal Payment Amount

Total Payment Level

INDIVIDUALS 1/

In Own Household

 

 

 

 

 

No EP

A

Z

$674.00

$674.00

1 EP

A

Z

$1012.00

$1012.00

In Certified Adult

A

A

$485.00

$674.00

$1,159.00

Foster Care Home 2/

A

B

$595.00

$674.00

$1,269.00

In Another's Household

 

 

 

 

 

No EP

B

Z

$449.34

$449.34

1 EP

B

Z

$674.67

$674.67

In Parental Household

C

Z

$674.00

$674.00

Medicaid Facility

D

G

40.00

$30.00

$70.00

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

Z

$1011.00

$1011.00

1 EP

A

Z

$1349.00

$1349.00

In Certified Adult

A

A

$1307.00

$1011.00

$2318.00

Foster Care Home 2/

A

B

$1527.00

$1011.00

$2538.00

In Another's Household

 

 

 

 

 

No EP

B

Z

$674.00

$674.00

1 EP

B

Z

$899.34

$899.34

Medicaid Facility

D

G

$80.00

$60.00

$140.00

1/ For individuals/couples whose FCI precludes a Federal payment, the amounts in the "O/S Amount" column will vary depending on income. See SI 02005.001, which discusses situations of this kind.

2/ Effective March 1, 2003, "Residential Care Homes" include Adult Foster Care Homes, Adult Residential Care Facilities and Assisted Living Facilities. Eligibility for the state supplement is contingent upon receipt of the ADULT RESIDENTIAL CARE CERTIFICATION FORM, completed and signed by the proper authority.

OS-A applies to recipients in Adult Foster Care Homes with 50 or fewer residents.
OS-B applies to recipients in Adult Foster Care Homes with 51 or more residents.

(DC), Appendix I — Chart 35 (RTN 57 12/2007)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2008 - 12/2008)

Living Arrangement

L/A Code

O/S Code

O/S Amount

Federal Payment Amount

Total Payment Level

INDIVIDUALS 1/

In Own Household

 

 

 

 

 

No EP

A

Z

$637.00

$637.00

1 EP

A

Z

$956.00

$956.00

In Certified Adult

A

A

$485.00

$637.00

$1,122.00

Foster Care Home 2/

A

B

$595.00

$637.00

$1,232.00

In Another's Household

 

 

 

 

 

No EP

B

Z

$424.67

$424.67

1 EP

B

Z

$637.34

$637.34

In Parental Household

C

Z

$637.00

$637.00

Medicaid Facility

D

G

40.00

$30.00

$70.00

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

Z

$956.00

$956.00

1 EP

A

Z

$1,275.00

$1,275.00

In Certified Adult

A

A

$1,288.00

$956.00

$2,244.00

Foster Care Home 2/

A

B

$1,508.00

$956.00

$2,464.00

In Another's Household

 

 

 

 

 

No EP

B

Z

$637.34

$637.34

1 EP

B

Z

$850.00

$850.00

Medicaid Facility

D

G

$80.00

$60.00

$140.00

(DC), Appendix I Chart 34 (RTN 53 12/2006)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2007 - 12/2007)

Living Arrangement

L/A Code

O/S Code

O/S Amount

Federal Payment Amount

Total Payment Level

INDIVIDUALS 1/

In Own Household

 

 

 

 

 

No EP

A

Z

$623.00

$623.00

1 EP

A

Z

$935.00

$935.00

In Certified Adult

A

A

$485.00

$623.00

$1,108.00

Foster Care Home 2/

A

B

$595.00

$623.00

$1,218.00

In Another's Household

 

 

 

 

 

No EP

B

Z

$415.34

$415.34

1 EP

B

Z

$623.34

$623.34

In Parental Household

C

Z

$623.00

$623.00

Medicaid Facility

D

G

40.00

$30.00

$70.00

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

Z

$934.00

$934.00

1 EP

A

Z

$1,246.00

$1,246.00

In Certified Adult

A

A

$1,282.00

$934.00

$2,216.00

Foster Care Home 2/

A

B

$1,502.00

$934.00

$2,436.00

In Another's Household

 

