SI 00520.001ff provides that residence in an institution can affect an SSI applicant's/recipient's eligibility or payment amount. While the SSA-8045, SSI Facility Information and Determination Form, serves as a precedent for the facility, an individual living arrangement (LA) determination must be made for each SSI applicant/ recipient. The SS-RVI-306, Record of Institutionalization, is used to document specific case information. For MSSICS, the SS-RVI-306 is optional and can be used to collect the information before transmitting it on MSSICS.

However, in both MSSICS and non-MSSICS cases, the language in “B” below should be used when telephoning a medical facility. This language provides an explanation to the medical facility of the purpose for the contact and facilitates a better understanding of the information required.

Use Part I of the SS-RVI-306 to document the type of facility and Parts II and III to document information particular to the SSI applicant/recipient.

If the facility is a medical facility, use the following language when soliciting an answer to question 1. in Part II.B. of the SS-RVI-306:

• •

  If (name of claimant/recipient) is allowed (or continues to be eligible) for SSI, the claimant/recipient will most likely be eligible for Medicaid.

• •

  Based on your records and knowledge of the Medicaid program, would you expect Medicaid to pay over 50 percent of the cost of care you are providing (name) during (state the period of confinement—except do not include any period prior to the month in which the SSI application is filed)?

Document the living arrangement determination during the period of confinement in Part IV of the SS-RVI-306.

Daily files an SSI application on January 10, 1999. Daily has been in Rowlett Community Hospital, a public institution in Texas, since December 25, 1998. Daily expects to be in the hospital until February 5, 1999.

Part I of the SS-RVI-306 is completed from information on the SSA-8045.

Part II is completed with information obtained from the Rowlett Community Hospital. Since this is a medical facility, the last sentence in the language in B. above would be ". . ., would you expect Medicaid to pay over 50 percent of the cost of care you are providing Daily during the entire month of January and for those days in February until Daily's anticipated release on February 5?" This information will be used to determine if the Medicaid exception to ineligibility in a public institution is met (SI 00520.001C.1.).

Part III is reviewed to determine if any of the listed provisions apply to Daily which can affect eligibility and payment amount.

Part IV is used to document the living arrangement during the period of confinement for Daily.

RECORD OF INSTITUTIONALIZATION

Name of Applicant/Recipient: ________________________________________

SSN: ___________________                                   DOB: _____________________________

Part I Information about the Facility from the SSA-8045 (SSI Facility Information and Determination Form):

Name of Facility:   _____________________________________

Address:   ___________________________________

               ___________________________________

               ___________________________________

Telephone:  ______________________                           Public or Private?:   _______________

Type of Facility: (e.g., Penal;   _______________________________

Educational; Medicaid Certified) _______________________________

Part II   Information about the SSI Applicant/Recipient Obtained from the Facility:

A. Admission Information

1.   Date Admitted:   __________________

2.   Expected/Actual Date of Release:   __________

3.   Was the individual admitted from another facility?

       ______ No           _____ Yes

Complete multiple SS-RVI-306s if multiple admissions to the same facility occurred, or if admitted from a different facility, during the month of filing or later.

B. Payment for Care Information

Period covered by SSI Application/Redetermination and Confinement:

From:      _________ To:      __________

NOTE: If the facility is a medical facility, use the language provided in SI DAL00520.001B. to obtain Medicaid information to 1 and 2 below.

1.   Is Medicaid expected to pay or has it paid over 50 percent of the cost of care during some or all of the specified period?

_____ Yes (Continue to 2.)          _______ No (Continue to 3.)

2.    If yes, list each month Medicaid is expected to pay or has paid over 50 percent of the cost of care:

___________________________________________________________

If not all months in the specified period are covered by Medicaid, continue to 3.

3.    Medicaid is not expected to pay for part or all of the period or the facility is not Medicaid certified, list the expected source of payment for months not covered by Medicaid (e.g., insurance, Medicare, etc.):

Month/year                                            Source

_____________                                         ___________________

_____________                                         ___________________

4.    Source of Part II Information

Name:   ______________            Title: _______________________

Date:     ______________            Phone: ______________________

Remarks: ________________________________________________

Part III   Special Conditions to Consider

Check all provisions pertinent to the SSI applicant/recipient:

___ Child under 18 in public or private institution receiving payments for care from privately provided health insurance. (SI 00520.011)

___ Levings vs. Califano Eighth Judicial Circuit (e.g., Ark, N. Dakota, S. Dakota) - Voluntary resident of a public institution paying for cost of care (SI 00520.120)

___ Continuation of benefits for recipients temporarily institutionalized applicable (SI 00520.140)

___ Penal confinement, but outside traditional correctional facility (SI 00520.009)

___ Recipient was section 1619 eligible in the month preceding the first full month of institutionalization.

List months of full payment: ____________  (SI 00520.130)

___ Transfer of resources for less than fair market value

—LA-D applies even if no Medicaid payments (SI 00520.012)

___ Medicaid provided under a Home and Community Based Services Waiver program (SI 00520.011C.2)

Part IV     Case Determination                        Living Arrangement: _________________

Effective from _______ thru ________. Amount of ISM: ____________________

Remarks: ____________________________________________________________________

__________________________

Decision by: __________________                                           Date:

SS-RVI-306 (Revised 02/01)