The SSI recipient’s admittance must be to:

• •

  a public institution, the primary purpose of which is the provision of medical or psychiatric care, or

• •

  a public or private Medicaid-certified medical treatment facility.

The recipient must continuously reside throughout the affected month in one or more of the facilities described in SI 00520.140B.1. (in this section).

The recipient must be eligible for an SSI payment (or a federally administered State supplement) in the month prior to the first month the $30 payment limit or ineligibility (payment status N02) would have applied (absent payment of TI benefits or the special benefits for institutionalized 1619 eligibles as described in SI 00520.130B.2.).

• •

  The physician must certify in writing they expect the recipient’s medical confinement to last no longer than 90 full consecutive days.

  Note: 

  The day of admission is not a full day of confinement and does not count toward the 90 days. The physician can submit the form SSA-186, Temporary Institutionalization Statement to Maintain Household and Physician Certification or a written statement, see SI 00520.140C in this section.

• •

  The physician (or other appropriate source, see SI 00520.140I.2. in this section) must submit the certification to the Social Security Administration (SSA) or postmarked no later than the 90th day of medical confinement, or by the day of release, whichever is earlier. For this purpose, “submitted” means received by the SSA or postmarked.

To be eligible for TI benefits, the recipient must demonstrate a need to pay some or all of the expenses of maintaining the home or living arrangement they may return to. The living arrangement may or may not be the last permanent living arrangement.

• •

  The recipient (or if the recipient is incapacitated and has no representative payee, a knowledgeable source acting on behalf of the recipient) must submit evidence of this need no later than the 90th day of medical confinement, or the day of release, whichever is earlier to SSA. For this purpose, “submitted” means received by SSA or postmarked. This can be completed by submitting the SSA-186, Temporary Institutionalization Statement to Maintain Household and Physician Certification or a written statement, see SI 00520.140C in this section.

• •

  The institution cannot require the recipient or the recipient's representative payee to pay the institution any portion of the TI benefits, except nominal sums for the recipient's personal needs (e.g., personal hygiene items, snacks, candy).

The form has two parts:

1. a. 

   The first part documents the statement of need allegation that the recipient needs to maintain their home or living arrangement. The first part must be completed by the recipient or representative payee. If the recipient is incapacitated and does not have a representative payee, a knowledgeable source acting on behalf of the recipient (e.g., family member, friend, or hospital staff) may sign the first part and submit the form on the recipient’s behalf to SSA.

2. b. 

   The second part must be completed by the physician. This is where the physician states and certifies the recipient’s length of stay within the medical institution is expected to be 90 days or less.

When a recipient reports a temporary admission to a medical facility, the claims specialist (CS) can use the SSA-186 to establish that there is a need for the recipient to maintain their home and to obtain the physician’s certification stating that the stay is expected to be no more than 90 days.

• •

  The CS will immediately review the SSA-186 to ensure that all questions are completed and the appropriate signatures are present.

• •

  Absent evidence to the contrary or other issues that require development, the CS will accept the information provided and use the SSA-186 form to document eligibility for TI benefits. For additional details about contrary evidence, see SI 00520.140I.3.b. through SI 0520.140.I.3.d (in this section).

• •

  The CS will document on a Report of Contact page the recipient’s allegation and the physician’s expectation that the recipient will be institutionalized for no more than 90 days (see SI 00520.140B.4. in this section).

• •

  Fax the SSA-186 into the appropriate electronic folder. Do not retain the paper form after the issue has been documented electronically.

TI benefits are payable for any of the first three full months of medical confinement where the recipient would be ineligible for SSI due to confinement in a public institution or subject to the $30 payment limit (absent payments under this provision or the special benefits provision for institutionalized 1619 eligibles as described in SI 00520.130).

• •

  Example 1: TI benefits apply for 3 full months

  Larry, an aged SSI recipient, went into the hospital on July 18. Medicare covered Larry's hospitalization. Larry completed the first section of the SSA-186, statement of need. Larry's doctor completed the second section and faxed it to Larry's local FO on July 19. Larry's doctor indicated an expectation of discharge on or by October 16. The CS documented the file with a copy of the SSA-186.