 

 

 

 

No EP

B

Z

$622.67

$622.67

1 EP

B

Z

$830.67

$830.67

Medicaid Facility

D

G

$80.00

$60.00

$140.00

(DC), Appendix I — Chart 33 (RTN 52 - 06/2006)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2006 - 12/2006)

Living Arrangement

L/A Code

O/S Code

O/S Amount

Federal Payment Amount

Total Payment Level

INDIVIDUALS 1/

In Own Household

 

 

 

 

 

No EP

A

Z

$603.00

$603.00

1 EP

A

Z

$904.00

$904.00

In Certified Adult

A

A

$455.00

$603.00

$1,058.00

Foster Care Home 2/

A

B

$565.00

$603.00

$1,168.00

In Another's Household

 

 

 

 

 

No EP

B

Z

$402.00

$402.00

1 EP

B

Z

$603.34

$603.34

In Parental Household

C

Z

$603.00

$603.00

Medicaid Facility

D

G

40.00

$30.00

$70.00

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

Z

$904.00

$904.00

1 EP

A

Z

$1,206.00

$1,206.00

In Certified Adult

A

A

$1,212.00

$904.00

$2,116.00

Foster Care Home 2/

A

B

$1,432.00

$904.00

$2,336.00

In Another's Household

 

 

 

 

 

No EP

B

Z

$602.67

$602.67

1 EP

B

Z

$804.00

$804.00

Medicaid Facility

D

G

$80.00

$60.00

$140.00

(DC), Appendix I — Chart 32 (RTN 51 - 1/2006)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2006 - 12/2006)

Living Arrangement

L/A Code

O/S Code

O/S Amount

Federal Payment Amount

Total Payment Level

INDIVIDUALS 1/

In Own Household

 

 

 

 

 

No EP

A

Z

$603.00

$603.00

1 EP

A

Z

$905.00

$905.00

In Certified Adult

A

A

$347.00

$603.00

$950.00

Foster Care Home 2/

A

B

$457.00

$603.00

$1,060.00

In Another's Household

 

 

 

 

 

No EP

B

Z

$402.00

$402.00

1 EP

B

Z

$603.34

$603.34

In Parental Household

C

Z

$603.00

$603.00

Medicaid Facility

D

G

40.00

$30.00

$70.00

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

Z

$904.00

$904.00

1 EP

A

Z

$1,206.00

$1,206.00

In Certified Adult

A

A

$996.00

$904.00

$1,900.00

Foster Care Home 2/

A

B

$1,216.00

$904.00

$2,120.00

In Another's Household

 

 

 

 

 

No EP

B

Z

$602.67

$602.67

1 EP

B

Z

$804.00

$804.00

Medicaid Facility

D

G

$80.00

$60.00

$140.00

(DC), Appendix I — Chart 31 (RTN 50- 10/2005)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2005-12/2005)

Living Arrangement

L/A Code

O/S Code

O/S Amount

Federal Payment Amount

Total Payment Level

INDIVIDUALS 1/

In Own Household

 

 

 

 

 

No EP

A

Z

$579.00

$579.00

1 EP

A

Z

$869.00

$869.00

In Certified Adult

A

A

$367.00

$579.00

$946.00

Foster Care Home 2/

A

B

$477.00

$579.00

$1,056.00

In Another's Household

 

 

 

 

 

No EP

B

Z

$386.00

$386.00

1 EP

B

Z

$579.34

$579.34

In Parental Household

C

Z

$579.00

$579.00

Medicaid Facility

D

G

40.00

$30.00

$70.00

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

Z

$869.00

$869.00

1 EP

A

Z

$1,159.00

$1,159.00

In Certified Adult

A

A

$1,023.00

$869.00

$1,892.00

Foster Care Home 2/

A

B

$1,243.00

$869.00

$2,112.00

In Another's Household

 

 

 

