SI NY01415.026 New York Payments (RTS 399 - 06/2006)

A. Introduction

Since the beginning of the SSI Program, SSA has administered Optional State Supplement (OSS) payments on behalf of New York State. New York State assumes that the per capita expenses of a person living alone are greater than the per capita expenses of a person living with others. For State purposes, shared preparation of food indicates the existence of a multi-person household. To help individuals who cannot live independently, New York provides higher supplements to residents of congregate care facilities. New York follows the Federal definition of child in SI 00501.010, including student child. This can be material to the OSS determination (e.g., a child cannot receive OSS A or OSS E).

B. OSS codes

Code

Definition

A

Living Alone - This category includes cases where the individual/couple lives physically alone, as well as less self-evident situations. It is not payable to an individual living with an ineligible spouse. It is not payable to an individual/couple living with a child for whom they have primary responsibility (except if the child is a foster child). It is not payable to a child. It is payable to an individual/couple in Federal living arrangement (FLA) A who meet one of the following criteria:

  1. Lives physically alone. Note - "Physically alone" cannot apply to an individual/couple renting a room in a private home or apartment. However, such persons may be OSS A via "flat fee," all meals outside, or separate preparation (see 2, 3, and 4 below).

  2. Pays a fixed, pre-established flat fee for both room and board in a commercial establishment. This includes the "flat fee" household arrangement described in SI 00835.120A. It also includes cases where the individual/couple resides in an institution that meets no other OSS criteria (e.g., not licensed as a congregate care facility and not a public emergency shelter).

  3. Lives with others but takes all meals outside the dwelling.

  4. Lives with others but separately prepares or has someone separately prepare his or her food. Occasional preparation of meals in common will not preclude a finding of separate preparation.

  5. Receives a fixed, pre-established flat fee for room and board from all others in the dwelling.

  6. Lives with only a foster child, or a homemaker authorized by the local department of social services (DSS), or a family care recipient placed by: the Office of Mental Health (OMH) or Office of Persons With Developmental Disabilities (OPWDD) or local DSS.

  7. Has no permanent living arrangement (i.e., transient or street person) and is not with a spouse or a child for whom they have primary responsibility.

B

Living with Others - Payable to an individual/couple/child in FLA A or C when they meet one of the following criteria:

  1. Resides in a dwelling with others and prepares food in common with at least one other person in the dwelling. Note - An individual living with an ineligible spouse must be considered living with others despite any separate preparation. The same is true if an individual/couple lives with a child for whom he or she has primary responsibility (except if the child is a foster child).

  2. Is a child who does not meet the criteria for OSS C or OSS D (below).

  3. Lives in a religious community and room and/or board is provided in full or in part by the religious community

  4. Has no permanent living arrangement (i.e., transient or street person), but is with an ineligible spouse or child for whom they have primary responsibility.

  5. Is Federal A due to "intervening A". (SM 01301.525E.)

C

Congregate Care Level 1 – Family Care Payable to an eligible individual/couple/child* in FLA A or C who meet one of the following criteria:

  1. Individual/couple/child* has been placed in a family type home certified by NYS Office of Children and Family Services and supervised by a local DSS. *Note - A child can only receive the C supplement based on placement by OMH or OPWDD (see 2 below), not DSS.

  2. Individual/couple/child has been placed in a family care home certified by OMH/OPWDD. *Note - If a child has been placed in family care with his or her parents, deeming applies, and the child is FLA C, OSS C.

D

Congregate Care Level 2 – Residential Care Payable to an eligible individual/couple/child* who is a resident of a licensed level 2 care facility. These consist of facilities, which provide supportive living environments and include: Residences for Adults certified by the NYS Department of Health; Privately operated facilities certified by the NYS OMH; Privately-operated facilities certified by the NYS OMH and OPWDD; and Privately-operated facilities certified by OASAS. *Note - A child can only receive a D supplement if the child is residing in a facility certified by OMH, OPWDD, or OASAS

NOTE - When a couple enters a Level 2 facility, they will usually get the couple FBR and couple OSS D for the month of change only. After that, they are treated as two individuals, since couple status can exist only in households, not institutions, per SI 00501.154. However, while Level 2 facilities usually meet the Federal definition of institution, this is not always the case (e.g., facility serves fewer than four people). In such small scale "household" (i.e., non-institutional) Level 2 facilities, couple status can continue.

