SI PHI01415.010 Administration of State Supplementary Programs — Pennsylvania (RTN 63 — 12/2014)

A. Introduction

This transmittal describes Pennsylvania's optional supplementation program from January 1974 on. Appendix 1 contains monthly supplementation coding and payment level charts for all periods from January 1993 through present. Payment level charts for periods prior to January 1993 can be obtained by contacting the SSI Programs Support Team in the regional office.

Optional supplementation in Pennsylvania has undergone several modifications since the inception of the SSI program in January 1974. The major changes include:

  • In January 1976, increases in the OSS amounts

  • In January 1976, an expansion of the supplementation program to include persons residing in private medical facilities

  • In April 1976, an expansion of the supplementation program to include persons who were not eligible for a Federal SSI benefit, but whose Federal Countable Income (FCI) was within the total payment level afforded by combining the applicable Federal Benefit Rate (FBR) with the relevant State supplementary payment amount

  • In April 1976, a living arrangement variation for residents of domiciliary care homes was added

  • In November 1982, the domiciliary care homes category was expanded to include residents of personal care boarding homes

  • In July 1989, a separate living arrangement variation for residents of personal care boarding homes was added

  • In July 1993, an increase in state supplement amounts paid to residents of domiciliary care homes and personal care boarding homes

  • In January 1996, a decrease in state supplement amounts paid to recipients in OS codes 'A' and 'B'

  • In July 2001, an increase in state supplement amounts paid to residents of domiciliary care homes and personal care boarding homes

  • In January 2005, a "split administration" of state supplement payments became effective

  • In July 2006, an increase in state supplement amounts paid to residents of personal care boarding homes

  • In October 2007, an increase in state supplement amounts paid to residents of domiciliary care homes

B. General description

1. Administration

From January 1974 through December 2004, SSA administered all of Pennsylvania's optional and mandatory state supplement payments. Effective January 2005, Pennsylvania took over administration of all optional state supplements except for those payable to individuals/couples with essential persons and for eligible individuals/couples residing in domiciliary care homes or personal care boarding homes. SSA continued to administer all mandatory state supplement payments.

2. Requirement for receipt of a Federal SSI benefit

From January 1974 through March 1976, individuals/couples could be eligible for a state supplement payment only if they were eligible for a Federal SSI payment.

Effective April 1976, individuals/couples could be eligible for a state supplement payment even if they were not eligible for a Federal SSI payment; that is, the countable income limit was increased to the applicable FBR plus the applicable state supplementary payment amount.

3. Variations

Geographic

None

4. Living arrangements

A general supplement is payable to all eligible individuals/couples who are residents of the State except those:

  • Residing in a medical facility where title XIX (Medicaid) is paying more than 50% of the cost of care

  • Who resided, throughout any month from 1/74 - 12/75, in a private medical facility, regardless of the source of payment.

  • Eligible for a special supplement for those converted individuals/couples who are residing with one or more essential persons.

  • Eligible for a supplement based on certified residence in a Domiciliary Care Home or Personal Care Boarding Home.

5. Lien or relative responsibility

None

6. Residency requirement

To be eligible to receive an optional supplement, an individual must be a resident of the state.

7. Durational residency requirements

None

8. Additional income exclusions

None

9. Adjusted payment levels

None

10. Input of optional supplement (OS) codes

When an OS code must be input, the coding shown in the "OS Code" column of the charts in Appendix 1 of these instructions should be used.

A special OS code 'Y' is to be used in those rare cases where an individual waives his or her right to an optional state supplement payment.

Effective January 2005, OS code 'Z' is used for those SSI recipients in FLA-A or FLA-B.

C. State "pass-along" of SSI cost-of-living increases

Beginning with the July 1974 SSI cost-of-living increase, Pennsylvania has opted to pass along the FBR increases to optional supplement recipients. Beginning with the July 1977 SSI cost-of-living increase, Federal law (Section 1618 of the Social Security Act) required all states to pass along the increases to optional and mandatory recipients, or at least to maintain their total state supplement expenditures. Pennsylvania has chosen to use the "payment levels" method of complying with the pass-along provisions; PA maintains its maximum supplementary payment amount for each of the supplemental living arrangement variations by increasing the various total payment levels (combined FBR plus state supplement amount) by the exact amount of the FBR increase for the specified living arrangement variation.

D. Special considerations for essential persons

For the period January 1974 through December 1975, an optional supplement was payable for each essential person in a family unit. Effective January 1976, the state supplement for all essential persons was frozen at the rate payable for one essential person, regardless of the number of EPs in the home. These amounts are added, as appropriate, to the proper federal benefit rate in order to establish the correct total payment level for all EP cases. Due to systems limitations, these EP cases must be manually controlled and payments "forced" to the proper level. There were very few of these cases in existence when the change was effectuated in January 1976.

E. Special considerations for split couples prior to October 1990

Prior to October 1, 1990, members of an eligible couple remained a "couple" for SSI payment computation purposes for six months following the month of separation. In "split-couple" situations, the applicable total payment level for each member was one-half of the total payment level which was applicable to an eligible couple in that particular living arrangement. Where each member of the split couple had the same Federal LA and OS code, the resulting payment (Federal and State) to each was identical. Where there was a variance in either the Federal LA or OS code, the resulting payment to each differed. The state did not provide a specific total payment level or special optional supplement which was applicable only to a split couple. Therefore, the couples' total payment levels which were used for split couple's computations were the same as those applicable to couples who were together.

