TN 31 (02-12)

SI 01415.044 Federally Administered Optional Supplementary Payment Programs for 01/12 Payment Levels

Citations:

Social Security Act as amended in 1973, Section 1616 ;Social Security Amendments of 1972, Section 301 ;Public Law 93-66, Section 212

A. Background

The following states participate in Federally Administered Optional Supplementary Payment Programs:

State

Reference

California

SI 01415.044B

Delaware

SI 01415.044C

District of Columbia

SI 01415.044D

Hawaii

SI 01415.044E

Iowa

SI 01415.044F

Massachusetts

(effective 4/01/12, Massachusetts began self-administering all categories)

SI 01415.044G

Michigan

SI 01415.044H

Montana

SI 01415.044I

Nevada

SI 01415.044J

New Jersey

SI 01415.044K

New York

SI 01415.044L

Pennsylvania

SI 01415.044M

Rhode Island

SI 01415.044N

Utah

SI 01415.044O

Vermont

SI 01415.044P

B. Description of supplements for California

1. Definitions of State living arrangement variations for California

Code

Definition

A

Independent Living with Cooking Facilities for an eligible individual or couple who meets one of the following situations:

  1. Lives in their own household, as defined for Federal living arrangement A purposes, and has cooking and food storage facilities or is provided meals as part of the living arrangement;

  2. Is a patient in a certified private medical facility where Title XIX does not pay more than 50 percent of the cost of care;

  3. Is a blind child under age 18 living in the household of a parent, or parents, or is a disabled child age 18 or over who meets sharing criteria and is living in the household of a parent or parents;

  4. Is a blind recipient who lives in an independent living arrangement with or without cooking and food storage facilities; or

  5. Lives in a private medical facility licensed by the State but not certified under Title XIX.

B

Non-medical Out-of-Home Care (NMOHC) applies when an individual or couple needs non-medical care or supervision in the following living arrangement situations:

Children (under age 18)

  1. Blind child residing in a State licensed NMOHC facility; or

  2. Blind child residing in the home of a relative who is not a parent and not a legal guardian; or

  3. Disabled child residing in a State licensed NMOHC facility; or

  4. Disabled child residing in the home of a legal guardian who is not a relative; or

  5. Disabled child residing in the home of a relative who is not a parent (Major v. McMahon decision); or

  6. A blind or disabled child in a “certified family” home approved by a licensed home-finding agency (“certified family home placement”); or

Adults (age 18 and over)

  1. Aged, blind or disabled individual or couple is determined to be in FLA A and resides in the home of a relative, legal conservator or guardian; or

  2. Aged, blind, or disabled individual is determined to be in FLA A and resides in a State licensed NMOHC facility; or

  3. Aged, blind or disabled individual is determined to be in FLA A and resides in a Family Home certified by a Family Home Agency under State law.

For California optional supplement (OS) purposes, a relative is defined as a parent, son, daughter, brother, sister, half-brother, half-sister, uncle, aunt, niece, nephew, first cousin, or any person of the preceding generation denoted by the prefix “grand” or “great.”

C

Independent Living Without Cooking Facilities – Apply this category to aged or disabled individuals or couples who are:

  • Not given meals, and

  • Do not have access to adequate cooking or food storage facilities as part of a living arrangement

Transients, as defined in SI 00835.060, are also eligible for OS C.

An individual or couple qualifies for OS C if any of the following situations exists:

  1. Immediate living quarters do not have cooking and food storage facilities with which the individual or couple or another person (who is responsible for preparing their meals) can prepare meals on a daily basis.

  2. Does not have access to adequate cooking and food storage facilities as part of the living arrangement (including cooking and food storage facilities which are outside the immediate living quarters) for the purpose of preparing meals or having them prepared on their behalf.

  3. Lives in a boarding house that does not have a communal kitchen with adequate cooking and food storage facilities to which they have access for preparation of meals.

  4. Lives with friends or relatives in private living quarters in the same house or in separate living quarters (for example, “over the garage”) or in a similar situation and does not have access to the cooking and food storage facilities in the main residence for preparation of meals.

  5. Lives in a room and board facility and does not contract with the facility to have meals prepared and provided as part of the living arrangement (for example, the Supplemental Security Income (SSI) recipient’s arrangement with the facility is to purchase only shelter on a monthly basis).

Adequate” cooking and food storage facilities exist when an individual or couple has access to:

  • Both a working refrigerator or icebox and a stove without a working oven but with at least two working burners (Do not consider the capacity of the refrigerator or icebox when making this determination. Also, do not consider an ice chest to be adequate storage.)

OR

  • Both a working refrigerator or icebox and a hotplate with at least two burners with separate temperature controls, or two one-burner hotplates with temperature controls (Do not consider hotplates without temperature controls used for warming food as “adequate cooking facilities.”)

OR

  • Both a working refrigerator or icebox and a stove with a working oven or functioning microwave oven in combination with at least one working burner on a stove or a one-burner hotplate with a temperature control.

Eligibility for OS C begins in the month the recipient applies for this supplement rate provided they have been without cooking and food storage facilities throughout the month.

NOTE: For purposes of OS C, “throughout a month” does not mean the recipient must lack adequate cooking or food storage facilities from the very first moment of the month. The recipient need only lack them from some time on the first day of the month.

If you based eligibility on temporary loss or nonfunctioning of an appliance, advise the recipient of their responsibility to report immediately when the temporary condition has ceased.

If the recipient provides an expected date when someone will replace or repair the appliance, diary the case for re-contact.

Eligibility for this supplementary payment ceases the month following the month in which meals are provided or adequate cooking and food storage facilities are available.

 

For a couple, comprised of an aged or disabled recipient and a blind recipient, whose living arrangement lacks adequate cooking and storage facilities, the couple must receive the Supplemental Security Income and State Supplement Payment level for a blind or aged or disabled couple plus the restaurant meals allowance for the disabled member of the couple. Force payment in this living arrangement is required.

D

Living in the Household of Another – Eligible individual or couple is living in the household of another and is receiving food and shelter from that person. Most individuals or couples who are subject to a one-third reduction of their Federal SSI payments are eligible for OS D because the criteria for this supplement level are the same as for charging the one-third reduction. However, when the eligible individual or couple lives in the home of a relative (other than a spouse) and needs care and supervision, you must obtain certification for non-medical out-of-home care (OS F) from the county welfare office since this is the highest categorical supplement for which an individual or couple can qualify.

E

Disabled Child Under Age 18 – Apply this OS code to a disabled (not blind) child under age 18 who resides with a parent or relative by blood or marriage.

NOTE: Only FLA A and C are compatible with OS E. If the VTR applies, see code G.

F

Non-medical Out-of-Home Care Living in the Household of Another – Applies whenever an eligible individual or couple meets the criteria for the non-medical out-of-home care payment rate, and is determined to receive the Federal code B payment for living in the household of another. For the One-Third Reduction Provision see SI 00835.200.

G

Disabled Child Under Age 18 Living in the Household of Another – Applies to a disabled (not blind) child under age 18, who resides with a parent or relative by blood or marriage, and is determined to receive the Federal code B payment for living in the household of another person. For the One-Third Reduction Provision see SI 00835.200.

J

Residents of Title XIX facilities – Also apply this State code to supplement Section 1619 cases.

Y

Optional Supplementation Waived – Use this code to indicate that a recipient is eligible for an optional supplement but has waived their right to receive such.

Z

No Supplement Cases – Eligible recipient who is a patient:

  1. In a medical facility where Title XIX pays more than 50 percent of the costs; or

  2. In a private medical facility not certified under Title XIX and not licensed by the State.

Include in this category those recipients who are residing throughout a month in a publicly operated emergency shelter.

