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.
Matthew remained in the hospital until 01/05/19, when Matthew went home to live with
their 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 care. Matthew is eligible for the $30 reduced benefit (plus any applicable
state supplemental payment) for November and December. Deeming of Matthew's parents'
income and resources begins in February, the month following the month Matthew 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 01310.145B.
EXAMPLE 2 — State buy-in Medicare Part A pays the cost of care:
Wilson entered a hospital on 11/28/18 for surgery. On 01/07/19, the doctor released
Wilson to go back home. When 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 Wilson’s Part A Medicare was “Premium
HI,” the CS checked SM 00510.280 and SM 00510.295 and determined that Wilson’s Medicare
coverage was through State buy-in. Because Wilson was in the hospital for the entire
month of December, Medicare paid more than 50 percent of the cost of Wilson's care,
and the State buy-in program purchased Wilson's Medicare coverage, the CS determined
that the $30 dollar payment limit applied to 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 Report of Contact page to verify the admission and release dates, and
documents that Medicare paid over 50 percent of the cost of Wilson's care. On the
Report of Contact page, the CS also summarizes their 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 08110.009.
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.