We cannot include the amount of the state supplement payment when determining eligibility
for SSI until the PA-747 has been received in the field office. We should not enter
OS codes 'G' or 'H' until the PA-747 is received. Without the PA-747, the Federal
Benefit Rate (FBR) should be used to determine whether the individual meets the income
limits for SSI.
-
•
If the claimant's countable income is equal to or less than the FBR, process the claim
using normal procedures. Enter OS 'Z'. If/when the PA-747 is received, the OS code
can be changed to 'G' or 'H' retroactive to the month of application or the effective
date shown on the PA-747, whichever is later.
-
•
If the claimant's countable income is greater than the FBR, process the claim as a
technical denial. This denied claim can be reopened for "new and material evidence"
within two years of the denial date. If a PA-747 for the claimant is received in the
office showing eligibility for the DOMCARE/PCBH state supplement, the claim can be
reopened with the appropriate OS code 'G' or 'H' retroactive to the month of application
or the
Exhibit 1 - PA 747 - Authorization for State Supplement for Persons in a Domiciliary
Care Facility/Personal Care Home
Exhibit 2 - PA 746 - Termination of State Supplement for Persons in Domiciliary Care/Personal
Care Home
See SI 01415.010
(PA), Appendix I -- Chart 35 (RTN 63 – 12/2014)
SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2015 -12/2016 )
Living Arrangement
|
L/A Code
|
O/S Code
|
O/S Amount
|
Federal Payment Amount
|
Total Payment Amount
|
INDIVIDUALS 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
Z
|
|
$ 733.00
|
$ 733.00
|
1 EP
|
A
|
C
|
$ 43.70
|
$1100.00
|
$1143.70
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
Z
|
|
$ 488.67
|
$ 488.67
|
1 EP
|
B
|
D
|
$ 43.70
|
$ 733.34
|
$ 777.04
|
In Parental Household
|
C
|
Z
|
|
$ 733.00
|
$ 733.00
|
Medicaid Facility
|
D
|
Z
|
---
|
$ 30.00
|
$ 30.00
|
IN DOMCARE
|
A
|
G
|
$434.30
|
$ 733.00
|
$1167.30
|
In PCBH
|
A
|
H
|
$439.30
|
$ 733.00
|
$1172.30
|
COUPLES 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
Z
|
|
$1100.00
|
$1100.00
|
1 EP
|
A
|
C
|
$ 68.05
|
$1467.00
|
$1535.05
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
Z
|
|
$ 733.34
|
$ 733.34
|
1 EP
|
B
|
D
|
$ 68.05
|
$ 978.00
|
$1046.05
|
Medicaid Facility
|
D
|
Z
|
---
|
$ 60.00
|
$ 60.00
|
IN DOMCARE 2/
|
A
|
G
|
$947.40
|
$1100.00
|
$2047.40
|
In PCBH 2/
|
A
|
H
|
$957.40
|
$1100.00
|
$2057.40
|
1/ For individuals/couples whose FCI precludes a Federal payment, the amounts in the
“O/S Amount” column will vary depending on income. See SI 02005.001.
2/ Couples can reside in a noninstitutional care arrangement such as DOMCARE. The
couple is considered to be living in their own household. See SI 00835.790A.2.
The payment level for couples in a PCBH will apply only in certain situations; i.e.,
the month of move. If a “couple” on the first of the month, each member should receive
1/2 of the couple's FBR for the month of move. The state supplement amount to the
member(s) who move(s) into the PCBH is 1/2 of the couple's rate for OS-H for the month
of move. The state supplement amount for the member who remains in a household situation
is 1/2 of the couple's rate for OS-A or OS-B for the month of move. Both are treated
as individuals the month following the month of move. MSSICS cannot handle the eligibility
and payment computations for this situation. Follow instructions in MSOM BUSSR 002.004,
MSOM BUSSR 002.005 and MSOM BUSSR 002.006.