When one member of a split couple was in Federal LA 'D', instructions now contained in SI 02005.031D. were followed to determine SSI eligibility/payment to each member of the couple.

F. Optional State supplement only payments

Prior to April 1976, an applicant/recipient had to be eligible for a Federal SSI payment for an optional state supplement to be payable in Pennsylvania. Effective April 1976, a recipient may receive an optional state supplement payment (and, therefore, Medicaid) as long as his or her Federal countable income (FCI) does not equal or exceed the applicable total payment level.

G. Pennsylvania supplement for certified domiciliary care and personal care boarding home residents

1. General

Effective April 1, 1976, a special optional supplement became payable to adult persons (age 18 and over) certified by the State to be residing in domiciliary care (DOMCARE) facilities. The state supplementary payment is meant to provide financially needy, aged, blind and disabled persons with the same kind of alternative living arrangement as is available to persons with higher income. In November 1982, the state expanded this supplementation category to pay certified residents of personal care boarding homes (PCBH) at the same rate as DOMCARE recipients. Effective July, 1989, Pennsylvania created a separate category of supplementation for PCBH residents.

The state placement agencies, the local county assistance offices (CAO) and Social Security field offices have separate and specific responsibilities under the DOMCARE/PCBH programs. Eligibility determinations for a state supplement based on residence in a domiciliary care home or a personal care boarding home are the state's responsibility. The Pennsylvania Department of Public Welfare, through its local County Assistance Offices, submits the appropriate form to the local Social Security office to certify eligibility for, or termination of, the state supplement. (Facsimiles of PA 747, AUTHORIZATION FOR STATE SUPPLEMENT FOR PERSONS IN A DOMICILIARY CARE FACILITY/PERSONAL CARE HOME and PA 746, TERMINATION OF STATE SUPPLEMENT FOR DOMICILIARY CARE FACILITY/PERSONAL CARE HOME, are shown in Exhibit 1 at the end of this section.) SSA is responsible for determining if the individual meets the eligibility criteria for SSI.

2. Functional responsibilities

a. Placement agency

The State Department of Public Welfare, through its regional offices, contracts with local government or private agencies to serve as placement agencies. The placement agency performs a wide range of administrative tasks, including inspecting and certifying the DOMCARE/PCBH facilities in accordance with standards set by the state. The placement agency also determines if the individual meets the criteria, based on standards set by the state, to be considered in need of the services provided by a DOMCARE or PCBH facility. The placement agency submits its evaluation forms to the CAO.

b. County assistance office

The CAO's tasks include:

  • Furnishing SSA field offices with a form PA-747 which certifies that the individual is eligible for the DOMCARE/PCBH supplement

  • Furnishing SSA field offices with a form PA-746 which certifies that the individual is no longer eligible for the DOMCARE/PCBH supplement

c. SSA field office

The SSA Field Office will receive form PA 747 from the CAO and undertake appropriate development.

  • If the DOMCARE/PCBH applicant is already receiving SSI, input an address change (if necessary) and the appropriate OS code* effective with the month of placement as specified on the PA 747.

  • If the DOMCARE/PCBH applicant is not receiving SSI, contact the individual to pursue an SSI application. Treat the PA-747 as a protective filing written statement.

*OS-G = resident of DOMCARE facility; OS-H = resident of PCBH

The SSA Field Office will receive form PA-746 from the CAO and issue appropriate Goldberg/Kelly notices (if not automated), and input the appropriate OS code for the individual's new living arrangement.

The SSA Field Office will notify the CAO (via telephone) of any change of address reported for a resident of a domiciliary care home or a personal care home. Actions to suspend the DOMCARE/PCBH supplement (that is, change the OS code) should be taken only if the CAO advises that the recipient is no longer eligible for the DOMCARE/PCBH supplement. This information should be recorded on a Report of Contact/DROC screen in MSSICS and kept in file pending receipt of the PA-746. If no PA-746 is received within 10 days, attempt one follow-up contact with the CAO. Record this action on a RC or a DROC screen in MSSICS.

The SSA Field Office will accept and process appeal requests relating to DOMCARE/PCBH eligibility. If the appealed adverse action was the result of a state decision (a denial or termination of DOMCARE/PCBH placement eligibility), SSA will request the CAO to review its action. If the CAO upholds its initial decision, advise the individual of his or her right to appeal the state's action through the CAO. If the appealed adverse action was the result of a Federal decision (a denial or suspension based on SSI eligibility, income or resources factors), pursue normal appeals procedures.

3. Federal living arrangement

Individuals/couples certified by the state to be eligible for DOMCARE/PCBH payments are considered to be in Federal Living Arrangement 'A' for the duration of the time they reside in the approved facility.