 

 

No EP

B

Z

$579.34

$579.34

1 EP

B

Z

$772.67

$772.67

Medicaid Facility

D

G

$80.00

$60.00

$140.00

(DC), Appendix I — Chart 30 (RTN 49 - 1/2005)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2005-12/2005)

Living Arrangement

L/A Code

O/S Code

O/S Amount

Federal Payment Amount

Total Payment Level

INDIVIDUALS 1/

In Own Household

 

 

 

 

 

No EP

A

Z

$579.00

$579.00

1 EP

A

Z

$869.00

$869.00

In Certified Adult

A

A

$347.00

$579.00

$926.00

Foster Care Home

A

B

$457.00

$579.00

$1,036.00

In Another's Household

 

 

 

 

 

No EP

B

Z

$386.00

$386.00

1 EP

B

Z

$579.34

$579.34

In Parental Household

C

Z

$579.00

$579.00

Medicaid Facility

D

G

40.00

$30.00

$70.00

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

Z

$869.00

$869.00

1 EP

A

Z

$1,159.00

$1,159.00

In Certified Adult

A

A

$983.00

$869.00

$1,852.00

Foster Care Home

A

B

$1,203.00

$869.00

$2,072.00

In Another's Household

 

 

 

 

 

No EP

B

Z

$579.34

$579.34

1 EP

B

Z

$772.67

$772.67

Medicaid Facility

D

G

$80.00

$60.00

$140.00

(DC), Appendix I — Chart 29 (RTN 48 - 10/2004)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2004-12/2004)

Living Arrangement

L/A Code

O/S Code

O/S Amount

Federal Payment Amount

Total Payment Level

INDIVIDUALS 1/

In Own Household

 

 

 

 

 

No EP

A

Z

$564.00

$564.00

1 EP

A

Z

$846.00

$846.00

In Certified Adult

A

A

$367.00

$564.00

$931.00

Foster Care Home

A

B

$477.00

$564.00

$1,041.00

In Another's Household

 

 

 

 

 

No EP

B

Z

$376.00

$376.00

1 EP

B

Z

$564.00

$564.00

In Parental Household

C

Z

$564.00

$564.00

Medicaid Facility

D

G

40.00

$30.00

$70.00

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

Z

$846.00

$846.00

1 EP

A

Z

$1,128.00

$1,128.00

In Certified Adult

A

A

$1,016.00

$846.00

$1,862.00

Foster Care Home

A

B

$1,236.00

$846.00

$2,082.00

In Another's Household

 

 

 

 

 

No EP

B

Z

$564.00

$564.00

1 EP

B

Z

$752.00

$752.00

Medicaid Facility

D

G

$80.00

$60.00

$140.00

(DC), Appendix I — Chart 28 (RTN 47 - 1/2004)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2004 - 12/2004)

Living Arrangement

L/A Code

O/S Code

O/S Amount

Federal Payment Amount

Total Payment Amount

INDIVIDUALS 1/

In Own Household

 

 

 

 

 

No EP

A

Z

$564.00

$564.00

1 EP

A

Z

$846.00

$846.00

In Certified Adult

A

A

$307.00

$564.00

$871.00

Foster Care Home

A

B

$417.00

$564.00

$981.00

In Another's Household

 

 

 

 

 

No EP

B

Z

$376.00

$376.00

1 EP

B

Z

$564.00

$564.00

In Parental Household

C

Z

$564.00

$564.00

Medicaid Facility

D

G

$40.00

$30.00

$70.00

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

Z

$846.00

$846.00

1 EP

A

Z

$1,128.00

$1,128.00

In Certified Adult

A

A

$896.00

$846.00

$1,742.00

Foster Care Home

A

B

$1,116.00

$846.00

$1,962.00

In Another's Household

 

 

 

 

 

No EP

B

Z

$564.00

$564.00

1 EP

B

Z

$752.00

$752.00

Medicaid Facility

D

G

$80.00

$60.00

$140.00

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2003 - 12/2003)