(PA), APPENDIX I – SUPPLEMENTATION CODING AND PAYMENT LEVELS CHART 34 (RTN 62 – 01/2014)
SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2014 – 12/2014)
Living Arrangement
|
L/A Code
|
O/S Code
|
O/S Amount
|
Federal Payment Amount
|
Total Payment Amount
|
INDIVIDUALS 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
Z
|
|
$ 721.00
|
$ 721.00
|
1 EP
|
A
|
C
|
$ 43.70
|
$1082.00
|
$1125.70
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
Z
|
|
$ 480.67
|
$ 480.67
|
1 EP
|
B
|
D
|
$ 43.70
|
$ 721.34
|
$ 765.04
|
In Parental Household
|
C
|
Z
|
|
$ 721.00
|
$ 721.00
|
Medicaid Facility
|
D
|
Z
|
---
|
$ 30.00
|
$ 30.00
|
IN DOMCARE
|
A
|
G
|
$434.30
|
$ 721.00
|
$1155.30
|
In PCBH
|
A
|
H
|
$439.30
|
$ 721.00
|
$1160.30
|
COUPLES 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
Z
|
|
$1082.00
|
$1082.00
|
1 EP
|
A
|
C
|
$ 68.05
|
$1443.00
|
$1511.05
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
Z
|
|
$ 721.34
|
$ 721.34
|
1 EP
|
B
|
D
|
$ 68.05
|
$962.00
|
$1030.05
|
Medicaid Facility
|
D
|
Z
|
---
|
$ 60.00
|
$ 60.00
|
IN DOMCARE 2/
|
A
|
G
|
$947.40
|
$1082.00
|
$2029.40
|
In PCBH 2/
|
A
|
H
|
$957.40
|
$1082.00
|
$2039.40
|
1/ For individuals/couples whose FCI precludes a Federal payment, the amounts in the
"O/S Amount" column will vary depending on income. See SI 02005.001.
2/ Couples can reside in a noninstitutional care arrangement such as DOMCARE. The
couple is considered to be living in their own household. See SI 00835.790A.2.
The payment level for couples in a PCBH will apply only in certain situations; i.e.,
the month of move. If a “couple” on the first of the month, each member should receive
1/2 of the couple's FBR for the month of move. The state supplement amount to the
member(s) who move(s) into the PCBH is 1/2 of the couple's rate for OS-H for the month
of move. The state supplement amount for the member who remains in a household situation
is 1/2 of the couple's rate for OS-A or OS-B for the month of move. Both are treated
as individuals the month following the month of move. MSSICS cannot handle the eligibility
and payment computations for this situation. Follow instructions in MSOM BUSSR 002.004,
MSOM BUSSR 002.005 and MSOM BUSSR 002.006.
(PA), APPENDIX I – SUPPLEMENTATION CODING AND PAYMENT LEVELS CHART 33 (RTN 61–01/2013
– 12/2013)
SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2013 – 12/2013)
Living Arrangement
|
L/A Code
|
O/S Code
|
O/S Amount
|
Federal Payment Amount
|
Total Payment Amount
|
INDIVIDUALS 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
Z
|
|
$ 710.00
|
$ 710.00
|
1 EP
|
A
|
C
|
$ 43.70
|
$1066.00
|
$1066.70
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
Z
|
|
$ 473.34
|
$ 473.34
|
1 EP
|
B
|
D
|
$ 43.70
|
$ 710.67
|
$ 754.37
|
In Parental Household
|
C
|
Z
|
|
$ 710.00
|
$ 710.00
|
Medicaid Facility
|
D
|
Z
|
---
|
$ 30.00
|
$ 30.00
|
IN DOMCARE
|
A
|
G
|
$434.30
|
$ 710.00
|
$1144.30
|
In PCBH
|
A
|
H
|
$439.30
|
$ 710.00
|
$1149.30
|
COUPLES 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
Z
|
|
$1066.00
|
$1066.00
|
1 EP
|
A
|
C
|
$ 68.05
|
$1422.00
|
$1490.05
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
Z
|
|
$ 710.67
|
$ 710.67
|
1 EP
|
B
|
D
|
$ 68.05
|
$ 948.00
|
$1016.05
|
Medicaid Facility
|
D
|
Z
|
---
|
$ 60.00
|
$ 60.00
|
IN DOMCARE 2/
|
A
|
G
|
$947.40
|
$1066.00
|
$2013.40
|
In PCBH 2/
|
A
|
H
|
$957.40
|
$1066.00
|
$2023.40
|
1/ For individuals/couples whose FCI precludes a Federal payment, the amounts in the
"O/S Amount" column will vary depending on income. See SI 02005.001.
2/ Couples can reside in a noninstitutional care arrangement such as DOMCARE. The
couple is considered to be living in their own household. See SI 00835.790A.2.