  On July 29, Larry moved to a nursing home, Medicaid began paying for Larry's care, which lasted until November 2. The TI benefits provision applies for August, September, and October, the three full months in which Larry was institutionalized as defined in SI 00520.140B.3. (in this section). The fact that Larry was not released by October 16 does not affect TI eligibility that was previously established.

• •

  Example 2: TI benefits apply for less than three months

  Anthony, an aged SSI recipient, broke their hip and went into the hospital on July 15. On the day of Anthony's admission, the hospital sent the FO a statement from Anthony's doctor. The doctor expected Anthony to transfer from the hospital to a nursing home with a final discharge to Anthony's home by October 13. On July 20, Anthony submitted a written statement of need.

  Medicare paid for Anthony's care in the hospital and the first three days of nursing home care, through September 29. On September 30, Medicaid began paying the cost of Anthony's care. Anthony continued to live in the nursing home through the months of October and November.

  TI benefits apply for the month of October only since it is within the first three full months of medical confinement, and it is the only one of those months for which the $30 payment limit federal living arrangement (FLA) D or ineligibility due to residence in a public medical institution (N02) would otherwise apply.

• •

  Example 3: TI benefits do not apply

  Ann, a disabled SSI recipient, suffered a stroke and entered a hospital on July 15. Ann does not have a representative payee and was incapacitated. Therefore, Ann's sibling (a knowledgeable source) submitted an SSA-186, per SI 00520.140C.1 (in this section), to the local FO on July 19 to report Ann's medical confinement and request TI benefits. The SSA-186 also provided the physician's certification that Ann expected to be discharged by October 13. Ann's private insurance paid for the hospitalization until January 10, when Ann returned home.

  Ann is ineligible for TI benefits since Ann's SSI benefits are not subject to the $30 payment limit or ineligible for SSI due to residence in a public institution. Ann may be eligible for regular SSI benefits based on being in a private institution. Since there is no TI and no temporary absence, as of August Ann's permanent residence is the medical facility, so there is no ISM, and the monthly payment amount is based on the full FBR minus any other income Ann may have.

• •

  Example 4: TI benefits do not apply — $30 payment began after the third full month of medical confinement

  The same facts as in the preceding example apply except that Ann did not leave the hospital. Medicaid began paying the cost of Ann's care for February, which is the first month the $30 payment limit applied. Since February is Ann's seventh full consecutive month of medical confinement, the TI benefits provision does not apply.

A recipient, including a member of a couple, is temporarily absent from the last permanent living arrangement for any months the recipient is receiving TI benefits. Therefore, a couple continues to be a couple during periods of eligibility for TI payment. The “last permanent living arrangement” refers to the living arrangement used to determine benefits for the month before the month for which the $30 payment limit or payment status N02 would otherwise apply.

For purposes of determining the living arrangement from which the recipient is temporarily absent, use the permanent living arrangement as of the first moment of the month before the month in which institutionalization began (as defined in SI 00520.140B.3. in this section).

The circumstances that exist in that permanent living arrangement prior to the first full month of institutionalization are the circumstances to use in determining:

• •

  the federal living arrangement (FLA),

• •

  in-kind support and maintenance (ISM),

• •

  deeming, and

• •

  federally administered State supplementary payments for that same month.

All FLA, ISM, deeming, and federally administered State supplementation provisions continue to apply as if the recipient were physically residing in the last permanent living arrangement.

The temporary absence continues through the last month TI benefits are paid, unless the recipient is discharged in the month following the last month TI benefits are paid. In that case, temporary absence continues through the date of discharge.

• •

  Example 1: TI benefits and deeming

  Lucy, an adult SSI recipient, lives with an ineligible spouse in their family member's home. On August 15, Lucy went to visit a sibling. On August 29, Lucy went into a Medicaid institution and was determined to be eligible for TI benefits for the months of September, October, and November. The family member's home was Lucy's permanent living arrangement as of August 1. Therefore, we would continue deeming from Lucy's ineligible spouse and we would continue to count any ISM received as if Lucy was physically residing in the family member's home.