Living Arrangement

L/A Code

O/S Code

O/S Amount

Federal Payment Amount

Total Payment Amount

INDIVIDUALS 1/

In Own Household

 

 

 

 

 

No EP

A

Z

$552.00

$552.00

1 EP

A

Z

$829.00

$829.00

In Certified Adult

A

A

$307.00

$552.00

$859.00

Foster Care Home

A

B

$417.00

$552.00

$969.00

In Another's Household

 

 

 

 

 

No EP

B

Z

$368.00

$368.00

1 EP

B

Z

$552.67

$552.67

In Parental Household

C

Z

$552.00

$552.00

Medicaid Facility

D

G

$40.00

$30.00

$70.00

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

Z

$829.00

$829.00

1 EP

A

Z

$1,106.00

$1,106.00

In Certified Adult

A

A

$889.00

$829.00

$1,718.00

Foster Care Home

A

B

$1,109.00

$829.00

$1,938.00

In Another's Household

 

 

 

 

 

No EP

B

Z

$552.67

$552.67

1 EP

B

Z

$737.34

$737.34

Medicaid Facility

D

G

$80.00

$60.00

$140.00

(DC), Appendix I — Chart 26 (RTN 45 - 1/2002)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2002 - 12/2002)

Living Arrangement

L/A Code

O/S Code

O/S Amount

Federal Payment Amount

Total Payment Amount

INDIVIDUALS 1/

In Own Household

 

 

 

 

 

No EP

A

Z

$545.00

$545.00

1 EP

A

Z

818.00

818.00

In Certified Adult

A

A

$307.00

545.00

852.00

Foster Care Home

A

B

417.00

545.00

962.00

In Another's Household

 

 

 

 

 

No EP

B

Z

363.34

363.34

1 EP

B

Z

545.34

545.34

In Parental Household

C

Z

545.00

545.00

Medicaid Facility

D

G

40.00

30.00

70.00

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

Z

$817.00

$817.00

1 EP

A

Z

1,090.00

1,090.00

In Certified Adult

A

A

$887.00

817.00

1,704.00

Foster Care Home

A

B

1,107.00

817.00

1,924.00

In Another's Household

 

 

 

 

 

No EP

B

Z

544.67

544.67

1 EP

B

Z

726.67

726.67

Medicaid Facility

D

G

80.00

60.00

140.00

(DC), Appendix I — Chart 25 (RTN 44 - 1/2001)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2001 - 12/2001)

Living Arrangement

L/A Code

O/S Code

O/S Amount

Federal Payment Amount

Total Payment Amount

INDIVIDUALS 1/

In Own Household

 

 

 

 

 

No EP

A

Z

$530.00

$530.00

1 EP

A

Z

796.00

796.00

In Certified Adult

A

A

$307.00

530.00

837.00

Foster Care Home

A

B

417.00

530.00

947.00

In Another's Household

 

 

 

 

 

No EP

B

Z

353.34

353.34

1 EP

B

Z

530.67

530.67

In Parental Household

C

Z

530.00

530.00

Medicaid Facility

D

G

40.00

30.00

70.00

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

Z

$796.00

$796.00

1 EP

A

Z

1,062.00

1,062.00

In Certified Adult

A

A

$878.00

796.00

1,674.00

Foster Care Home

A

B

1,098.00

796.00

1,894.00

In Another's Household

 

 

 

 

 

No EP

B

Z

530.67

530.67

1 EP

B

Z

708.00

708.00

Medicaid Facility

D

G

80.00

60.00

140.00

(DC), Appendix I — Chart 24 (RTN 43 - 1/2000)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2000 - 12/2000)

Living Arrangement

L/A Code

O/S Code

O/S Amount

Federal Payment Amount

Total Payment Amount

INDIVIDUALS 1/

In Own Household

 

 

 

 

 

No EP

A

Z

$512.00

$512.00

1 EP

A

Z

769.00

769.00

In Certified Adult

A

A

$307.00

512.00

819.00

Foster Care Home

A

B

417.00

512.00

929.00

In Another's Household

 