2. Coding and monthly payment levels

The following charts display the coding and monthly payment levels for California effective 01/01/2012.

a. Individual

Federal Code

State OS Code

Category

FBR

State Supplement Level

Total Payment Levels

A

A

Aged

698.00

156.40

854.40

 

 

Blind

698.00

211.40

909.40

 

 

Disabled

698.00

156.40

854.40

 

B

All

698.00

412.00

1110.00

 

C

Aged

698.00

240.40

938.40

 

 

Blind

698.00

0.00

698.00

 

 

Disabled

698.00

240.40

938.40

 

E

Disabled

698.00

63.40

761.40

 

Z

All

698.00

0.00

698.00

B

D

Aged

465.341

159.83

625.17

 

 

Blind

465.341

214.83

680.17

 

 

Disabled

465.341

159.83

625.17

 

F

All

465.341

407.00

872.34

 

G

Disabled

465.341

66.83

532.17

C

A

Blind

698.00

211.40

909.40

 

E

Disabled

698.00

63.40

761.40

 

Z

All

698.00

0.

698.00

D

J

All

30.002

20.00

50.00

1Not a Federal benefit rate (FBR); the amount represents the FBR less VTR.

2Not the FBR; the amount represents a payment cap to recipients in a Title XIX institution.

NOTE: California is a concurrent category State and permits SSI recipients to receive the highest categorical supplement for which they can qualify. For more information on multicategory eligibility, see SI 00501.300B.3.

b. Couple

Federal Code

State OS Code

Category

FBR

State Supplement Level

Total Payment Levels

A

A

Aged/Aged

1048.00

396.20

1444.20

 

 

Blind/Blind

1048.00

543.20

1591.20

 

 

Disabled/Disabled

1048.00

396.20

1444.20

 

 

Aged/Blind

1048.00

487.20

1535.20

 

 

Aged/Disabled

1048.00

396.20

1444.20

 

 

Blind/Disabled

1048.00

487.20

1535.20

 

B

All

1048.00

1172.00

2220.00

 

C

Aged/Aged

1048.00

564.20

1612.20

 

 

Disabled/Disabled

1048.00

564.20

1612.20

 

 

Aged/Disabled

1048.00

564.20

1612.20

 

Z

All

1048.00

0.00

1048.00

B

D

Aged/Aged

698.671

401.33

1100.00

 

 

Blind/Blind

698.671

548.33

1247.00

 

 

Disabled/Disabled

698.671

401.33

1100.00

 

 

Aged/Blind

698.671

492.33

1191.00

 

 

Aged/Disabled

698.671

401.33

1100.00

 

 

Blind/Disabled

698.671

492.33

1191.00

 

F

All

698.671

1045.66

1744.33

D

J

All

60.002

40.00

100.00

1Not the FBR; the amount represents the FBR less VTR.

2Not the FBR; the amount represents a payment cap to recipients in a Title XIX institution.

C. Description of supplements for Delaware

1. Definitions of State living arrangement variations for Delaware

Code

Definition

A

Adult Residential Care Facility, Assisted Living Facility, or Adult Foster Care Home – To be eligible for this category the State must provide documentation that a recipient is a resident of a certified Adult Residential Care Facility, Assisted Living Facility, or Adult Foster Care Home.

Y

Optional Supplementation Waived – Use this code to indicate that a recipient is eligible for an optional supplement, but has waived their right to receive such.

Z

No Supplement Cases – Use this code for any recipient who is not included in OS categories A or Y.

Alternately, use OS code “Z” when the recipient is an “intervening” Federal code A.

For more information on Optional State Supplement codes see SM 01301.535

2. Coding and monthly payment levels

The following charts display the coding and monthly payments levels for Delaware effective 01/01/12.

a. Individual

Federal Code

State OS Code

Category

FBR

State Supplement Level

Total Payment Levels

A

A

All

698.00

140.00

838.00

 

Z

All

698.00

0.

698.00

B

Z

All

465.34

0.

465.34

C

Z

All

698.00

0.

698.00

D

Z

All

30.001

0.00

30.00

1Not the FBR; the amount represents a payment cap to recipients in a Title XIX institution.

b. Couple

Federal Code

State OS Code

Category

FBR

State Supplement Level

Total Payment Levels

A

A

All

1048.00

448.00

1496.00

 

Z

All

1048.00

0.

1048.00

B

Z

All

698.67

0.

698.67

D

Z

All

60.001

0.00

60.00

1Not the FBR; the amount represents a payment cap to recipients in a Title XIX institution.

D. Description of supplements for District of Columbia

1. Definitions of State living arrangement variations for the District of Columbia

Code

Definition

A

Adult Foster Care Home with 50 or Fewer Residents – Use OS code “A” to indicate that you received certification from the District of Columbia, Department of Health that the recipient is a resident of an adult foster care home with 50 or fewer residents

B

Adult Foster Care Home with More than 50 Residents – Use OS code “B” to indicate that you received certification from the District of Columbia, Department of Health that the recipient is a resident of an adult foster care home with more than 50 residents.

G

Apply this OS code to residents of Title XIX facilities.

Y

Optional Supplementation Waived – Use this code to indicate that a recipient is eligible for an optional supplement, but has waived their right to receive such.

Z

No Supplement Cases – All recipients who are not included in OS codes A, B, G, or Y.

2. Coding and monthly payment levels

The following charts display the coding and monthly payment levels for the District of Columbia effective 01/01/12.

a. Individual

Federal Code

State OS Code

Category

FBR

State Supplement Level

Total Payment Levels

A

A

All

698.00

485.00

1183.00

 

B

All

698.00

595.00

1293.00

 

Z

All

698.00

0.

698.00

B

Z

All

465.341

0.

465.34

C

Z

All

698.00

0.

698.00

D

G

All

30.001

40.00

70.00

1Not the FBR; the amount represents a payment cap to recipients in a Title XIX institution.

b. Couple

Federal Code

State OS Code

Category

FBR

State Supplement Code

Total Payment Levels

A

A

All

1048.00

1318.00

2366.00

 

B

All

1048.00

1538.00

2586.00

 

Z

All

1048.00

0.

1048.00

B

Z

All

698.67

0.

698.67

D

G

All

60.001

80.00

140.00

1Not the FBR; the amount represents a payment cap to recipients in a Title XIX institution.

E. Description of supplements for Hawaii

1. Definitions of State living arrangement variations for Hawaii

Code

Definition

B

Living in a Community Care or Foster Care Home – Apply this OS code to recipients who are both over age 18 and live in a State approved Care or Foster Care Home.

D

Living in a Certified Medical Facility – Eligible individual living in a medical treatment facility where Title XIX pays a substantial part (more than 50 percent) of the cost of care.

H

Domiciliary Care I – (Maximum of five residents) – Eligible recipient (including a child) or couple living in a domiciliary care facility that provides varying levels of care and services. A domiciliary care facility is a private, non-medical facility established and maintained to provide personal care and services to aged, infirm, or handicapped persons. The State provides SSA with listings of these facilities.

I

Domiciliary Care II – Same as H except the facility provides care for six or more residents.

Y

Optional Supplementation Waived – Use this code to indicate that a recipient is eligible for an optional supplement, but has waived their right to receive such.

Z

Use OS code “Z” when recipient is not eligible to receive Hawaii state supplement because they are living in the following situations:

  • Recipient is living in the household of another;

  • Recipient is a patient in a private medical facility which is not certified under Title XIX; or

  • Recipient is residing throughout a month in a publicly operated emergency shelter.

2. Coding and monthly payment levels

The following charts display the coding and monthly payment levels for Hawaii effective 01/01/12.

a. Individual

Federal Code

State OS Code

Category

FBR

State Supplement Level

Total Payment Levels

B

All

698.00

651.90

1349.90

 

H

All

698.00

651.90

1349.90

 

I

All

698.00

759.90

1457.90

 

Z

All

698.00

0.

698.00

B

Z

All

465.34

0.