4. Month of eligibility/ineligibility

Eligibility for the DOMCARE/PCBH supplement begins with the first month of payment eligibility for SSI, or the month of placement in the facility, whichever is later. Receipt of a PA-747 can serve as "protective filing" for SSI, but the protected filing date cannot be earlier than the date that the form is received by SSA.

Ineligibility for the DOMCARE/PCBH supplement is effective with the month specified by the CAO on the PA-746 form.

5. Special considerations for DOMCARE/PCBH processing

a. Coordination between agencies

Close coordination between SSA field offices and the County Assistance Offices is essential to ensure efficient administration of this supplementation program. Any liaison or processing difficulties should be brought to the attention of the SSI Programs Support Team in the regional office.

The state's certification of eligibility for DOMCARE/PCBH supplement assumes all SSI eligibility factors are met. SSA must determine if they are actually met. CAOs should be notified of all approvals/disallowances. The original PA-747 should be returned to the CAO for all denials.

b. Effect on SSI eligibility

We cannot include the amount of the state supplement payment when determining eligibility for SSI until the PA-747 has been received in the field office. We should not enter OS codes 'G' or 'H' until the PA-747 is received. Without the PA-747, the Federal Benefit Rate (FBR) should be used to determine whether the individual meets the income limits for SSI.

  • If the claimant's countable income is equal to or less than the FBR, process the claim using normal procedures. Enter OS 'Z'. If/when the PA-747 is received, the OS code can be changed to 'G' or 'H' retroactive to the month of application or the effective date shown on the PA-747, whichever is later.

  • If the claimant's countable income is greater than the FBR, process the claim as a technical denial. This denied claim can be reopened for "new and material evidence" within two years of the denial date. If a PA-747 for the claimant is received in the office showing eligibility for the DOMCARE/PCBH state supplement, the claim can be reopened with the appropriate OS code 'G' or 'H' retroactive to the month of application or the

       

Exhibit 1 - PA 747 - Authorization for State Supplement for Persons in a Domiciliary Care Facility/Personal Care Home

G-SI_PHI01415.010G-1

 View PDF Version

      

Exhibit 2 - PA 746 - Termination of State Supplement for Persons in Domiciliary Care/Personal Care Home

G-SI_PHI01415.010G-2

 View PDF Version

    

See SI 01415.010

(PA), Appendix I -- Chart 35 (RTN 63 – 12/2014)
SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2015 -12/2016 )

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

 

$ 733.00

$ 733.00

1 EP

A

C

$ 43.70

$1100.00

$1143.70

In Another's Household

     

No EP

B

Z

 

$ 488.67

$ 488.67

1 EP

B

D

$ 43.70

$ 733.34

$ 777.04

In Parental Household

C

Z

 

$ 733.00

$ 733.00

Medicaid Facility

D

Z

---

$ 30.00

$ 30.00

IN DOMCARE

A

G

$434.30

$ 733.00

$1167.30

In PCBH

A

H

$439.30

$ 733.00

$1172.30

COUPLES 1/

In Own Household

     

No EP

A

Z

 

$1100.00

$1100.00

1 EP

A

C

$ 68.05

$1467.00

$1535.05

In Another's Household

     

No EP

B

Z

 

$ 733.34

$ 733.34

1 EP

B

D

$ 68.05

$ 978.00

$1046.05

Medicaid Facility

D

Z

---

$ 60.00

$ 60.00

IN DOMCARE 2/

A

G

$947.40

$1100.00

$2047.40

In PCBH 2/

A

H

$957.40

$1100.00

$2057.40

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.

2/ Couples can reside in a noninstitutional care arrangement such as DOMCARE. The couple is considered to be living in their own household. See SI 00835.790A.2.

The payment level for couples in a PCBH will apply only in certain situations; i.e., the month of move. If a “couple” on the first of the month, each member should receive 1/2 of the couple's FBR for the month of move. The state supplement amount to the member(s) who move(s) into the PCBH is 1/2 of the couple's rate for OS-H for the month of move. The state supplement amount for the member who remains in a household situation is 1/2 of the couple's rate for OS-A or OS-B for the month of move. Both are treated as individuals the month following the month of move. MSSICS cannot handle the eligibility and payment computations for this situation. Follow instructions in MSOM BUSSR 002.004, MSOM BUSSR 002.005 and MSOM BUSSR 002.006.

(PA), APPENDIX I – SUPPLEMENTATION CODING AND PAYMENT LEVELS CHART 34 (RTN 62 – 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 Amount

INDIVIDUALS 1/

In Own Household

     

No EP

A

Z

 

$ 721.00

$ 721.00

1 EP

A

C

$ 43.70

$1082.00

$1125.70

In Another's Household

     

No EP

B

Z

 

$ 480.67

$ 480.67

1 EP

B

D

$ 43.70

$ 721.34

$ 765.04

In Parental Household

C

Z

 

$ 721.00

$ 721.00

Medicaid Facility

D

Z

---

$ 30.00

$ 30.00

IN DOMCARE

A

G

$434.30

$ 721.00

$1155.30

In PCBH

A

H

$439.30

$ 721.00

$1160.30

COUPLES 1/

In Own Household

     

No EP

A

Z

 

$1082.00

$1082.00

1 EP

A

C

$ 68.05

$1443.00

$1511.05

In Another's Household

     

No EP

B

Z

 

$ 721.34

$ 721.34

1 EP

B

D

$ 68.05

$962.00

$1030.05

Medicaid Facility

D

Z

---

$ 60.00

$ 60.00

IN DOMCARE 2/

A

G

$947.40

$1082.00

$2029.40

In PCBH 2/

A

H

$957.40

$1082.00

$2039.40

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.