 

 

 

 

No EP

B

Z

341.34

341.34

1 EP

B

Z

512.67

512.67

In Parental Household

C

Z

512.00

512.00

Medicaid Facility

D

G

40.00

30.00

70.00

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

Z

$769.00

$769.00

1 EP

A

Z

1,026.00

1,026.00

In Certified Adult

A

A

$869.00

769.00

1,638.00

Foster Care Home

A

B

1,089.00

769.00

1,858.00

In Another's Household

 

 

 

 

 

No EP

B

Z

512.67

512.67

1 EP

B

Z

684.00

684.00

Medicaid Facility

D

G

80.00

60.00

140.00

(DC), Appendix I — Chart 23 (RTN 42 - 1/1999)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/1999-12/1999)

Living Arrangement

L/A Code

O/S Code

O/S Amount

Federal Payment Amount

Total Payment Level

INDIVIDUALS 1/

In Own Household

 

 

 

 

 

No EP

A

Z

$500.00

$500.00

1 EP

A

Z

751.00

751.00

In Certified Adult 2/

A

A

307.00

500.00

807.00

Foster Care Home 2/

A

B

417.00

500.00

917.00

In Another's Household

 

 

 

 

 

No EP

B

Z

333.34

333.34

1 EP

B

Z

500.00

500.00

In Parental Household

C

Z

500.00

500.00

Medicaid Facility

D

G

40.00

30.00

70.00

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

Z

$751.00

$751.00

1 EP

A

Z

1001.00

1011.00

In Certified Adult 2/

A

A

863.00

751.00

1,614.00

Foster Care Home 2/

A

B

1083.00

751.00

1,834.00

In Another's Household

 

 

 

 

 

No EP

B

Z

500.67

500.67

1 EP

B

Z

667.33

667.33

Medicaid Facility

D

G

80.00

60.00

140.00

1/ For individuals/couples whose FCI precludes a Federal payment, the amounts in the "O/S Amount" column will vary depending on income. See SI 02005.001, which discusses situations of this kind.

2/ In July 1998, the District of Columbia increased OS codes A and B rates by $30.00 per individual and $65.00 per couple retroactive to 01.98. A retroactive check was issued for amounts due from 01/98 to 08/98.

In January 1999, the District of Columbia increased OS codes A and B rates by $10.00 per individual and $22.00 per couple.

(DC, Appendix I — Chart 22 (RTN 41 - 09/1998)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/1998 – 12/1998)

Living Arrangement

L/A Code

O/S Code

O/S Amount

Federal Payment Amount

Total Payment Level

INDIVIDUALS 1/

In Own Household

 

 

 

 

 

No EP

A

Z

————

$494.00

$494.00

1 EP

A

Z

————

741.00

741.00

In Certified Adult 2/

A

A

$ 297.00

494.00

791.00

Foster Care Home 2/

A

B

407.00

494.00

901.00

In Another's Household

     

No EP

B

Z

————

$329.34

$329.34

1 EP

B

Z

————

494.00

494.00

In Parental Household

C

Z

————

494.00

494.00

Medicaid Facility

D

G

40.00

30.00

70.00

COUPLES 1/

In Own Household

     

No EP

A

Z

————

$741.00

$ 741.00

1 EP

A

Z

————

988.00

988.00

In Certified Adult 2/

A

A

$ 841.00

741.00

1582.00

Foster Care Home 2/

A

B

1061.00

741.00

1802.00

In Another's Household

     

No EP

B

Z

————

494.00

494.00

1 EP

B

Z

————

658.67

658.67

Medicaid Facility

D

G

80.00

60.00

140.00

(DC), Appendix I — Chart 21 (RTN 41 - 1/1998)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/1998-12/1998)

Living Arrangement

L/A Code

O/S Code

O/S Amount

Federal Payment Amount

Total Payment Level

INDIVIDUALS 1/

In Own Household

 

 

 

 

 