465.34

D

D

All

30.001

20.00

50.00

1Not the FBR; the amount represents a payment cap to recipients in a Title XIX institution.

b. Couple

Federal Code

State OS Code

Category

FBR

State Supplement Level

Total Payment Levels

 A

B

All

1048.00

1640.80

2688.80

 

H

All

1048.00

1640.80

2688.80

 

I

All

1048.00

1856.80

2904.80

 

Z

All

1048.00

0.

1048.00

B

Z

All

698.67

0.

698.67

D

D

All

60.001

40.00

100.00

1Not the FBR; the amount represents a payment cap to recipients in a Title XIX institution.

F. Description of supplements for Iowa

1. Definitions of State living arrangement variations for Iowa

Code

Definition

A

Living in Own Household (Blind Only) – Apply code only to an eligible blind recipient and the blind member of a couple who:

  • Does not live in any other State living arrangement variation, does not have an essential person (EP) and is not otherwise excepted from supplementation; or

  • Is a blind recipient living in a Title XIX facility where Medicaid pays 50 percent or less of the cost of their care. Optional supplement code A is also compatible with Federal codes A and C.

Optional supplement code A is the proper code to use with an “intervening” Federal code A.

For State Supplement codes, see SM 01301.535.

B

Living in the Household of Another (Blind Only) – Only an eligible blind recipient and the blind member of a couple who does not live in any other State living arrangement variation, lives in the household of another for Federal purposes, does not have an EP, and is not otherwise excepted from supplementation.

C

Living with a Dependent Person – Eligible recipient or each member of an eligible couple in Federal living arrangement A or C who has an ineligible spouse, parent, child, or adult child living in the home with them, and who is financially dependent upon the eligible recipient as defined by the State Department of Human Services.

The payment level for this variation increases by $22 for each blind recipient or blind member of a couple to reflect the categorical blind supplement.

D

Living in a Family Life or Boarding Home – Eligible recipient or each member of an eligible couple in Federal living arrangement A who resides in a family life home or boarding home licensed by the State Department of Health or certified by the State Department of Human Services

H

Living with a Dependent Person – Eligible recipient or each member of an eligible couple in Federal living arrangement B who has an ineligible spouse, parent, child, or adult child living in the home with them, and who is financially dependent upon the eligible recipient as defined by the State Department of Human Services.

Increase the payment level for this variation by $22 for each blind recipient or blind member of a couple to reflect the categorical blind supplement.

G

Used to indicate that no supplement is payable to a recipient living in a Title XIX facility and Title XIX pays more than 50 percent of the cost of care; however, a Federal D living arrangement is not appropriate because the “throughout a month” requirement is not met at the time initial claims input is made.

Y

Optional Supplementation Waived – Use this code to indicate that a recipient is eligible for an optional supplement, but has waived their right to receive such.

Z

No Supplement Cases – Use this OS code to address:

  • SSI recipients residing throughout a month in publicly operated emergency shelters;

  • Aged or disabled recipients living in their own households or living in the households of others;

  • Recipients living in medical facilities not certified under Title XIX;

  • Recipients whose Federal payments are reduced to $30 or $60 due to living in a Title XIX facility;

  • Aged or disabled recipients whose Federal payments are not reduced but who live in a Title XIX facility where Medicaid pays 50 percent or less of the cost of care.

NOTE: The State Department of Human Services administers three optional supplementation programs:

  1. “In-Home Health Related Care”;

  2. “Residential Care”; and

  3. “Supplement for Medicare and Medicaid Eligible.”

NOTE: Iowa is a concurrent category State and permits SSI recipients to receive the highest categorical supplement for which they can qualify. For more information on multicategory eligibility, see SI 00501.300B.3.

Blind recipients (either individuals or member of a couple) whose records include an EP have a supplementary payment level that includes $22 for each individual in addition to the FBR and EP increment and must be force paid.

2. Coding and monthly payment levels

The following charts display the coding and monthly payment levels for Iowa effective 01/01/12.

a. Individual

Federal Code

State OS Code

Category

FBR

State Supplement Level

Total Payment Levels

A

A

Blind

698.00

22.00

720.00

 

C

Aged

698.00

357.00

1055.00

 

 

Blind

698.00

379.00

1077.00

 

 

Disabled

698.00

357.00

1055.00

 

D

Aged

698.00

142.00

840.00

 

 

Blind

698.00

164.00

862.00

 

 

Disabled

698.00

142.00

840.00

 

Z

All

698.00

0.00

698.00

B

B

Blind

465.341

22.00

487.34

 

H

Aged

465.341

357.00

822.34

 

 

Blind

465.341

379.00

844.34

 

 

Disabled

465.341

357.00

822.34

 

Z

All

465.341

0.00

465.34

C

A

Blind

698.00

22.00

720.00

 

C

Blind

698.00

379.00

1077.00

 

 

Disabled

698.00

357.00

1055.00

 

Z

Disabled

698.00

0.00

698.00

D

Z

All

30.002

0.00

30.00

1Not the FBR; the amount represents the FBR less VTR.

2Not the FBR; the amount represents a payment cap to recipients in a Title XIX institution.

NOTE: State-administered programs for calendar year 2012:

  • Individuals receiving “Residential Care” receive payment based on a per diem rate plus a monthly personal allowance.

  • Individuals receiving “In-Home Health Care” receive a payment based on actual cost of in-home health care plus basic Federal benefits.

  • Individuals receiving a supplement for Medicare and Medicaid Eligible receive a $1 monthly payment.

b. Couple

Federal Code

State OS Code

Category

FBR

State Supplement Level

Total Payment Levels

A

A

Blind/Blind

1048.00

44.00

1092.00

 

 

Blind/Aged

1048.00

22.00

1070.00

 

 

Blind/Disabled

1048.00

22.00

1070.00

 

C

Aged/Aged

1048.00

357.00

1405.00

 

 

Blind/Blind

1048.00

401.00

1449.00

 

 

Disabled/Disabled

1048.00

357.00

1405.00

 

 

Aged/Blind

1048.00

377.00

1425.00

 

 

Aged/Disabled

1048.00

357.00

1405.00

 

 

Blind/Disabled

1048.00

377.00

1425.00

 

D

Aged/Aged

1048.00

652.00

1700.00

 

 

Blind/Blind

1048.00

696.00

1744.00

 

 

Disabled/Disabled

1048.00

652.00

1700.00

 

 

Aged/Blind

1048.00

672.00

1720.00

 

 

Aged/Disabled

1048.00

652.00

1700.00

 

 

Blind/Disabled

1048.00

672.00

1720.00

 

Z

Aged/Aged

1048.00

0.00

1048.00

 

 

Disabled/Disabled

1048.00

0.00

1048.00

 

 

Aged/Disabled

1048.00

0.00

1048.00

B

B

Blind/Blind

698.671

44.00

742.67

 

 

Blind/Aged

698.671

22.00

720.67

 

 

Blind/Disabled

698.671

22.00

720.67

 

H

Aged/Aged

698.671

357.00

1055.67

 

 

Blind/Blind

698.671

401.00

1099.67

 

 

Disabled/Disabled

698.671

357.00

1055.67

 

 

Aged/Blind

698.671

377.00

1075.67

 

 

Aged/Disabled

698.671

357.00

1055.67

 

 

Blind/Disabled

698.671

377.00

1075.67

 

Z

Aged/Aged

698.671

0.00

698.67

 

 

Disabled/Disabled

698.671

0.00

698.67

 

 

Aged/Disabled

698.671

0.00

674.00

D

Z

All

60.002

0.00

60.00

1Not the FBR; the amount represents the FBR less VTR.

2Not the FBR; the amount represents a payment cap to recipients in a Title XIX institution.

NOTE: State-administered programs for calendar year 2012:

  • Recipients receiving “Residential Care” receive payment based on a per diem rate plus a monthly personal allowance.