• •

  Example 2: When temporary absence ends

  In example 1, in SI 00520.140D.2. (in this section), the permanent living arrangement from which Larry is absent is the household shared with a roommate. The temporary absence ended on November 2 when Larry left the nursing home.

• •

  Example 3: When temporary absence ends

  In example 2, in SI 00520.140D.2. (in this section), the permanent living arrangement from which Anthony is temporarily absent is the hospital. The temporary absence ends on October 31 because it is the third and final month of TI benefits.

Payments made under the TI provision are not overpayments when the recipient's actual stay exceeds the expected stay of 90 days or less.

After initially providing a statement the recipient's confinement was expected not to exceed 90 days, if the physician subsequently provides a new certification that indicates they now expects the confinement to exceed 90 days, TI benefits continue to be payable since the original certification established eligibility.

• •

  Example 1: Confinement exceeds 90 days

  On March 10, Bobby, a 67-year-old aged recipient, went into a hospital for surgery. On March 12, the doctor faxed over an SSA-186 with Bobby's statement of need and the physician's certification with the expected period of medical confinement, including post-operative care in a nursing home, would not exceed 90 days. The FO initiated continued payments effective April. On June 7, Bobby's physician provided a written statement indicating that Bobby had suffered complications and now believed that the period of medical confinement would likely exceed 90 days. This change does not affect eligibility for TI benefits since the initial certification established eligibility.

• •

  Example 2: Confinement does not exceed 90 days

  On February 9, Lisa, an adult SSI recipient, went into a hospital for surgery due to a broken hip. Lisa's physician faxed the SSA-186 to the local FO on February 12 stating that Lisa would go to the rehabilitation wing of the hospital and be admitted for more than 90 days. We denied Lisa's TI benefits based on the physician's certification. After the surgery on February 14, Lisa's physician sent an updated written notification to the FO stating that Lisa's expected release date would be by the end of April. The FO, then initiated an TI benefit payment effective March 1, based on already having Lisa's statement of need to from the SSA-186.

  Note: 

  If the FO did not have Lisa's SSA-186, which stated the need to maintain the home, the FO would have to obtain the statement before Lisa's release (or the 91st day of confinement) in order for Lisa to be eligible for TI benefit payments.

Overpayments may occur as a result of misapplication of the TI provision if it is later learned that:

• •

  a requirement for the receipt of TI benefits was not met; or

• •

  we paid the recipient incorrectly due to another payment or eligibility reason.

  Note: 

  Overstaying the expected 90 days is not a failure to meet a requirement.

For federally administered State supplementary payments (mandatory and optional), the State supplement payable for the months of TI benefits is the same as that which would be payable if the recipient were physically residing in their last permanent living arrangement.

An SSI recipient may be eligible under the special benefits provision for institutionalized 1619 eligibles for the first 2 full months of institutionalization and also be eligible (if all applicable requirements are met) for TI benefits for the same 2 months, or the third full month of institutionalization. See SI 00520.130 for information about special benefits for 1619 eligibles.

• •

  Immediately upon learning a recipient has entered a medical facility, if TI eligibility may apply, using the SSA-186 request a physician's certification and a statement of need to maintain the home or living arrangement.

• •

  Do not input a TI benefits allowance or denial or make any change in payment or eligibility status because of the recipient's institutionalization until the issue of eligibility for TI benefits is resolved.

• •

  Take all appropriate steps to resolve the issue as quickly as possible.

Using the SSA-186, obtain a physician's written certification stating whether they expect the recipient’s medical confinement to last less than 90 full consecutive days, beginning with the day after the recipient entered the institution.

If the recipient entered a medical facility on August 1, the certification must establish that the physician expects the facility to discharge the recipient on October 30 or earlier. The 90 full consecutive days would be August 2 through October 30.

Document the physician's certification of a 90 day or less stay by accepting the SSA-186 via mail, fax, or delivery to the FO from the recipient, representative payee or physician.

If the SSA-186 is unavailable, and you are unable to obtain, consider the following alternative acceptable forms of evidence:

• •

  accept the physician's written statement via mail, fax, or delivery to the FO from the recipient, representative payee, or physician; or

• •

  accept other records which reflect a physician's written statement; or

• •

  use information from the attending physician's written records; or

• •

  use information from a reliable source (e.g., hospital staff) such written certification exists.