2/ Couples can reside in a noninstitutional care arrangement such as DOMCARE. The couple is considered to be living in their own household. See SI 00835.790A.2.

The payment level for couples in a PCBH will apply only in certain situations; i.e., the month of move. If a “couple” on the first of the month, each member should receive 1/2 of the couple's FBR for the month of move. The state supplement amount to the member(s) who move(s) into the PCBH is 1/2 of the couple's rate for OS-H for the month of move. The state supplement amount for the member who remains in a household situation is 1/2 of the couple's rate for OS-A or OS-B for the month of move. Both are treated as individuals the month following the month of move. MSSICS cannot handle the eligibility and payment computations for this situation. Follow instructions in MSOM BUSSR 002.004, MSOM BUSSR 002.005 and MSOM BUSSR 002.006.

   

(PA), APPENDIX I – SUPPLEMENTATION CODING AND PAYMENT LEVELS CHART 33 (RTN 61–01/2013 – 12/2013)

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 Amount

INDIVIDUALS 1/

In Own Household

     

No EP

A

Z

 

$ 710.00

$ 710.00

1 EP

A

C

$ 43.70

$1066.00

$1066.70

In Another's Household

     

No EP

B

Z

 

$ 473.34

$ 473.34

1 EP

B

D

$ 43.70

$ 710.67

$ 754.37

In Parental Household

C

Z

 

$ 710.00

$ 710.00

Medicaid Facility

D

Z

---

$ 30.00

$ 30.00

IN DOMCARE

A

G

$434.30

$ 710.00

$1144.30

In PCBH

A

H

$439.30

$ 710.00

$1149.30

COUPLES 1/

In Own Household

     

No EP

A

Z

 

$1066.00

$1066.00

1 EP

A

C

$ 68.05

$1422.00

$1490.05

In Another's Household

     

No EP

B

Z

 

$ 710.67

$ 710.67

1 EP

B

D

$ 68.05

$ 948.00

$1016.05

Medicaid Facility

D

Z

---

$ 60.00

$ 60.00

IN DOMCARE 2/

A

G

$947.40

$1066.00

$2013.40

In PCBH 2/

A

H

$957.40

$1066.00

$2023.40

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.

2/ Couples can reside in a noninstitutional care arrangement such as DOMCARE. The couple is considered to be living in their own household. See SI 00835.790A.2.

The payment level for couples in a PCBH will apply only in certain situations; i.e., the month of move. If a “couple” on the first of the month, each member should receive 1/2 of the couple's FBR for the month of move. The state supplement amount to the member(s) who move(s) into the PCBH is 1/2 of the couple's rate for OS-H for the month of move. The state supplement amount for the member who remains in a household situation is 1/2 of the couple's rate for OS-A or OS-B for the month of move. Both are treated as individuals the month following the month of move. MSSICS cannot handle the eligibility and payment computations for this situation. Follow instructions in MSOM BUSSR 002.004, MSOM BUSSR 002.005 and MSOM BUSSR 002.006.

   

(PA), APPENDIX I – SUPPLEMENTATION CODING AND PAYMENT LEVELS CHART 32 (RTN 60–12/2011)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2012)

Living Arrangement

L/A Code

O/S Code

O/S Amount

Federal Payment Amount

Total Payment Amount

INDIVIDUALS 1/

In Own Household

     

No EP

A

Z

 

$ 698.00

$ 698.00

1 EP

A

C

$ 43.70

$1048.00

$1091.70

In Another's Household

     

No EP

B

Z

 

$ 465.34

$ 465.34

1 EP

B

D

$ 43.70

$ 698.67

$ 742.37

In Parental Household

C

Z

 

$ 698.00

$ 698.00

Medicaid Facility

D

Z

---

$ 30.00

$ 30.00

IN DOMCARE

A

G

$434.30

$ 698.00

$1132.30

In PCBH

A

H

$439.30

$ 698.00

$1137.30

COUPLES 1/

In Own Household

     

No EP

A

Z

 

$1048.00

$1048.00

1 EP

A

C

$ 68.05

$1398.00

$1466.05

In Another's Household

     

No EP

B

Z

 

$ 698.67

$ 698.67

1 EP

B

D

$ 68.05

$ 932.00

$1000.05

Medicaid Facility

D

Z

---

$ 60.00

$ 60.00

IN DOMCARE 2/

A

G

$947.40

$1048.00

$1995.40

In PCBH 2/

A

H

$957.40

$1048.00

$2005.40

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.

2/ Couples can reside in a noninstitutional care arrangement such as DOMCARE. The couple is considered to be living in their own household. See SI 00835.790A.2.

