Before and during the conversion process, the resident usually pays for their own care. This payment may be from the resident's income, including SSI benefits, or from a third party on their behalf. We may apply SSI benefits to the cost of care if the special benefits provision for recipients eligible under 1619, or the continuation of benefits provision for recipients temporarily institutionalized applies, see policy in SI 00520.130. When a certification decision is made, the effective date of Medicaid coverage is often retroactive (usually to the date of the survey), and the provider is eligible for reimbursement for Medicaid funds for the retroactive period.

Under Medicaid, determine the amount of reimbursement based on the recipient’s total income (including amounts disregarded in determining Medicaid eligibility) during this period.

We reduce the Medicaid reimbursement rate by the amount of the recipient’s income (including SSI and State supplementary payments). However, any amounts of SSI or State supplementary payments that the recipient or representative payee refunded to SSA or the State (e.g., via the overpayment recovery process) would not be counted in determining Medicaid reimbursement.

Reference

SI 00520.140 Temporary Institutionalization (TI) Benefits

ROs establish procedures that ensure that SSA promptly receives notification of certification.

When the RO receives a certification notification directly from the State Medicaid certifying agency or from the Centers for Medicare and Medicaid Services (CMS), the RO is responsible for notifying the appropriate field office (FO).

The RO can negotiate with the State Medicaid certifying agency or have the parallel FO negotiate, to establish a system of direct reporting of certifications from the certifying agency to the retirement and survivors insurance (RSI) and SSI Programs Branch of the SSA RO or to the parallel FO. Appropriate reports show the name of the facility, the date the State Medicaid agency made the certification, and the effective date of the certification.

RO staff should maintain a close working relationship with CMS to ensure that prompt notification of certification to SSA is routine.

The ROs have flexibility in determining who uses what system or systems. ROs and FOs should attempt to develop a system of receiving reports, including negative reports, at least monthly.

For SSI purposes, the “month of certification” is the month we make the certification decision by the certifying agency, not the month the decision is effective, if retroactive. The recipient becomes a resident of a Medicaid-certified facility in the month of certification.

The $30 payment limit applies for the month of certification only if:

• •

  throughout the entire month, the recipient was a resident of the facility or another Medicaid institution; and

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  the Medicaid payment exceeds 50 percent of the cost of care for the period in the Medicaid facility during that month; and

• •

  the facility is a public institution.

NOTE: If the facility is private, we apply the $30 payment limit the month after the month of certification.