No EP

A

Z

$494.00

$494.00

1 EP

A

Z

741.00

741.00

In Certified Adult 2/

A

A

297.00

494.00

791.00

Foster Care Home 2/

A

B

407.00

494.00

901.00

In Another's Household

 

 

 

 

 

No EP

B

Z

329.34

329.34

1 EP

B

Z

494.00

494.00

In Parental Household

C

Z

494.00

494.00

Medicaid Facility

D

G

40.00

30.00

70.00

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

Z

$741.00

$741.00

1 EP

A

Z

988.00

988.00

In Certified Adult 2/

A

A

841.00

741.00

1,582.00

Foster Care Home 2/

A

B

1061.00

741.00

1,802.00

In Another's Household

 

 

 

 

 

No EP

B

Z

494.00

494.00

1 EP

B

Z

658.67

658.67

Medicaid Facility

D

G

80.00

60.00

140.00

2/ In July 1998, the District of Columbia increased OS codes A and B rates by $30.00 per individual and $65.00 per couple retroactive to 01.98. A retroactive check was issued for amounts due from 01/98 to 08/98.

(DC), Appendix I — Chart 20

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/1997-12/1997)

Living Arrangement

L/A Code

O/S Code

O/S Amount

Federal Payment Amount

Total Payment Level

INDIVIDUALS 1/

In Own Household

 

 

 

 

 

No EP

A

Z

$484.00

$484.00

1 EP

A

Z

726.00

726.00

In Certified Adult

A

A

267.00

484.00

751.00

Foster Care Home

A

B

377.00

484.00

861.00

In Another's Household

 

 

 

 

 

No EP

B

Z

322.67

322.67

1 EP

B

Z

484.00

484.00

In Parental Household

C

Z

484.00

484.00

Medicaid Facility

D

G

40.00

30.00

70.00

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

Z

$726.00

$726.00

1 EP

A

Z

968.00

968.00

In Certified Adult

A

A

776.00

726.00

1,502.00

Foster Care Home

A

B

996.00

726.00

1,722.00

In Another's Household

 

 

 

 

 

No EP

B

Z

484.00

484.00

1 EP

B

Z

645.34

645.34

Medicaid Facility

D

G

80.00

60.00

140.00

(DC), Appendix I — Chart 19

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/1996-12/1996)

Living Arrangement

L/A Code

O/S Code

O/S Amount

Federal Payment Amount

Total Payment Level

INDIVIDUALS 1/

In Own Household

 

 

 

 

 

No EP

A

C

$ 4.70

$470.00

$474.00

1 EP

A

E

0.00

705.00

705.00

In Certified Adult

A

A

147.20

470.00

617.00

Foster Care Home

A

B

257.20

470.00

727.00

In Another's Household

 

 

 

 

 

No EP

B

D

8.13

313.34

321.47

1 EP

B

F

4.46

470.00

474.46

In Parental Household

C

CZ

4.70

470.00

474.70

Medicaid Facility

D

G

40.00

30.00

70.00

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

C

$ 14.60

$705.00

$719.60

1 EP

A

E

9.10

940.00

949.00

In Certified Adult

A

A

523.40

705.00

1,228.00

Foster Care Home

A

B

743.40

705.00

1,448.00

In Another's Household

 

 

 

 

 

No EP

B

D

19.73

470.00

489.73

1 EP

B

F

16.06

623.67

642.73

Medicaid Facility

D

G

80.00

60.00

140.00

(DC), Appendix I — Chart 18

SUPPLEMENTATION CODING AND PAYMENT LEVELS (05/1995-12/1995)

Living Arrangement

L/A Code

O/S Code

O/S Amount

Federal Payment Amount

Total Payment Level

INDIVIDUALS 1/

In Own Household

 

 

 

 

 

No EP

A

C

$4.70

$458.00

$462.70

1 EP

A

E

0.00

687.00

687.00

In Certified Adult

A

A

147.20

458.00

605.20

Foster Care Home

A

B

257.20

458.00

715.20

In Another's Household

 