The payment level for couples in a PCBH will apply only in certain situations; i.e., the month of move. If a “couple” on the first of the month, each member should receive 1/2 of the couple's FBR for the month of move. The state supplement amount to the member(s) who move(s) into the PCBH is 1/2 of the couple's rate for OS-H for the month of move. The state supplement amount for the member who remains in a household situation is 1/2 of the couple's rate for OS-A or OS-B for the month of move. Both are treated as individuals the month following the month of move. MSSICS cannot handle the eligibility and payment computations for this situation. Follow instructions in MSOM BUSSR 002.004, MSOM BUSSR 002.005 and MSOM BUSSR 002.006.

   

APPENDIX I – SUPPLEMENTATION CODING AND PAYMENT LEVEL CHARTS

CODING AND PAYMENT LEVELS 01/2009 - 12/2009

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

$ 00.00

$674.00

$674.00

1 EP

A

C

43.70

1012.00

1055.70

In Another's Household

 

 

 

 

 

No EP

B

Z

00.00

449.34

449.34

1 EP

B

D

43.70

674.67

718.37

In Parental Household

C

Z

00.00

674.00

674.00

Medicaid Facility

D

Z

---

30.00

30.00

IN DOMCARE

A

G

434.30

674.00

1108.30

In PCBH

A

H

439.30

674.00

1113.30

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

Z

00.00

1011.00

1011.00

1 EP

A

C

68.05

1349.00

1417.05

In Another's Household

 

 

 

 

 

No EP

B

Z

00.00

674.00

674.00

1 EP

B

D

68.05

899.34

967.39

Medicaid Facility

D

Z

---

60.00

60.00

IN DOMCARE 2/

A

G

947.40

1011.00

1958.40

In PCBH 2/

A

H

957.40

1011.00

1968.40

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.

2/ Couples can reside in a noninstitutional care arrangement such as DOMCARE. The couple is considered to be living in their own household. See SI 00835.790A.2.

The payment level for couples in a PCBH will apply only in certain situations; i.e., the month of move. If a “couple” on the first of the month, each member should receive 1/2 of the couple's FBR for the month of move. The state supplement amount to the member(s) who move(s) into the PCBH is 1/2 of the couple's rate for OS-H for the month of move. The state supplement amount for the member who remains in a household situation is 1/2 of the couple's rate for OS-A or OS-B for the month of move. Both are treated as individuals the month following the month of move. MSSICS cannot handle the eligibility and payment computations for this situation. Follow instructions in MSOM BUSSR 002.004, MSOM BUSSR 002.005 and MSOM BUSSR 002.006.

   

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

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

$ 00.00

$637.00

$637.00

1 EP

A

C

43.70

956.00

999.70

In Another's Household

 

 

 

 

 

No EP

B

Z

00.00

424.67

424.67

1 EP

B

D

43.70

637.34

681.04

In Parental Household

C

Z

00.00

637.00

637.00

Medicaid Facility

D

Z

---

30.00

30.00

IN DOMCARE

A

G

434.30

637.00

1071.30

In PCBH

A

H

439.30

637.00

1076.30

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

Z

00.00

$956.00

$956.00

1 EP

A

C

68.05

1275.00

1343.05

In Another's Household

 

 

 

 

 

No EP

B

Z

00.00

637.34

637.34

1 EP

B

D

68.05

850.00

918.05

Medicaid Facility

D

Z

---

60.00

60.00

IN DOMCARE 2/

A

G

947.40

956.00

1903.40

In PCBH 2/

A

H

957.40

956.00

1913.40

CODING AND PAYMENT LEVELS (10/2007 - 12/2007)

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

$ 00.00

$623.00

$623.00

1 EP

A

C

43.70

935.00

978.70

In Another's Household

 

 

 

 

 

No EP

B

Z

00.00

415.34

415.34

1 EP

B

D

43.70

623.34

667.04

In Parental Household

C

Z

00.00

623.00

623.00

Medicaid Facility

D

Z

---

30.00

30.00

IN DOMCARE

A

G

434.30

623.00

1057.30

In PCBH

A

H

439.30

623.00

1062.30

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

Z

00.00

$934.00

$934.00

1 EP

A

C

68.05

1246.00

1314.05

In Another's Household

 

 

 

 

 

No EP

B

Z

00.00

622.67

622.67

1 EP

B

D

68.05

830.67

898.72

Medicaid Facility

D

Z

---

60.00

60.00

IN DOMCARE 2/

A

G

947.40

934.00

1881.40

In PCBH 2/

A

H

957.40

934.00

1891.40

CODING AND PAYMENT LEVELS (01/2007 - 09/2007)

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

$ 00.00

$623.00

$623.00

1 EP

A

C

43.70

935.00

978.70

In Another's Household

 

 

 

 

 

No EP

B

Z

00.00

415.34

415.34

1 EP

B

D

43.70

623.34

667.04

In Parental Household

C

Z

00.00

623.00

623.00

Medicaid Facility

D

Z

---

30.00

30.00

IN DOMCARE

A

G

389.30

623.00

1012.30

In PCBH

A

H

439.30

623.00

1062.30

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

Z

00.00

$934.00

$934.00

1 EP

A

C

68.05

1246.00

1314.05

In Another's Household

 

 

 

 

 