  • Recipients receiving “In-Home Health Care” receive a payment based on actual cost of in-home health care plus basic Federal benefits. Treat members of a couple as individuals.

  • Recipients receiving a supplement for Medicare and Medicaid receive a $1 monthly payment.

G. Description of supplements for Massachusetts

1. Definitions of State living arrangement variations for Massachusetts

IMPORTANT: Effective April 1, 2012, Massachusetts began self-administering all categories. 

Code

Definition

A

Full Cost-of-Living:

A recipient who is in Federal living arrangement A is in State living arrangement A, if they are living in their own household1 and meet one of the following:

  1. Living alone – recipients who live alone, who rent rooms in commercial rooming houses which openly advertise to the public and which do not provide board, or who live in a hotel. Also, recipients who rent only rooms in private residences are considered living alone provided they do not use the residential kitchen facilities for preparing meals;

  2. Living only with their eligible spouse;

  3. Living with their eligible spouse and ineligible child or children 2 none of whom (children) receive public income maintenance payments;3 or

  4. Living only with their ineligible spouse or their ineligible child or children, none of whom (spouse and children) receive public income maintenance payments.

NOTE: For purposes of 1 through 4, do not consider foster children placed with anyone other than their parents to be living with the foster parent.

 

  • A recipient who is in Federal living arrangement C is in State living arrangement A if none of the other people with whom they are living receive public income maintenance payments.

  • A recipient who is in Federal living arrangement A or C and who does not meet the criteria contained in SI 01415.040G.1. (See Code A, 1 or 2 (in this chart)) is in State living arrangement A if they pay at least two-thirds of the household expenses. In making a determination whether the recipient pays two-thirds or more of the expenses, use the method defined in SI 00835.160. Use only the household expenses shown in that section. You may use an ineligible spouse's income (except any assistance based upon need) to determine if the eligible person is paying two-thirds of the household expenses.

  • A recipient living in a public congregate housing development is in OS category “A.” The State makes the determination that a public congregate housing development is eligible for listing. Optional supplement code A is the proper code to use with an “intervening” Federal code A. For Optional State Supplement codes, see SM 01301.535.

B

Shared Living Expenses – Consider a recipient who is in Federal living arrangement A or C but who does not meet the criteria listed for State living arrangement A, E or G to be in OS category “B.” Also include in this living arrangement category:

  • Transients/homeless;

  • Recipients residing in public emergency shelters for the homeless (PESH) throughout a month;

  • Residents of group-care facilities such as halfway houses;

  • Claimants residing in private medical facilities where Medicaid is paying 50 percent or less of the cost of care;

  • Foster homes;

  • Recipients living in commercial boarding homes;

  • Any recipient living in a facility which does not meet the criteria for living arrangement E or public congregate housing defined in SI 01415.040G.1., Code A.4. This includes children under the age of 18 who are in Federal living arrangement D because a private health insurance policy or a combination of Medicaid and a private health insurance policy pays or is expected to pay over 50 percent of the cost of care for that month. For determination of applicability of $30 payment limit, see second and third bullets in SI 00520.011C.1.b;

  • Recipients placed under the auspices of the State adult foster care program;

  • Recipients living in a household where all members receive public income maintenance payments unless they are paying at least two-thirds of the household expenses (A);

  • Recipients living in a mixed household – i.e., a household where one or more other members receive a public income maintenance payment – are also included unless the individual is paying at least two-thirds of the household expenses (A).

C

Living in the Household of Another – Apply this OS code to recipients who live in the household of another and receive support and maintenance from them (FLA- B).

E

Licensed Rest Home – Persons residing in a licensed rest home, all of which or the portion in which they live in is licensed by, and has a provider agreement with the State. This does not include residents of a Medicaid certified portion of a rest home.

F

Effective 07/01/87, the State elected Federal administration of this optional State supplementary payment to residents of Title XIX facilities where Medicaid pays more than 50 percent of the cost of care. This includes children under the age of 18 for whom Medicaid alone pays or is expected to pay over 50 percent of the cost of care for that month.

G

Assisted Living – Effective 07/01/94, the State elected Federal administration of this variation. Includes a recipient, certified by the State to be residing in an Assisted Living residence served by a certified Group Adult Foster Care provider, who does not receive assistance under any other Federal or State rental assistance program, and who pays a fixed, non-separable fee for rent and supportive services, other than medically necessary services reimbursed by Medicaid. The State certifies to SSA each recipient who is eligible for this optional supplement living arrangement. This living arrangement was discontinued effective 01/01/96; but restored retroactively to 01/01/97.

Y

Optional Supplementation Waived – Use this code to indicate that a recipient is eligible for an optional supplement, but has waived their right to receive such.

NOTE: Massachusetts is a concurrent category State and permits SSI recipients to receive the highest categorical supplement for which they can qualify. For more information on multicategory eligibility, see SI 00501.300B.3.

1For purposes of determining State living arrangements, do not consider a commercial boarding house, foster home, or halfway house to be an individual's household.

2Use the SSI definition of “child” found in SI 00501.010.

3A public income maintenance payment is a payment from any of the following programs:

  • Temporary Assistance for Needy Families (TANF);

  • Supplemental Security Income (SSI);

  • The Refugee Act of 1980;

  • The Disaster Relief Act of 1974:

  • General assistance programs of the Bureau of Indian Affairs;

  • State or local government income maintenance programs that are based on need; or

  • Department of Veterans Affairs benefits that are based on need.

2. Coding and monthly payments levels

The following charts display the coding and monthly payment levels for Massachusetts effective 01/01/12.

IMPORTANT: Effective 4/01/12, Massachusetts began self-administering all categories.

a. Individual

Federal Code

State OS Code

Category

FBR

State Supplement Level

Total Payment Levels

A

A

Aged

698.00

128.82

826.82

 

 

Blind

698.00

149.74

847.74

 

 

Disabled

698.00

114.39

812.39

 

B

Aged

698.00

39.26

737.26

 

 

Blind

698.00

149.74

847.74

 

 

Disabled

698.00

30.40

728.40

 

E

Aged

698.00

293.00

991.00

 

 

Blind

698.00

149.74

847.74

 

 

Disabled

698.00

293.00

991.00

 

G

Aged

698.00

454.00

1152.00

 

 

Blind

698.00

454.00

1152.00

  

Disabled

698.00

454.00

1152.00

B

C

Aged

465.341

104.36

569.70

 

 

Blind

465.341

382.40

847.74

 

 

Disabled

465.341

87.58

552.92

C

A

Blind

698.00

149.74

847.74

 

 

Disabled

698.00

114.39

812.39

 

B

Blind

698.00

149.74

847.74

 

 

Disabled

698.00

30.40

728.40

D

B2

Blind

30.003

149.74

179.74

 

 

Disabled

30.003

30.40

60.40

 

F

All

30.003

42.80

72.80

1Not the FBR; the amount represents the FBR less VTR.

2State OS Code B applies to children under the age of 18 who are in Federal living arrangement D because of private health insurance payments.