E

Congregate Care Level 3 – Enhanced Residential Care Payable to an eligible individual/couple who is a resident of a licensed level 3 care facility which includes: Adult Homes and Enriched Housing programs certified by the NYS Department of Health or Schools for the Mentally Retarded certified by the NYS Office of Persons With Developmental Disabilities (OPWDD). Schools for the Mentally Retarded usually meet the basic Federal definition of institution and consist of residential facilities that provide academic, vocational, recreational and social skills programs. Although sometimes called schools, they often do not meet the Federal definition of schools. NOTE - A child residing in a Level 3 facility cannot receive OSS E; he or she will receive OSS B.

NOTE (1) - When a couple enters a Level 3 facility, they will usually get the couple FBR and couple OSS E for the month of change only. After that, they are treated as two individuals, since couple status can exist only in households, not institutions, per SI 00501.154. However, while Level 3 facilities usually meet the Federal definition of institution, this is not always the case (e.g., facility serves fewer than four people). In such small scale "household" (i.e., non-institutional) Level 3 facilities, couple status can continue.

NOTE (2) - Prior to January 1, 2006 Adult Homes and Enriched Housing were Level 2 facilities and should be coded OS “D”.

F

Living in the Household of Another - Payable to recipients who are FLA B.

G

Payable effective January 1, 1988 through September 30, 2003 to individuals/couples in FLA D- Title XIX (Medicaid certified) Institutions.

Z

No Supplement Cases

Includes the following:

  • Eligible individual/couple in FLA A or B who:

    1. Is in a licensed medical facility where Medicaid is paying less than 50% of the cost of care; or

    2. Is in a publicly operated community residence which serves 16 or fewer residents; or

    3. Is in a publicly operated emergency shelter (PESH); or

    4. Qualifies under the special provision in SI 00520.130 (1619 eligible goes into medical institution)

  • Effective 10/1/03 eligible individual/couple in FLA D and also cases that were FLA D prior to January 1988.

    NOTE: Effective October 1, 2003, NYS began to directly issue optional State supplementation payments to residents of Title XIX facilities. Residents of nursing homes licensed by the NYS DOH receive a State Supplemental Personal Needs Allowance (SSPNA) of $25 a month from NYS. Residents of all other medical facilities receive $5 a month from NYS.

  • Effective 12/1/96, children under age 18 residing in certain public or private facilities receiving payment for their care under any health insurance policy issued by a private provider (SI 00520.011).

C. Development and documentation

  1. Determine the FLA (and ISM) first since it often leads to the OSS determination. For initial claims and redeterminations, optional state supplement determinations are documented on the New York Optional Supplement (LNYO) screen in MSSICS.

  2. OSS C (Level 1 Care). The file must show that the individual/couple/child was placed by the appropriate State component. The documentation must be specifically for the recipient; the care provider's license is not sufficient.

Placement by

Documented on

1. local department of social services

LDSS-2287

2. Office of Persons With Developmental Disabilities (OPWDD)

BRO-572

3. Office of Mental Health (OMH)

BPR-572

For adults, placements by any of the above establishes OSS C. For children only, placements by OMH or OPWDD will establish OSS C.

It is not necessary to re-document this on "no change" redeterminations.

  • OSS D (Level 2 Care). Authorization to make this payment is based on the recipient's residence at a facility listed in the New York State Congregate Care Facilities Directory. Document the file with a printout from the directory database that shows the OSS is D. For children, the Directory must also show OMH, OPWDD, or OASAS as the certifying agency. It is not necessary to re-document OSS D on no change redeterminations.

  • OSS E (Level 3 Care). Authorization to make this payment is based on the recipient's residence at a facility listed in the New York State Congregate Care Facilities Directory. Document the file with a printout from the Directory database that shows the OSS is E. Children cannot receive this OSS. It is not necessary to re-document OSS D on no change redeterminations.

D. Congregate care facilities directory

Field offices currently have a personal computer version of this Directory. It lists certified Level 2 and 3 facilities and identifies the appropriate OSS code (D or E).

If an applicant or operator of a congregate care facility advises the SSA office that the facility has been approved as a Level 2 or 3 facility and the facility is not listed in the Directory, the office should verify the allegation per PM 05-096 dated 11/23/05.

E. Residents of shelters

If the shelter is a PESH, the OSS is Z. However, if the shelter is privately run, the recipient will probably be OSS A by virtue of "living physically alone" or "flat fee." If the recipient is in such a shelter with child(ren) for whom he or she has primary responsibility, or with a spouse, the OSS is B.

F. Geographical variations

New York State has elected to include different geographical payment variations for their congregate care payments. As of 1/06 Levels 1, 2 and 3 variations