 

 

 

 

No EP

B

D

8.13

305.34

313.47

1 EP

B

F

4.46

458.00

462.46

In Parental Household

C

C

4.70

458.00

462.70

Medicaid Facility

D

G

40.00

30.00

70.00

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

C

$ 14.60

$687.00

$701.60

1 EP

A

E

9.10

916.00

925.10

In Certified Adult

A

A

523.40

687.00

1,210.00

Foster Care Home

A

B

743.40

687.00

1,430.00

In Another's Household

 

 

 

 

 

No EP

B

D

19.73

458.00

477.73

1 EP

B

F

16.06

610.67

626.73

Medicaid Facility

D

G

80.00

60.00

140.00

(DC), Appendix I — Chart 17

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/1995-04/1995)

Living Arrangement

L/A Code

O/S Code

O/S Amount

Federal Payment Amount

Total Payment Level

INDIVIDUALS 1/

In Own Household

 

 

 

 

 

No EP

A

C

$ 15.00

$458.00

$473.00

1 EP

A

E

15.00

687.00

702.00

In Certified Adult

A

A

147.20

458.00

605.20

Foster Care Home

A

B

257.20

458.00

715.20

In Another's Household

 

 

 

 

 

No EP

B

D

15.00

305.34

320.34

1 EP

B

F

15.00

458.00

473.00

In Parental Household

C

C

15.00

458.00

473.00

Medicaid Facility

D

G

40.00

30.00

70.00

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

C

$ 30.00

$687.00

$717.00

1 EP

A

E

30.00

916.00

946.00

In Certified Adult

A

A

523.40

687.00

1,210.00

Foster Care Home

A

B

743.40

687.00

1,430.00

In Another's Household

 

 

 

 

 

No EP

B

D

30.00

458.00

488.00

1 EP

B

F

30.00

610.67

640.67

Medicaid Facility

D

G

80.00

60.00

140.00

(DC), Appendix I — Chart 16

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/1994-12/1994)

Living Arrangement

L/A Code

O/S Code

O/S Amount

Federal Payment Amount

Total Payment Level

INDIVIDUALS 1/

In Own Household

 

 

 

 

 

No EP

A

C

$ 15.00

$446.00

$461.00

1 EP

A

E

15.00

669.00

684.00

In Certified Adult

A

A

147.20

446.00

593.20

Foster Care Home

A

B

257.20

446.00

703.20

In Another's Household

 

 

 

 

 

No EP

B

D

15.00

297.34

312.34

1 EP

B

F

15.00

446.00

461.00

In Parental Household

C

C

15.00

446.00

461.00

Medicaid Facility

D

G

40.00

30.00

70.00

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

C

$ 30.00

$669.00

$699.00

1 EP

A

E

30.00

892.00

922.00

In Certified Adult

A

A

517.40

669.00

1,186.40

Foster Care Home

A

B

737.40

669.00

1,406.40

In Another's Household

 

 

 

 

 

No EP

B

D

30.00

446.00

476.00

1 EP

B

F

30.00

594.67

624.67

Medicaid Facility

D

G

80.00

60.00

140.00

(DC), Appendix I — Chart 15

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/1993-12/1993)

Living Arrangement

L/A Code

O/S Code

O/S Amount

Federal Payment Amount

Total Payment Level

INDIVIDUALS 1/

In Own Household

 

 

 

 

 

No EP

A

C

$ 15.00

$434.00

$449.00

1 EP

A

E

15.00

651.00

666.00

In Certified Adult

A

A2/

147.20

434.00

581.20

Foster Care Home

A

B3/

257.20

434.00

691.20

In Another's Household

 

 

 

 

 

No EP

B

D

15.00

289.34

304.34

1 EP

B

F

15.00

434.00

449.00

In Parental Household

C

C

15.00

434.00

449.00

Medicaid Facility

D

G

40.00

30.00

70.00

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

C

$ 30.00

$652.00

$682.00

1 EP

A

E

30.00

869.00

899.00

In Certified Adult

A

A2/

510.40

652.00

1,162.40

Foster Care Home

A

B3/

730.40

652.00

1,382.40

In Another's Household

 

 

 

 

 

No EP

B

D

30.00

434.67

464.67

1 EP

B

F

30.00

579.34

609.34

Medicaid Facility4/

D

G

80.00

60.00

140.00

2/ A special supplement is payable to an adult foster home resident in a small (50 or fewer residents) facility.