3Not the FBR; the amount represents a payment cap to recipients in a Title XIX institution.

b. Couple

Federal Code

State OS Code

Category

FBR

State Supplement Level

Total Payment Levels

A

A

Aged/Aged

1048.00

201.72

1249.72

 

 

Blind/Blind

1048.00

647.48

1695.48

 

 

Disabled/Disabled

1048.00

180.06

1228.06

 

 

Aged/Blind

1048.00

424.60

1472.60

 

 

Aged/Disabled

1048.00

190.89

1238.89

 

 

Blind/Disabled

1048.00

413.77

1461.77

 

B

Aged/Aged

1048.00

201.72

1249.72

 

 

Blind/Blind

1048.00

647.48

1695.48

 

 

Disabled/Disabled

1048.00

180.06

1228.06

 

 

Aged/Blind

1048.00

424.60

1472.60

 

 

Aged/Disabled

1048.00

190.89

1238.89

 

 

Blind/Disabled

1048.00

413.77

1461.77

 

E

Aged/Aged

1048.00

934.00

1982.00

 

 

Blind/Blind

1048.00

647.48

1695.48

 

 

Disabled/Disabled

1048.00

934.00

1982.00

 

 

Aged/Blind

1048.00

790.74

1838.74

 

 

Aged/Disabled

1048.00

934.00

1982.00

 

 

Blind/Disabled

1048.00

790.74

1838.74

 

G

All

1048.00

681.00

1729.00

B

C

Aged/Aged

698.671

215.80

914.47

 

 

Blind/Blind

698.671

996.80

1695.47

 

 

Disabled/Disabled

698.671

194.18

892.85

 

 

Aged/Blind

698.671

606.30

1304.97

 

 

Aged/Disabled

698.671

204.99

903.66

 

 

Blind/Disabled

698.671

595.49

1294.16

D

F

All

60.002

85.60

145.60

1Not the FBR; the amount represents the FBR less VTR.

2Not the FBR; the amount represents a payment cap to recipients in a Title XIX institution.

H. Description of supplements for Michigan

1. Definitions of State living arrangement variations for Michigan

Code

Definition

D

Domiciliary Care – Use this OS code for recipients residing in licensed non-medical facilities that provide room, board, and supervision. The State provides a list of these facilities and certifies which recipients are residents requiring this level of care.

E

Personal Care – Apply this OS code to recipients residing in licensed non-medical facilities that provide general supervision, physical care, and assistance to residents as they carry out the basic activities of daily living. The State provides a list of these facilities and certifies which recipients are residents requiring this level of care. Such care situations include, but are not limited to, licensed homes for the aged.

F

Home for the Aged – The State provides SSA with a list of these non-medical facilities for the aged and certifies which recipients are residents requiring this level of care.

G

Independent Living with an EP – This category applies to recipients with an essential person who are not living in the household of another. Exclude children under age 18 from this category.

H

Living in the Household of Another with an EP – This category applies to recipients with an EP who are living in the household of another for Federal purposes. Exclude children under age 18 from this category.

I

Effective 01/01/88, the State elected Federal administration of an optional State supplementary payment to residents of Title XIX facilities.

Y

Optional Supplementation Waived – Use this code to indicate that a recipient is eligible for an optional supplement, but has waived their right to receive such.

Z

No Supplement Cases – Recipients in Title XIX facilities where Medicaid pays more than 50 percent of the cost of care and recipients in medical facilities not certified under Title XIX.

2. Coding and monthly payment levels

The following charts display the coding and monthly payment levels for Michigan effective 01/01/12.

a. Individual

Federal Code

State OS Code

Category

FBR

State Supplement Level

Total Payment Levels

A

D

All

698.00

87.00

785.00

 

E

All

698.00

157.50

855.50

 

F

All

698.00

179.30

877.30

 

G

All

1048.002

14.00

1062.00

B

H

All

698.671

9.33

708.00

D

I

All

  30.003

7.00

37.00

 

Z

All

30.00

0.

30.00

1Not the FBR; the amount represents the FBR plus EP increment less VTR.

2Not the FBR; the amount represents the FBR plus EP increment.

3Not the FBR; the amount represents a payment cap to recipients in a Title XIX institution.

b. Couple

Federal Code

State OS Code

Category

FBR

State Supplement Level

Total Payment Levels

A

D

All

1048.00

522.00

1570.00

 

E

All

1048.00

663.00

1711.00

 

F

All

1048.00

706.60

1754.60

 

G

All

1398.001

21.00

1419.00

B

H

All

932.00

14.00

946.00

D

I

All

60.002

14.00

74.00

1Not the FBR; the amount represents the FBR plus EP increment.

2Not the FBR; the amount represents a payment cap to recipients in a Title XIX institution.

I. Description of supplements for Montana

1. Definitions of State living arrangement variations

Code

Definition

G

State-Certified Personal Care

H

State-Certified Residence in Group Home for Mentally Disabled

I

State-Certified Residence in Group Home for Physically or Developmentally Disabled

J

State-Certified Residence for Child and Adult Foster Care

K

State-Certified Transitional Living for Developmentally Disabled

Y

Optional Supplementation Waived – Use this code to indicate that a recipient is eligible for an optional supplement, but has waived their right to receive such.

Z

No Supplement Cases – Includes all individuals and couples not certified in State codes G, H, I, J, or K.

2. Coding and monthly payment levels

The following charts display the coding and monthly payment levels for Montana effective 01/01/12.

a. Individual

Federal Code

State OS Code

Category

FBR

State Supplement Level

Total Payment Levels

A

G

All

698.00

94.00

792.00

 

H

All

698.00

94.00

792.00

 

I

All

698.00

94.00

792.00

 

J

All

698.00

52.75

750.75

 

K

All

698.00

26.00

724.00

 

Z

All

698.00

0.00

698.00

B

Z

All

465.341

0.00

465.34

C

Z

All

698.00

0.00

698.00

D

Z

All

30.002

0.00

30.00

1Not the FBR; the amount represents the FBR less VTR.

2Not the FBR; the amount represents a payment cap to recipients in a Title XIX institution.

b. Couple

Federal Code

State OS Code

Category

FBR

State Supplement Level

Total Payment Levels

A

G

All

1048.00

193.00

1241.00

 

H

All

1048.00

193.00

1241.00

 

I

All

1048.00

193.00

1241.00

 

J

All

1048.00

110.50

1158.50

 

K

All

1048.00

57.00

1105.00

 

Z

All

1048.00

0.00

1048.00

B

Z

All

698.671

0.00

698.67

D

Z

All

60.002

0.00

60.00

1Not the FBR; the amount represents the FBR less VTR.

2Not the FBR; the amount represents a payment cap to recipients in a Title XIX institution.

J. Description of supplements for Nevada

1. Definitions of State living arrangement variations

Code

Definition

A

Independent Living or Living in Parental Household – Aged or blind eligible recipient who meets one of the following situations:

  1. Lives in their own household as defined for Federal living arrangement A purposes;

  2. Is a patient in a certified private medical facility where Title XIX does not pay more than 50 percent of the cost of care; or

  3. Is a blind child under age 18 (age 21 for individuals who qualify as a “protected child”) living in a parent's household.

Used with an “intervening” Federal code A. For Optional State Supplement codes, see SM 01301.535.

B

Living in the Household of Another – Aged or blind recipient who is living in the household of another and receiving food and shelter from that person. Aged or blind recipients who are subject to a one-third reduction (VTR) of their Federal SSI payment are eligible for optional supplement B because the criteria for this supplement level are the same as for Federal code B.

C

Domiciliary Care – Apply this OS code to aged or blind recipients who the State has certified live in a private non-medical facility or, a residential facility serving 16 or fewer persons, which provides personal care and services to aged, infirm, or handicapped adult persons who are unrelated to the proprietor.

The State licenses these facilities for direct payment. The State provides SSA with listings of these facilities.

Y

Optional Supplementation Waived – Use this code to indicate that a recipient is eligible for an optional supplement, but has waived their right to receive such.

Z

Apply this “No Supplement” code to the following recipients:

  • Disabled eligible individual or disabled member of eligible couple;

  • Eligible individual or member of eligible couple in a medical facility where Title XIX pays more than 50 percent of the cost;

  • Eligible individual or member of eligible couple who is patient in a private medical facility which is not certified under Title XIX; or

  • Recipients who are residing throughout a month in publicly operated emergency shelters.

NOTE: Nevada is a concurrent category State and permits SSI recipients to receive the highest categorical supplement for which they can qualify. For more information on multicategory eligibility, see SI 00501.300B.3.