No EP

B

Z

00.00

622.67

622.67

1 EP

B

D

68.05

830.67

898.72

Medicaid Facility

D

Z

---

60.00

60.00

IN DOMCARE 2/

A

G

857.40

934.00

1791.40

In PCBH 2/

A

H

957.40

934.00

1891.40

CODING AND PAYMENT LEVELS (07/2006 - 12/2006)

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

$ 00.00

$603.00

$603.00

1 EP

A

C

43.70

905.00

948.70

In Another's Household

 

 

 

 

 

No EP

B

Z

00.00

402.00

402.00

1 EP

B

D

43.70

603.34

647.04

In Parental Household

C

Z

00.00

603.00

603.00

Medicaid Facility

D

Z

---

30.00

30.00

IN DOMCARE

A

G

389.30

603.00

992.30

In PCBH

A

H

439.30

603.00

1042.30

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

Z

00.00

$904.00

$904.00

1 EP

A

C

68.05

1,206.00

1,274.05

In Another's Household

 

 

 

 

 

No EP

B

Z

00.00

602.67

602.67

1 EP

B

D

68.05

804.00

872.05

Medicaid Facility

D

Z

---

60.00

60.00

IN DOMCARE 2/

A

G

857.40

904.00

1,761.40

In PCBH 2/

A

H

957.40

904.00

1,861.40

CODING AND PAYMENT LEVELS (01/2006 - 06/2006)

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

$ 00.00

$603.00

$603.00

1 EP

A

C

43.70

905.00

948.70

In Another's Household

 

 

 

 

 

No EP

B

Z

00.00

402.00

402.00

1 EP

B

D

43.70

603.34

647.04

In Parental Household

C

Z

00.00

603.00

603.00

Medicaid Facility

D

Z

---

30.00

30.00

IN DOMCARE

A

G

389.30

603.00

992.30

In PCBH

A

H

394.30

603.00

997.30

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

Z

00.00

$904.00

$904.00

1 EP

A

C

68.05

1,206.00

1,274.05

In Another's Household

 

 

 

 

 

No EP

B

Z

00.00

602.67

602.67

1 EP

B

D

68.05

804.00

872.05

Medicaid Facility

D

Z

---

60.00

60.00

IN DOMCARE 2/

A

G

857.40

904.00

1,761.40

In PCBH 2/

A

H

867.40

904.00

1,771.40

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

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

$ 00.00

$579.00

$579.00

1 EP

A

C

43.70

869.00

912.70

In Another's Household

 

 

 

 

 

No EP

B

Z

00.00

386.00

386.00

1 EP

B

D

43.70

579.34

623.04

In Parental Household

C

Z

00.00

579.00

579.00

Medicaid Facility

D

Z

---

30.00

30.00

IN DOMCARE

A

G

389.30

579.00

968.30

In PCBH

A

H

394.30

579.00

973.30

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

Z

00.00

$869.00

$869.00

1 EP

A

C

68.05

1,159.00

1,227.05

In Another's Household

 

 

 

 

 

No EP

B

Z

00.00

579.00

579.00

1 EP

B

D

68.05

772.67

840.72

Medicaid Facility

D

Z

---

60.00

60.00

IN DOMCARE 2/

A

G

857.40

869.00

1,726.40

In PCBH 2/

A

H

867.40

869.00

1,736.40

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

A

$ 27.40

$564.00

$591.40

1 EP

A

C

$43.70

$846.00

$889.70

In Another's Household

 

 

 

 

 

No EP

B

B

$27.40

$376.00

$403.40

1 EP

B

D

$43.70

$564.00

$607.70

In Parental Household

C

A

$27.40

$564.00

$591.40

Medicaid Facility

D

Z

---

$30.00

$30.00

IN DOMCARE

A

G

$389.30

$564.00

$953.30

In PCBH

A

H

$394.30

$564.00

$958.30

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

A

$ 43.70

$846.00

$889.70

1 EP

A

C

$68.05

$1,128.00

$1,196.05

In Another's Household

 

 

 

 

 

No EP

B

B

$43.70

$564.00

$607.70

1 EP

B

D

$68.05

$752.00

$820.05

Medicaid Facility

D

Z

---

$60.00

$60.00

In DOMCARE 2/

A

G

$857.40

$846.00

$1,703.40

In PCBH 2/

A

H

$867.40

$846.00

$1,1713.40

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

A

$ 27.40

$552.00

$579.40

1 EP

A

C

$43.70

$829.00

$872.70

In Another's Household

 

 

 

 

 

No EP

B

B

$27.40

$368.00

$395.40

1 EP

B

D

$43.70

$552.67

$596.37

In Parental Household

C

A

$27.40

$552.00

$579.40

Medicaid Facility

D

Z

---

$30.00

$30.00

IN DOMCARE

A

G

$389.30

$552.00

$941.30

In PCBH

A

H

$394.30

$552.00

$946.30

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

A

$ 43.70

$829.00

$872.70

1 EP

A

C

$68.05

$1,106.00

$1,174.05

In Another's Household

 

 

 

 

 