3/ A special supplement is payable to an adult foster home resident in a large (51 or more residents) facility.

4/ Effective October 1, 1990, the benefit rate to each member of a couple which separates must be adjusted to that of an individual the month after the month of separation. Prior to October 1, 1990, eligible couples who separated continued to be treated as a couple for 6 months.

(DC), Appendix I — Chart 14 (RTN 32 - 1/1992)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/1992-12/1992)

Living Arrangement

L/A Code

O/S Code

O/S Amount

Federal Payment Amount

Total Payment Level

INDIVIDUALS 1/

In Own Household

 

 

 

 

 

No EP

A

C

$ 15.00

$422.00

$437.00

1 EP

A

E

15.00

633.00

648.00

In Certified Adult

A

A2/

147.20

422.00

569.20

Foster Care Home

A

B3/

257.20

422.00

679.20

In Another's Household

 

 

 

 

 

No EP

B

D

15.00

281.34

296.34

1 EP

B

F

15.00

422.00

437.00

In Parental Household

C

C

15.00

422.00

437.00

Medicaid Facility

D

G

40.00

30.00

70.00

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

C

$ 30.00

$633.00

$663.00

1 EP

A

E

30.00

844.00

874.00

In Certified Adult

A

A2/

505.40

633.00

1,138.40

Foster Care Home

A

B3/

725.40

633.00

1,358.40

In Another's Household

 

 

 

 

 

No EP

B

D

30.00

422.00

452.00

1 EP

B

F

30.00

562.67

592.67

Medicaid Facility4/

D

G

80.00

60.00

140.00

(DC), Appendix I — Chart 13

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/1991-12/1991)

Living Arrangement

L/A Code

O/S Code

O/S Amount

Federal Payment Amount

Total Payment Level

INDIVIDUALS 1/

In Own Household

 

 

 

 

 

No EP

A

C

$ 15.00

$407.00

$422.00

1 EP

A

E

15.00

611.00

626.00

In Certified Adult

A

A2/

147.20

407.00

554.20

Foster Care Home

A

B3/

257.20

407.00

664.20

In Another's Household

 

 

 

 

 

No EP

B

D

15.00

271.34

286.34

1 EP

B

F

15.00

407.34

422.34

In Parental Household

C

C

15.00

407.00

422.00

Medicaid Facility

D

G

40.00

30.00

70.00

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

C

$ 30.00

$610.00

$640.00

1 EP

A

E

30.00

814.00

844.00

In Certified Adult

A

A2/

498.40

610.00

1,108.40

Foster Care Home

A

B3/

718.40

610.00

1,328.40

In Another's Household

 

 

 

 

 

No EP

B

D

30.00

406.67

436.67

1 EP

B

F

30.00

524.67

572.67

Medicaid Facility4/

D

G

80.00

60.00

140.00

2/ A special supplement is payable to an adult foster home resident in a small (50 or fewer residents) facility.

3/ A special supplement is payable to an adult foster home resident in a large (51 or more residents) facility.

4/ Effective October 1, 1990, the benefit rate to each member of a couple which separates must be adjusted to that of an individual the month after the month of separation. Prior to October 1, 1990, eligible couples who separated continued to be treated as a couple for 6 months.

Exhibit — Appendix II — Certification Form For DC State Supplement

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To Link to this section - Use this URL:
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SI PHI01415.009 - Administration of State Supplementary Programs -- District of Columbia (RTN 66 - 12/2014) - 12/08/2014
Batch run: 12/08/2014
Rev:12/08/2014