2. Coding and monthly payment levels

The following charts display the coding and monthly payment levels for Nevada effective 01/01/12.

a. Individual

Federal Code

State OS Code

Category

FBR

State Supplement Level

Total Payment Levels

A

A

Aged

698.00

36.40

734.40

 

 

Blind

698.00

109.30

807.30

 

C

Aged

698.00

391.00

1089.00

 

 

Blind

698.00

391.00

1089.00

 

Z

Disabled

698.00

0.00

698.00

B

B

Aged

465.341

24.27

489.61

 

 

Blind

465.34

213.96

679.30

 

Z

Disabled

465.34

0.00

465.34

C

A

Blind

698.00

109.30

807.30

 

Z

Disabled

698.00

0.00

698.00

D

Z

All

30.002

0.00

30.00

1Not the FBR; the amount represents the FBR less VTR.

2Not the FBR; the amount represents a payment cap to recipients in a Title XIX institution.

b. Couple

Federal Code

State OS Code

Category

FBR

State Supplement Level

Total Payment Levels

A

A

Aged/Aged

1048.00

74.46

1122.46

 

 

Blind/Blind

1048.00

374.60

1422.60

 

 

Aged/Blind

1048.00

224.53

1272.53

 

 

Aged/Disabled

1048.00

37.23

1085.23

 

 

Blind/Disabled

1048.00

187.30

1235.30

 

C

Aged/Aged

1048.00

881.00

1929.00

 

 

Blind/Blind

1048.00

881.00

1929.00

 

 

Aged/Blind

1048.00

881.00

1929.00

 

 

Aged/Disabled

1048.00

440.50

1488.50

 

 

Blind/Disabled

1048.00

440.50

1488.50

 

Z

Disabled

1048.00

0.00

1048.00

B

B

Aged/Aged

698.67

49.64

748.31

 

 

Blind/Blind

698.67

531.94

1230.61

 

 

Aged/Blind

698.67

290.79

989.46

 

 

Aged/Disabled

698.67

24.82

723.49

 

 

Blind/Disabled

698.67

265.97

964.64

 

Z

Disabled

698.67

0.00

698.67

D

Z

All

60.002

0.00

60.00

1Not the FBR; the amount represents the FBR less VTR.

2Not the FBR; the amount represents a payment cap to recipients in a Title XIX institution.

K. Description of supplements for New Jersey

1. Definitions of State living arrangement variations for NJ

Code

Definition

A

Congregate Care – Apply this OS code to recipients in Federal living arrangement A. The living arrangement includes the following:

  • Recipients in residential facilities who are under the supervision of the Department of Human Services:

  • Children and adults in residential facilities (both inside and outside of NJ) who are under the supervision of, or placed by the NJ Department of Human Services’ Division of Developmental Disabilities (DDD) or Division of Youth and Family Services (DYFS)); and

  • Recipients living in Assisted Living Residences or Comprehensive Personal Care Homes (CPCH) that are licensed by the Department of Health and Senior Services.

B

Living Alone or with Others – Recipients whose Federal living arrangements are A or C and do not meet the requirements defined in other supplementation categories.

You must consider any eligible recipient who meets the requirement for a Federal code A to be in optional supplement B unless they are residing in a residential health care facility or living alone with an ineligible spouse.

Likewise, any child meeting the criteria for a Federal code C is automatically entitled to optional supplement B.

This category includes, but is not limited to, those recipients who are in one of the following situations:

  1. Living physically alone;

  2. Living with others in a private dwelling, but meeting some criteria for Federal living arrangement A; or

  3. Recipients placed in a Transitional Residency Program by the Division of Mental Health and Hospitals, Department of Human Services.

Optional supplement code B is the proper code to be used with an “intervening” Federal code A. For State Supplement codes, see SM 01301.535.

Use this OS code to address Section 1619 cases.

C

Living Alone with an Ineligible Spouse – Use this OS code when a recipient lives with ONLY his or her ineligible spouse and NO other persons are part of the household. Use Federal criteria to determine an ineligible spouse for State supplementation purposes i.e., a spouse, either by marriage or holding out who is either not eligible for SSI or who chooses not to apply. If other persons, even minor children, are present in the household, you cannot apply this OS code.

However, it is possible that a claimant and the ineligible spouse live with others and allege that they are a separate “household” by virtue of the fact that they eat their meals out or have separate purchase and preparation of food. In this instance, you may consider an optional supplement C as long as no other person is considered part of the “household.” There is no couple counterpart in this category.

A transient recipient who co-exists only with an ineligible spouse also qualifies as OS “C.”

Always consider parent(s) with minor children to be in the same household and code the case OS “B.”

D

Living in the Household of Another – Apply this OS code to recipients who are “living in the household of another” for Federal purposes.

I

Licensed Residential Health Care Facilities (RHCF) – Apply this OS code to recipients living in the following:

  • Attached nursing homes;

  • Assisted Living Residence;

  • CPCH; or

  • “Free standing” licensed residential health care facilities. We paid residents of these facilities the OS “A” rate prior to 1/1/06.

We must base our authorization for this payment on the recipient's verified residence at a facility listed in the New Jersey Congregate Care Directory .

Only the RHCF section of a multipurpose facility is eligible for the OS “I” rate. Pay residents of the Assisted Living Resident (ALR, or CPCH section of a multipurpose facility at the OS “A” rate. Nursing home residents are in living arrangement (D/G) if Medicaid pays more than 50 percent of the cost of care.

G

Effective 09/01/88, the State elected Federal administration of an optional State supplementary payment to residents of Title XIX facilities.

Y

Optional Supplementation Waived – Use this code to indicate that a recipient is eligible for an optional supplement, but has waived their right to receive such.

Z

No Supplement Cases – Apply this OS code to:

  • Recipients in licensed medical facilities where Medicaid is paying less than 50 percent of the cost of care;

  • Recipients in publicly operated community residences having 16 or less residents; and

  • Recipients residing throughout a month in publicly operated emergency shelters.

You can also apply this OS code to cases that were FLA D prior to 01/1988 or to children residing in public or private facilities whose care was paid by private health insurance (effective 12/01/96). For determination of applicability of $30 payment limit, see SI 00520.011.

2. Coding and monthly payment levels

The following charts display the coding and monthly payments levels for New Jersey effective 01/01/12.

a. Individual

Federal Code

State OS Code

Category

FBR

State Supplement Level

Total Payment Levels

A

A

All

698.00

150.05

848.05

 

B

All

698.00

31.25

729.25

 

C

Individual

698.00

153.00

851.00

 

 

w/EP

1048.001

25.36

1073.36

 

I

All

698.00

210.05

908.05

 

Z

All

698.00

0.00

698.00

B

D

All

465.342

44.31

509.65

C

B

All

698.00

31.25

729.25

D

G

All

30.003

10.00

40.00

 

Z

All

30.00

0.

30.00

1Not the FBR; the amount represents the FBR plus EP increment.

2Not the FBR; the amount represents the FBR less VTR.

3Not the FBR; the amount represents a payment cap to recipients in a Title XIX institution.

b. Couple

Federal Code

State OS Code

Category

FBR

State Supplement Level

Total Payment Levels

A

A

All

1048.00

618.36

1666.36

 

B

All

1048.00

25.36

1073.36

 

I

All

1048.00

738.36

1786.36

 

Z

All

1048.00

  0.00

1048.00

B

D

All

698.671

93.09

791.76

D

G

All

60.002

20.00

80.00

1Not the FBR; the amount represents the FBR less VTR.

2Not the FBR; the amount represents a payment cap to recipients in a Title XIX institution.

