California pays OSS A to an eligible individual/couple who:

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  lives in own household, as defined for Federal living arrangement (FLA) A purposes, and has cooking and food storage facilities (see SI SF01415.140 for definition of “cooking and food storage facilities”) or is provided meals as part of the living arrangement; or

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  is a patient in a private medical facility certified for Title XIX and Title XIX does not pay more than 50% of the patient's cost of care; or

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  effective July 1, 1983, is a patient in a private medical facility licensed as a skilled nursing facility by the State but not certified for Title XIX; or

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    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, or

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    is a blind individual who lives in an independent living arrangement with or without cooking and food storage facilities; or

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    effective December 1, 1996, is a child under age 18 in FLA D due to residence in a private medical facility paid by private insurance. (See SI 00520.011C.)

IHSS Referral: Individuals who qualify for OSS A because they live in their own homes (i.e., either home ownership or rental liability), and who need care and supervision, should be referred to the county for In-Home Supportive Services (IHSS).

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. Room and board are generally not covered under an HCBS waiver.

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. 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 an 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 SF01415.170 for state supplementation of FLA D.

Examples:

1. 1. 

   Oliver Wood lives with and shares expenses with Oliver's brother. Oliver's brother owns the home in which they live. Oliver is determined to be in FLA A because Oliver's contribution for the household expenses exceeds Oliver's pro-rata share of the expenses. Oliver is eligible for OSS A because Oliver is in an independent living arrangement and has access to adequate cooking and food storage facilities.

2. 2. 

   Donovan Ojeda lives in a publicly operated community residence (POCR) designed to serve no more than 16 residents and meals are provided. Since this residential facility meets all the requirements set forth in SI 00520.500 (per the precedent established for this facility on the Seattle SSA-8045 Facility Determination site), the residents are not considered to be living in a public institution and are, therefore, eligible for SSI payments based on FLA A and OSS A rates.

3. 3. 

   Sharon Lewis, a 17-year-old blind student, lives with Sharon's parents in their home. Sharon was determined to be in FLA C and is eligible for the OSS A rate because Sharon is blind.

4. 4. 

   Consuelo Penrod lives in a licensed Developmentally Disabled Continuous Nursing Care (DD-CNC) facility whose license has been voluntarily suspended while the facility operates under a Home and Community Based Services (HCBS) waiver. Consuelo's living arrangement is FLA A and OSS A while the waiver is in effect.

5. 5. 

   Li Nguyen, a 12-year-old child, is residing in a private hospital whose care is being paid for by Li's parents’ private insurance. Li's living arrangement is FLA D and OSS is A while private insurance pays over 50% of the cost of care.

For initial claims and posteligibility reports, determine the proper Federal Living Arrangement (FLA) using guidelines provided in SI 00520.000 and SI 00835.000.

Absent evidence to the contrary, an individual or couple, who is determined to be living in an independent living arrangement for Federal purposes (FLA A), will also be found to be in an independent living arrangement for State supplement purposes (OSS A).

If an individual is in a private medical facility not certified for Title XIX, develop whether the State Licensing and Certification Division of the California Department of Public Health has licensed the facility as a skilled nursing facility:

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  Obtain the State licensure status from the management of the facility and record the determination in "Remarks" on the SSA-8045 Facility Determination. Use the Seattle SSA-8045 Facility Determination site to create and store the SSA-8045 (See SI 00520.800 Facility Determinations).

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  Contact the Licensing and Certification District Office only if the licensure status of a facility requires clarification.