SI SF01415.170 California Optional State Supplement (OSS) J – Resident of a Public or Private Institution with Title XIX (Medicaid/Medi-Cal) paying more than 50% of the cost of care (RTN 01, 05/2015)

A. General

California pays OSS J to:

  • effective July 1, 1987, a resident of a public or private institution where Title XIX is paying more than 50% of the cost of care

    NOTE: From February 1986 - June 1987, the California Department of Health Care Services administered a $10.00 state supplement for recipients in a D/Z living arrangement because the then current federal legislation prevented SSA from administering a state supplement for recipients in Federal Living Arrangement (FLA) D. With the change in that legislation, SSA began administering that supplement effective July 1, 1987.

  • a resident of a public or private institution where Medicare Part A pays or is expected to pay over 50% of the cost of care for that month and the Part A coverage was purchased for the recipient under a State plan approved under Title XIX of the Social Security Act (i.e., “State buy-in”)

  • an individual eligible for special benefits for institutionalized 1619 eligible individuals (see SI 00520.130 and SI 00520.131 for policy and procedures)

B. Development and Documentation

See SI 00520.011 for development of confinement in a medical treatment facility. Follow SI SF01415.110B. for development and documentation requirements on determining a facility's State licensure status. Use the Seattle SSA-8045 Facility Determination site to create and store a SSA-8045 (See SI 00520.800 Facility Determinations).

Per the Medi-Cal Provider Manual, Part 2 Admissions and Discharges, the State requires Long Term Care (LTC) facilities to complete a Medi-Cal Long Term Care Facility Admission and Discharge Notification (MC 171) form for individuals upon admission to the facility. When an SSI recipient enters a Nursing Facility, providers must notify a Social Security Administration field office of the name, SSN, and date of entry to the facility via a MC171. Field offices should consider this a first party report of change and must take prompt action upon receipt.

NOTE: Medicaid payments made under a Home or Community Based Services (HCBS) Medicaid waiver (as defined by title XIX of the Social Security Act) usually do not result in imposing the $30 payment limit, even if the Medicaid payment is over 50% of the cost of care.

The residents of a facility whose care is paid for under an HCBS waiver are FLA A regardless of the percentage of their care being paid by Medicaid funds; OSS A applies. The payments made by the state are not counted as ISM. For more information on waivers in these situations, see SI 00520.510D. For information about an exception to this policy, see the second bullet of SI 00520.011C.4.

NOTE: Do not assume that an individual residing in a facility categorized as an Institution for Mental Disease (IMD) is automatically eligible for FLA A and OSS A. Completion of a SSA-8045 and contact with the facility to verify whether Medicaid is or is not paying over 50% of the cost of care is always required. See SI 00520.011 for development of confinement in a medical treatment facility and SI SF01415.110 for state supplementation of FLA A.

C. Examples

  1. Sofia Maynard resides in the Comfy Living Nursing Home. Medi-Cal (California’s Medicaid program) pays for 75% of her cost of care. The remaining 25% is paid for by a long-term care insurance policy. Because Medi-Cal pays over 50% of the cost, her living arrangement is FLA D/OSS J.

  2. Xenophile Arsenault is in a private rehabilitation facility paid for by Medicare Part A. His Medicare Part A coverage was purchased by Medi-Cal through state buy-in. Therefore, his living arrangement is FLA D/OSS J. Had Mr. A