Using the SSA-186, ask the recipient whether they need to pay some or all of the expenses to maintain the home or living arrangement to which they intend to return. In determining the recipient’s need to maintain a home or living arrangement, accept the SSA-186 via mail, fax, or delivery to the FO from the recipient (or from a person knowledgeable about the recipient's expenses and permanent living arrangement), representative payee.

If the SSA-186 is unavailable, and you are unable to obtain, consider the following alternative acceptable forms of evidence:

1. a. 

   Accept, absent evidence to the contrary, a written statement from the recipient or representative payee (or, if the recipient is incapacitated and does not have a representative payee, from a person knowledgeable about the recipient's expenses and permanent living arrangement) that the recipient needs to maintain and provide for some or all of the expenses of the home or living arrangement to which the recipient intends to return.

2. b. 

   Consider the following (not all-inclusive) examples as contrary evidence:

   • •

     an indication the recipient was homeless; or

   • •

     a statement from a knowledgeable person the recipient is not required to pay any of the expenses of the home or living arrangement to which the recipient intends to return; or

   • •

     an indication that the recipient is returning to a domiciliary or congregate care facility and is not required to continue to pay the facility to “hold the bed.”

3. c. 

   Do not consider the fact that a recipient was subject to the value of the one-third reduction (VTR) in the month of entry into the institution as evidence to the contrary. The recipient may be paying something less than their pro rata share or may be paying some expense which was not considered to be a household operating expense for purposes of the ISM determination.

4. d. 

   If evidence to the contrary exists, undertake the necessary development needed to determine whether the recipient needs to maintain and provide for some or all the expenses of the home or living arrangement to which they may return to.

Contact appropriate institutions:

• •

  to establish a process to assure institutions alert SSA promptly upon admissions of SSI recipients; and

• •

  to determine the feasibility of obtaining information from the facility to meet the physician certification requirement.

Document the file once an SSA-186 or written statement is received:

• •

  a determination of the recipient's need to maintain the home or living arrangement to which they intend to return (the recipient's or knowledgeable source's statement is sufficient documentation when evidence to the contrary does not exist);

• •

  a report of contact reflecting the physician's statement or the actual written certification from the physician that the recipient is expected to be institutionalized for no more than 90 full consecutive days (see SI 00520.140B.4. in this section); and

• •

  when a TI benefit is required, per SI 00520.141, ensure any manual TI notice is present in the online notice retrieval system (ORS), or if unable to post it in ORS, send it to the electronic or paper file.

When the TI determination or notices are not automated, ensure the file documents the determination, including why TI benefits do not apply or a statement that the recipient declined TI benefits; and ensure any manual TI denial notice is in ORS or stored in the electronic or paper file. See SI 00520.141.

In most TI benefit cases, the system automatically computes payments, sends notices, and controls TI cases. (For information on resolution date (RS) and TI field inputs, see SM 01305.750, SM 01305.760, SM 01005.750, SM 01005.760, and MS 08110.009.)

Manual processing and manual notices are required for the following exceptions to the automated process:

1. a. 

   couples' cases where one member on the record has been paid and the other has been denied or is pending a decision;

2. b. 

   couples' cases where the FO determines that the couple is separated prior to continued benefits input;

3. c. 

   couples' cases where neither member has been paid or only presumptive disability or presumptive blindness payments have been made;

4. d. 

   cases where the record is in force due;

5. e. 

   cases where a month of TI benefits is followed by a month for which the recipient is not eligible for TI benefits (i.e., the $30 payment limit or payment status N02 would not apply in the absence of the TI benefits provision).

   Example 1: A recipient receives TI continued benefits in January. Private insurance pays the cost of care in February so the $30 payment limit would not apply in February. The recipient receives TI continued benefits in March.

   Example 2: A recipient begins to receive TI continued benefits in January. Medicare pays the cost of care in February and March, so the $30 limit does not apply for February and March.

6. f. 

   all initial claims that are TI denial cases.