L. Description of supplements for New York

1. Definitions of State living arrangement variations for New York

Code

Definition

A

Living Alone – Apply this OS code to recipients living in one of the following situations:

  1. Live physically alone;

  2. Pay a fixed, pre-established flat fee for both room and board in a commercial establishment;

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

  4. Live with others but separately prepares or has someone separately prepare their food. Occasional preparation of meals in common does not preclude a finding of separate preparation;

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

  6. Live 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 Mental Retardation and Developmentally Disabilities (OMRDD) or local DSS; or

  7. Have 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 – Apply this OS code to recipients living in one of the following situations:

1. Resides in a dwelling with others and prepares food in common with at least one other person in the dwelling.

NOTE: Consider a recipient living with an ineligible spouse to be living with others despite any separate preparation. The same is true if a recipient lives with a child for whom they have primary responsibility (except if the child is a foster child)

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

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

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.

C

Congregate Care Level I – Apply this OS code to recipients in the following situations:

  • Recipient placed in a family type home certified by New York State (NYS) Office of Children and Family Services and supervised by a local DSS.

  • Recipient placed in a family care home certified by OMH or OMRDD.

D

Congregate Care Level II – Apply this OS code to a recipient who is a resident of a licensed Level II care facility.

These supportive living facilities include:

  • Residences for Adults certified by the NYS Department of Health;

  • Privately operated facilities certified by the NYS OMH;

  • Privately operated facilities certified by NYS OMH and OMRDD; and

  • Privately operated facilities certified by OASAS.

E

Congregate Care Level III – Enhanced Residential Care – Apply this OS code to recipients residing in a licensed level III care facility (including a recipient over age 18 who still meets the definition of a child per SI 00501.010).

Level III care facilities include:

  • Adult homes and enriched housing programs certified by the NYS Department of Health; or

  • Schools for the Mentally Retarded – The NYS Office of Mental Retardation and Developmental Disabilities must certify that these residential facilities provide academic, vocational, recreational, and social skills programs. Although sometimes called schools, they often do not meet the Federal definition of schools.

NOTE: Do not apply OS E to a situation in which a child, who is receiving SSI, resides in a Level III facility. Apply OS Code B for those recipients.

F

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

G

Effective 01/01/88, the State elected Federal administration of an optional State supplementary payment to residents of Title XIX facilities. SSA and the state agreed to terminate Federal administration effective 09/30/03 and the State began administering this payment 10/01/03.

Y

Optional Supplementation Waived – Use this code to indicate that a recipient is eligible for an optional supplement, but has waived their right to receive such.

Z

No Supplement Cases – Apply OS Z to recipients in FLA A or D who meet one of the following:

  1. Recipient is in a licensed medical facility where Medicaid is paying less than 50 percent of the cost of care;

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

  3. Recipient is in a publicly operated emergency shelter (PESH) throughout a month;

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

  5. Effective 10/01/03, recipient is FLA-D ; or

  6. Recipient is a child, under age 18; whose stay in a public or private facility was paid by private health insurance (applies prior to 12/1/96). For determination of applicability of $30 payment limit see SI 00520.011).

2. Coding and monthly payment levels

The following charts display the coding and monthly payment levels for New York effective 01/01/12.

a. Individual

Federal Code

State OS Code

Category

FBR

State Supplement Level

Total Payment Levels

A,C

A

All

698.00

87.00

785.00

 

B

All

698.00

23.00

721.00

 

C

NY City and selected counties1

698.00

266.48

964.48

 

 

All other counties

698.00

228.48

926.48

 

D

NY City and selected counties1

698.00

435.00

1133.00

 

 

All other counties

698.00

405.00

1103.00

 

E

NY City and selected counties1

698.00

694.00

1392.00

 

 

All other counties

698.00

694.00

1392.00

 

Z

All

698.00

  0.00

698.00

B

F

All

465.342

23.00

488.34

D

Z

All

30.003

0.004

30.00

1Includes and applies to: Bronx, Kings, Manhattan, Nassau, Queens, Richmond, Rockland, Suffolk, and Westchester counties effective 01/01/07.

2Not the FBR; the amount represents the FBR less VTR.

3Not the FBR; the amount represents a payment cap to recipients in a Title XIX institution.

4New York administers a supplement of $25 to some recipients in a Title XIX institution.

b. Couple

Federal Code

State OS Code

Category

FBR

State Supplement Level

Total Payment Levels

A,C

A

All

1048.00

104.00

1152.00

 

B

All

1048.00

46.00

1094.00

 

C

NY City and selected counties1

1048.00

880.96

1928.96

 

 

All other counties

1048.00

804.96

1852.96

 

D

NY City and selected counties1

1048.00

1218.00

2266.00

 

 

All other counties

1048.00

1158.00

2206.00

 

E

NY City and selected counties1

1048.00

1736.00

2784.00

 

 

All other counties

1048.00

1736.00

2784.00

 

Z

All

1048.00

0.00

1048.00

B

F

All

698.672

46.00

744.67

D

Z

All

60.003

0.004

60.00

1Includes and applies to: Bronx, Kings, Manhattan, Nassau, Queens, Richmond, Rockland, Suffolk, and Westchester counties effective 01/01/07.

2Not the FBR; the amount represents the FBR less VTR.

3Not the FBR; the amount represents a payment cap to recipients in a Title XIX institution.

4New York administers a supplement of $25 to some recipients in a Title XIX institution.

M. Description of supplements for Pennsylvania

1. Definitions of State living arrangement variations for Pennsylvania

Code

Definition

C

Living with an Essential Person (EP) – Apply this OS code to recipients who are not living in the household of another or in a foster care home for adults and who have one or more EP’s as defined under the Federal rules.

D

Living in the Household of Another with an EP – Recipients who live in the household of another and have one or more EP’s as defined under the Federal rules.

G

Living in a Domiciliary Care Facility – Adult persons (age 18 and over) certified by the State to be residing in non-medical residential care facilities.

H

Living in a Personal Care Boarding Home (PCBH) – Adult Persons (age 18 and over) certified by the State to be residing in non-medical residential care facilities.

Y

Optional Supplementation Waived – Use this code to indicate that a recipient is eligible for an optional supplement, but has waived their right to receive such.

Z

No Supplement Cases – Includes all recipients who are residing in a medical facility in which Title XIX is paying more than 50 percent of the cost of care and recipients in FLA-A or FLA-B who receive a State-administered supplement.

2. Coding and monthly payment levels

The following charts display the coding and monthly payment levels for Pennsylvania effective 01/01/12.

a. Individual

Federal Code

State OS Code

Category

FBR

State Supplement Level

Total Payment Levels

A

C

All

1048.001

43.70

1091.70

 

G

All

698.00

434.30

1132.30

 

H

All

698.00

439.30

1137.30

 

Z

All

698.00

0.

698.00

B

Z

All

465.342

0.00

465.34

 

D

All

698.673

43.70

742.37

C

Z

All

698.00

0.00

698.00

D

Z

All

30.004

0.00

30.00

1Not the FBR; the amount represents the FBR plus EP increment.

2Not the FBR; the amount represents the FBR less VTR.

3Not the FBR; the amount represents the FBR plus EP increment less VTR.

4Not the FBR; the amount represents a payment cap to recipients in a Title XIX institution.

b. Couple

Federal Code

State OS Code

Category

FBR

State Supplement Level

Total Payment Levels

 A

C

All

1398.001

68.05

1466.05

 

G

All

1048.00

947.40

1995.40

 

H

All

1048.00

957.40

2005.405

 

Z

All

1048.00

0.

1048.00

D

All

932.00

68.05

1000.05

D

Z

All

60.004

0.00

60.00

1Not the FBR; the amount represents the FBR plus EP increment.

2Not the FBR; the amount represents the FBR less VTR.

3Not the FBR; the amount represents the FBR plus EP increment less VTR.

4Not the FBR; the amount represents a payment cap to recipients

NOTE: Apply the payment level for couples in Pennsylvania’s PCBHs only in the month they move into the PCBH. You must regard them as individuals in the month following the month of move. For more information on this topic, see SI PHI01415.010 BASIC 10/2009.