No EP

B

B

$43.70

$552.67

$596.37

1 EP

B

D

$68.05

$737.34

$805.39

Medicaid Facility

D

Z

---

$60.00

$60.00

IN DOMCARE 2/

A

G

$857.40

$829.00

$1,686.40

In PCBH 2/

A

H

$867.40

$829.00

$1,696.40

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

A

$ 27.40

$545.00

$572.40

1 EP

A

C

$43.70

$818.00

$861.70

In Another's Household

 

 

 

 

 

No EP

B

B

$27.40

$363.34

$390.74

1 EP

B

D

$43.70

$545.34

$589.04

In Parental Household

C

A

$27.40

$545.00

$572.40

Medicaid Facility

D

Z

---

$30.00

$30.00

IN DOMCARE

A

G

$389.30

$545.00

$934.30

In PCBH

A

H

$394.30

$545.00

$939.30

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

A

$ 43.70

$817.00

$860.70

1 EP

A

C

$68.05

$1,090.00

$1,158.05

In Another's Household

 

 

 

 

 

No EP

B

B

$43.70

$544.67

$588.37

1 EP

B

D

$68.05

$726.67

$794.72

Medicaid Facility

D

Z

---

$60.00

$60.00

IN DOMCARE 2/

A

G

$857.40

$817.00

$1,674.40

In PCBH 2/

A

H

$867.40

$817.00

$1,684.40

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

A

$ 27.40

$530.00

$557.40

1 EP

A

C

$43.70

$796.00

$839.70

In Another's Household

 

 

 

 

 

No EP

B

B

$27.40

$353.34

$380.74

1 EP

B

D

$43.70

$530.67

$574.37

In Parental Household

C

A

$27.40

$530.00

$557.40

Medicaid Facility

D

Z

---

$30.00

$30.00

IN DOMCARE

A

G

$329.30

$530.00

$859.30

In PCBH

A

H

$334.30

$530.00

$864.30

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

A

$ 43.70

$796.00

$839.70

1 EP

A

C

$68.05

$1,062.00

$1,130.05

In Another's Household

 

 

 

 

 

No EP

B

B

$43.70

$530.67

$574.37

1 EP

B

D

$68.05

$708.00

$776.05

Medicaid Facility

D

Z

---

$60.00

$60.00

IN DOMCARE 2/

A

G

$737.40

$796.00

$1,533.40

In PCBH 2/

A

H

$747.40

$796.00

$1,543.40

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

A

$ 27.40

$512.00

$539.00

1 EP

A

C

43.70

769.00

812.70

In Another's Household

 

 

 

 

 

No EP

B

B

27.40

341.34

368.74

1 EP

B

D

43.70

512.67

556.37

In Parental Household

C

A

27.40

512.00

539.40

Medicaid Facility

D

Z

---

30.00

30.00

IN DOMCARE

A

G

329.30

512.00

841.30

In PCBH

A

H

334.30

512.00

846.30

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

A

$ 43.70

$769.00

$812.70

1 EP

A

C

68.05

1,026.05

1,094.05

In Another's Household

 

 

 

 

 

No EP

B

B

43.70

512.67

556.37

Medicaid Facility

D

Z

---

60.00

60.00

IN DOMCARE 2/

A

G

737.40

769.00

1,506.40

In PCBH 2/

A

H

747.40

769.00

1,516.40

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

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

A

$ 27.40

$500.00

$ 527.40

1 EP

A

C

43.70

751.00

794.70

In Another's Household

 

 

 

 

 

No EP

B

B

27.40

333.34

360.74

1 EP

B

D

43.70

500.00

543.70

In Parental Household

C

A

27.40

500.00

527.40

Medicaid Facility

D

Z

---

30.00

30.00

IN DOMCARE

A

G

329.30

500.00

829.30

In PCBH

A

H

334.30

500.00

834.30

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

A

$ 43.70

$751.00

$ 794.70

1 EP

A

C

68.05

1001.00

1069.05

In Another's Household

 

 

 

 

 

No EP

B

B

43.70

500.67

544.37

Medicaid Facility

D

Z

---

60.00

60.00

IN DOMCARE 2/

A

G

737.40

751.00

1488.40

In PCBH 2/

A

H

747.40

751.00

1498.40

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

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

A

$ 27.40

$494.00

$ 521.40

1 EP

A

C

43.70

741.00

784.70

In Another's Household

 

 

 

 

 

No EP

B

B

27.40

329.34

356.74

1 EP

B

D

43.70

494.00

537.70

In Parental Household

C

A

27.40

494.00

521.40

Medicaid Facility

D

Z

---

30.00

30.00

IN DOMCARE

A

G

329.30

494.00

823.30

In PCBH

A

H

334.30

494.00

828.30

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

A

$ 43.70

$741.00

$ 784.70

1 EP

A

C

68.05

988.00

1056.05

In Another's Household

 

 

 

 

 

No EP

B

B

43.70

494.00

537.70

Medicaid Facility

D

Z

---

60.00

60.00

IN DOMCARE 2/

A

G

737.40

741.00

1478.40

In PCBH 2/

A

H

747.40

741.00

1488.40

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

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

A

$ 27.40

$484.00

$ 511.40

1 EP

A

C

43.70

726.00

769.70

In Another's Household

 

