For children under age 18, a combination of Medicaid and any health insurance policy issued by a private provider pays or is expected to pay over 50 percent of the cost of care for that month. NOTE: We will refer to the term “any health insurance policy issued by a private provider” as “private health insurance.”
IMPORTANT: The benefit rate for an eligible couple when both members are in medical treatment facilities, is $60 per month when the conditions in SI 00520.011C.1 are met and they have not separated, i.e., they intend to return to their prior living arrangement (regardless of the length of their stay in the facility).
EXAMPLE 1-- Child with private insurance: Matthew, a disabled child, was born at Tall Oaks Multi-Care Center on 10/04/18. He remained in the hospital until 01/05/19, when he went home to live with his parents. Private health insurance paid for more than 50 percent of the cost of Matthew's care for the months of October and November. For December and January, a combination of private health insurance and Medicaid paid more than 50 percent of the cost of his care. Matthew is eligible for the $30 reduced benefit (plus any applicable state supplemental payment) for November and December. Deeming of his parents' income and resources begins in February, the month following the month he comes home from the hospital. E02 applies for October, FLA-D for November and December, FLA-A for January, and FLA-C for February. See the policy for when to deem from a parent at SI
EXAMPLE 2 — State buy-in Medicare Part A pays the cost of care:
Mr. Wilson entered a hospital on 11/28/18 for surgery. On 01/07/19, the doctor released him to go back home. When Mr. Wilson reported these changes to SSA, the Claims Specialist (CS) contacted the hospital and determined that Medicare Part A paid for more than 50% of the cost of the care at the hospital.
Because the HI data line on the MBR indicated that Mr. Wilson’s Part A Medicare was “Premium HI,” the CS checked SM 00510.280 and SM 00510.295 and determined that Mr. Wilson’s Medicare coverage was through State buy-in. Because Mr. Wilson was in the hospital for the entire month of December, Medicare paid more than 50 percent of the cost of his care, and the State buy-in program purchased his Medicare coverage, the CS determined that the $30 dollar payment limit applied to Mr. Wilson for December.
On the SSI Claims system 'Institution Residence' page, the CS answers “yes” to the question, “ MEDICAID, OR MEDICARE PART A WITH STATE BUY-IN, PAYS MORE THAN 50%”. The CS completes a DROC to verify the admission and release dates, and documents that Medicare paid over 50 percent of the cost of his care. On the DROC, the CS also summarizes his or her determination that the $30 payment limit applies for December due to State buy-in of Medicare. For more information on the Institution Residence page, see MS
NOTE: If the CS identifies a recipient who has Medicare Part A due to State buy-in, and was put in FLA/A instead of FLA/D, see the rules for administrative finality in SI 04070.010.