N. Description of supplements for Rhode Island

1. Definitions of State living arrangement variations for Rhode Island

Definitions of State Living Arrangement Variations are as follows:

Code

Definition

D

Residential Care or Assisted Living – Apply this OS code to recipients only.

Y

Optional Supplementation Waived – Use this code to indicate that a recipient is eligible for an optional supplement, but has waived their right to receive such.

Z

No State Supplement payable – The State of Rhode Island does not pay a supplement unless recipient resides in a Licensed Adult Care Facility (“Residential Care or Assisted Living”) as described in category “D”.

2. Coding and monthly payment levels

The following charts display the coding and monthly payment levels for Rhode Island effective 01/01/12.

a. Individual

Federal Code

State OS Code

Category

FBR

State Supplement Level

Total Payment Levels

A

D

All

698.00

332.00

1030.00

 

Z

All

698.00

0.

698.00

O. Description of supplements for Utah

1. Definitions of State living arrangement variations for Utah

Code

Definition

A

Living Alone or With Others – Apply this OS code to recipients who are in Federal codes A and C.

B

Living in the Household of Another – Apply this OS code to recipients who are “living in the household of another” for Federal purposes. Children under age 18 are included in this living arrangement variation.

Z

No Supplement Cases – Apply this OS code to all recipients who are not included in OS codes A or B.

2. Coding and monthly payment levels

The following charts display the coding and monthly payment levels for Utah effective 01/01/12.

a. Individual

Federal Code

State OS Code

Category

FBR

State Supplement Level

Total Payment Level

A,C

Z

All

698.00

0.00

698.00

B

B

All

465.342

3.13

468.47

D

Z

All

30.001

0.00

30.00

1Not the FBR; the amount represents a payment cap to recipients in a Title XIX institution.

2Not the FBR, the amount represents the FBR less VTR.

b. Couple

Federal Code

State OS Code

Category

FBR

State Supplement Level

Total Payment Levels

A,C

A

All

1048.00

4.60

1052.60

B

B

All

698.672

9.73

708.40

D

Z

All

60.001

0.00

60.00

1Not the FBR; the amount represents a payment cap to recipients in a Title XIX institution.

2Not the FBR, the amount represents the FBR less VTR.

P. Description of supplements for Vermont

1. Definitions of State living arrangement variations for Vermont

Use this table to view the code and definitions of State Living Arrangement Variations.

Code

Definition

A

Independent Living (except Chittenden County) – This OS code applies to several situations including:

  • Recipients who are not living in the household of another;

  • Recipients who are not in a residential or custodial care situation;

  • Recipients who are under age 18 and live with a parent;

  • Recipients who reside in a private Title XIX facility where Medicaid is not paying more than 50 percent of the cost of care;

  • Recipients who are under age 18 in a private medical facility where private health insurance is paying more than 50% of their care;

  • Recipients who are under age 18 in a private medical facility where a combination of Medicaid and a private health insurance policy pays or is expected to pay over 50 percent of the cost of their care. For information regarding the $30 payment limit see second and third bullets in SI 00520.011C.1.b.; and

  • Recipients who reside throughout a month in a publicly operated emergency shelter.

B

Independent Living in Chittenden County – Apply this code to all recipients living in situations described in “A” above except restricted to residents of Chittenden County.

C

Licensed Residential Care Home or Assisted Living Residence with Assistive Community Care Services (Level III) – Recipients residing in Level III facilities identified by the State. To determine if the facility meets the requirements for OS code C, refer to the Vermont Community Care Facilities (OS C and G) list on BOSNET http://sharepoint.ba.ssa.gov/dco/bo/default.aspx .

E

Living in the Household of Another – Apply this OS code to recipients who live in the household of another and receive support and maintenance from them (subject to the Federal one-third reduction provisions).

G

Licensed Residential Care Home or Therapeutic Community Residence (Level IV) – Apply this OS code to recipients residing in Level IV facilities identified by the State. To determine if a facility meets the requirements for OS code G, refer to the Vermont Community Care Facilities (OS C and G) list on BOSNET http://sharepoint.ba.ssa.gov/dco/bo/default.aspx .

H

Custodial Care: Family Home – Apply this OS code to recipients who:

  • Live in another's home,

  • Pay room and board to that home owner, and

  • Receive one or more of the services outlined under the custodial care definition (below).

In order to qualify as a home under this arrangement, these services must be provided to two persons or less by a resident of the home.

In some cases, the Vermont Department of Disabilities, Aging, and Independent Living (DAIL) has established outplacement programs meeting the definition of living arrangement (L/A) H. To qualify these programs must meet the requirements stated above.

Custodial care means providing basic room and board, plus personal services such as:

  • Help with feeding,

  • Dressing,

  • Bathing,

  • Moving about under normal circumstances,

  • Occasional tray service (tray service two-three times a week), which may include supervision for the recipient's protection. Supervision for the recipient's protection deals primarily with protection services for retarded and emotionally disturbed recipients.

A person who receives one or more of these personal services is receiving custodial care.

I

Effective 07/01/87, the State elected Federal administration of an optional State supplementary payment to residents in Title XIX facilities. This includes children under the age of 18 for whom Medicaid alone pays or is expected to pay over 50 percent of the cost of care for that month.

Y

Optional Supplementation Waived – Use this code to indicate that a recipient is eligible for an optional supplement, but has waived their right to receive such.

2. Coding and monthly payment levels

The following charts display the coding and monthly payment levels for Vermont effective 01/01/12.

a. Individual

Federal Code

State OS Code

Category

FBR

State Supplement Level

Total Payment Levels

A

A

All (Except Chittenden County)

698.00

52.04

750.04

 

B

All (Restricted to Chittenden County)

698.00

52.04

750.04

 

C

All

698.00

48.38

746.38

 

G

All

698.00

223.94

921.94

 

H

All

698.00

98.69

796.69

B

E

All

465.34

39.30

504.64

C

A

All (Except Chittenden County)

698.00

52.04

750.04

 

B

All (Restricted to Chittenden County)

698.00

52.04

750.04

D

A or B2

Children Private Insurance

30.001

52.04

82.04

 

I

All

30.002

17.66

47.66

1State OS code A or B applies to children under the age of 18 who are in Federal living arrangement D because of private health insurance payments.

2Not the FBR; the amount represents a payment cap to recipients in a Title XIX institution.

b. Couple

Federal Code

State OS Code

Category

FBR

State Supplement Level

Total Payment Levels

A

A

All(Except Chittenden County)

1048.00

98.88

1146.88

 

B

All (Restricted to Chittenden County)

1048.00

98.88

1146.88

 

C

All

1048.00

96.77

1144.77

 

G

All

1048.00

562.06

1610.06

 

H

All

1048.00

332.82

1380.82

B

E

All

698.671

48.31

746.98

D

I

All

60.002

35.33

95.33

1Not the FBR; the amount represents the FBR less VTR.

2Not the FBR; the amount represents a payment cap to recipients in a Title XIX institution.

Q. Procedure for documenting optional state category determination

1. General documentation requirements for initial claims, pre-effectuation reviews, and redeterminations

No additional documentation is required unless you have reason to question the situation.

2. General documentation requirements for all other claims events

Unless you have reason to question the situation, document the individual's statement that supports the optional state category determination on an SSA-795 (Statement of Claimant or Other Person), or on an SSA-5002 (Report of Contact).

3. Questionable situations

In questionable situations, review any available evidence that supports the individual’s allegation of his or her optional state supplement category. Contact other persons with knowledge of the individual’s living situation, if necessary (e.g. landlord, homeowner, facility manager). Document the file per GN 00301.285 through GN 00301.289.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0501415044
SI 01415.044 - Federally Administered Optional Supplementary Payment Programs for 01/12 Payment Levels - 08/06/2012
Batch run: 08/06/2012
Rev:08/06/2012