 

 

 

 

No EP

B

B

27.40

322.67

350.07

1 EP

B

D

43.70

484.00

527.70

In Parental Household

C

A

27.40

484.00

511.40

Medicaid Facility

D

Z

---

30.00

30.00

IN DOMCARE

A

G

329.30

484.00

813.30

In PCBH

A

H

334.30

484.00

818.30

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

A

$ 43.70

$726.00

$ 769.70

1 EP

A

C

68.05

968.00

1036.05

In Another's Household

 

 

 

 

 

No EP

B

B

43.70

484.00

527.70

Medicaid Facility

D

Z

---

60.00

60.00

IN DOMCARE 2/

A

G

737.40

726.00

1463.40

In PCBH 2/

A

H

747.40

726.00

1473.40

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

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

A

$ 27.40

$470.00

$ 497.40

1 EP

A

C

43.70

705.00

748.70

In Another's Household

 

 

 

 

 

No EP

B

B

27.40

313.34

340.74

1 EP

B

D

43.70

470.00

513.70

In Parental Household

C

A

27.40

470.00

497.40

Medicaid Facility

D

Z

---

30.00

30.00

IN DOMCARE

A

G

329.30

470.00

799.30

In PCBH

A

H

334.30

470.00

804.30

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

A

$ 43.70

$705.00

$ 748.70

1 EP

A

C

68.05

940.00

1008.05

In Another's Household

 

 

 

 

 

No EP

B

B

43.70

470.00

513.70

Medicaid Facility

D

Z

---

60.00

60.00

IN DOMCARE 2/

A

G

737.40

705.00

1442.40

In PCBH 2/

A

H

747.40

705.00

1452.40

CODING AND PAYMENT LEVELS (01/1995 - 12/1995)

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

A

$ 32.40

$458.00

$ 490.40

1 EP

A

C

48.70

687.00

735.70

In Another's Household

 

 

 

 

 

No EP

B

B

32.40

305.34

337.74

1 EP

B

D

48.70

458.00

506.70

In Parental Household

C

A

32.40

458.00

490.40

Medicaid Facility

D

Z

---

30.00

30.00

IN DOMCARE

A

G

329.30

458.00

787.30

In PCBH

A

H

334.30

458.00

792.30

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

A

$ 48.70

$687.00

$ 735.70

1 EP

A

C

73.05

916.00

989.05

In Another's Household

 

 

 

 

 

No EP

B

B

48.70

458.00

506.70

Medicaid Facility

D

Z

---

60.00

60.00

IN DOMCARE 2/

A

G

737.40

687.00

1424.40

In PCBH 2/

A

H

747.40

687.00

1434.40

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

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

A

$ 32.40

$446.00

$ 478.40

1 EP

A

C

48.70

669.00

717.70

In Another's Household

 

 

 

 

 

No EP

B

B

32.40

297.34

329.74

1 EP

B

D

48.70

446.00

494.70

In Parental Household

C

A

32.40

446.00

478.40

Medicaid Facility

D

Z

---

30.00

30.00

IN DOMCARE

A

G

329.30

446.00

775.30

In PCBH

A

H

334.30

446.00

780.30

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

A

$ 48.70

$669.00

$ 717.70

1 EP

A

C

73.05

892.00

965.05

In Another's Household

 

 

 

 

 

No EP

B

B

48.70

446.00

494.70

Medicaid Facility

D

Z

---

60.00

60.00

IN DOMCARE 2/

A

G

737.40

669.00

1406.40

In PCBH 2/

A

H

747.40

669.00

1416.40

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

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

A

$ 32.40

$434.00

$ 466.40

1 EP

A

C

48.70

651.00

699.70

In Another's Household

 

 

 

 

 

No EP

B

B

32.40

289.34

321.74

1 EP

B

D

48.70

434.00

482.70

In Parental Household

C

A

32.40

434.00

466.40

Medicaid Facility

D

Z

---

30.00

30.00

IN DOMCARE

A

G

329.30

434.00

763.30

In PCBH

A

H

334.30

434.00

768.30

COUPLES 1/

In Own Household

 

 

 

 

 

No EP

A

A

$ 48.70

$652.00

$ 700.70

1 EP

A

C

73.05

869.00

942.05

In Another's Household

 

 

 

 

 

No EP

B

B

48.70

434.67

483.37

Medicaid Facility

D

Z

---

60.00

60.00

IN DOMCARE 2/

A

G

737.40

652.00

1389.40

In PCBH 2/

A

H

747.40

652.00

1399.40

CODING AND PAYMENT LEVELS (01/1993 - 06/1993)

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

A

$ 32.40

$434.00

$ 466.40

1 EP

A

C

48.70

651.00

699.70

In Another's Household

 

 

 

 

 

No EP

B

B

32.40

289.34

321.74

1 EP

B

D

48.70

434.00

482.70

In Parental Household

C

A

32.40

434.00

466.40

Medicaid Facility

D

Z

---

30.00

30.00

IN DOMCARE

A

G

147.30

434.00

581.30

In PCBH

A

H

152.30

434.00

586.30

COUPLES 1/

In Own Household

 

 

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