Example 1: Evaluating a New Facility
Situation: A new private facility opens with the name Meadowland Senior Residence and the slogan
“Dignified Assisted Living”. The CR ascertains that it offers individual apartments
with some cooking facilities, also a central dining hall, and recreational facilities.
It has a shuttle service that will take residents shopping, to medical visits, to
the movies, etc. A registered nurse is on duty one day a week, gives some medical
care, and makes referrals to a doctor when needed. The residents are funded by a variety
of sources including private funds and Medicaid.
Determination: The Claims Representative (CR) determines that this facility is an ALF and not a
medical treatment facility. Even though some medical treatment is available, it is
not inpatient care. The definition of a Medical Treatment Facility in SI 00520.011B.1 is that it be licensed or otherwise approved to provide inpatient medical care.
Based on a contact with the facility administrator, the CR confirms that the facility
is not licensed to provide inpatient medical care. The CR records an electronic precedent
for the facility per SI 00520.800 that the residents are FLA/A.
Example 2: Married Couple in ALF
Situation: John and Marie each have an apartment in the Friendly Neighbor facility, a private
facility which SSA has determined to be an ALF. Both are receiving SSI benefits as
FLA/A individuals. They form a relationship and decide to get married and move into
Determination: The CR determines that they are living in the same household and are not “residents
of an institution” as described in SI 00520.001B.5. Although the facility provides meals and services, John and Marie utilize services
in the community such as doctors, dentists, and recreational activities. In addition,
they have a rental agreement with the facility for their private living quarters.
Because they are living in the same household, couple computation rules apply and
we begin paying them as a couple, not as two individuals. For more information about
couple computation rules, see “Determining When Couple Computation Rules Apply” SI 00501.154.