The payment level for couples in a PCBH will apply only in certain situations; i.e.,
the month of move. If a “couple” on the first of the month, each member should receive
1/2 of the couple's FBR for the month of move. The state supplement amount to the
member(s) who move(s) into the PCBH is 1/2 of the couple's rate for OS-H for the month
of move. The state supplement amount for the member who remains in a household situation
is 1/2 of the couple's rate for OS-A or OS-B for the month of move. Both are treated
as individuals the month following the month of move. MSSICS cannot handle the eligibility
and payment computations for this situation. Follow instructions in MSOM BUSSR 002.004,
MSOM BUSSR 002.005 and MSOM BUSSR 002.006.
(PA), APPENDIX I – SUPPLEMENTATION CODING AND PAYMENT LEVELS CHART 32 (RTN 60–12/2011)
SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2012)
Living Arrangement
|
L/A Code
|
O/S Code
|
O/S Amount
|
Federal Payment Amount
|
Total Payment Amount
|
INDIVIDUALS 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
Z
|
|
$ 698.00
|
$ 698.00
|
1 EP
|
A
|
C
|
$ 43.70
|
$1048.00
|
$1091.70
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
Z
|
|
$ 465.34
|
$ 465.34
|
1 EP
|
B
|
D
|
$ 43.70
|
$ 698.67
|
$ 742.37
|
In Parental Household
|
C
|
Z
|
|
$ 698.00
|
$ 698.00
|
Medicaid Facility
|
D
|
Z
|
---
|
$ 30.00
|
$ 30.00
|
IN DOMCARE
|
A
|
G
|
$434.30
|
$ 698.00
|
$1132.30
|
In PCBH
|
A
|
H
|
$439.30
|
$ 698.00
|
$1137.30
|
COUPLES 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
Z
|
|
$1048.00
|
$1048.00
|
1 EP
|
A
|
C
|
$ 68.05
|
$1398.00
|
$1466.05
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
Z
|
|
$ 698.67
|
$ 698.67
|
1 EP
|
B
|
D
|
$ 68.05
|
$ 932.00
|
$1000.05
|
Medicaid Facility
|
D
|
Z
|
---
|
$ 60.00
|
$ 60.00
|
IN DOMCARE 2/
|
A
|
G
|
$947.40
|
$1048.00
|
$1995.40
|
In PCBH 2/
|
A
|
H
|
$957.40
|
$1048.00
|
$2005.40
|
1/ For individuals/couples whose FCI precludes a Federal payment, the amounts in the
"O/S Amount" column will vary depending on income. See SI 02005.001.
2/ Couples can reside in a noninstitutional care arrangement such as DOMCARE. The
couple is considered to be living in their own household. See SI 00835.790A.2.
The payment level for couples in a PCBH will apply only in certain situations; i.e.,
the month of move. If a “couple” on the first of the month, each member should receive
1/2 of the couple's FBR for the month of move. The state supplement amount to the
member(s) who move(s) into the PCBH is 1/2 of the couple's rate for OS-H for the month
of move. The state supplement amount for the member who remains in a household situation
is 1/2 of the couple's rate for OS-A or OS-B for the month of move. Both are treated
as individuals the month following the month of move. MSSICS cannot handle the eligibility
and payment computations for this situation. Follow instructions in MSOM BUSSR 002.004,
MSOM BUSSR 002.005 and MSOM BUSSR 002.006.
APPENDIX I – SUPPLEMENTATION CODING AND PAYMENT LEVEL CHARTS
CODING AND PAYMENT LEVELS 01/2009 - 12/2009
Living Arrangement
|
L/A Code
|
O/S Code
|
O/S Amount
|
Federal Payment Amount
|
Total Payment Amount
|
INDIVIDUALS 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
Z
|
$ 00.00
|
$674.00
|
$674.00
|
1 EP
|
A
|
C
|
43.70
|
1012.00
|
1055.70
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
Z
|
00.00
|
449.34
|
449.34
|
1 EP
|
B
|
D
|
43.70
|
674.67
|
718.37
|
In Parental Household
|
C
|
Z
|
00.00
|
674.00
|
674.00
|
Medicaid Facility
|
D
|
Z
|
---
|
30.00
|
30.00
|
IN DOMCARE
|
A
|
G
|
434.30
|
674.00
|
1108.30
|
In PCBH
|
A
|
H
|
439.30
|
674.00
|
1113.30
|
COUPLES 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
Z
|
00.00
|
1011.00
|
1011.00
|
1 EP
|
A
|
C
|
68.05
|
1349.00
|
1417.05
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
Z
|
00.00
|
674.00
|
674.00
|
1 EP
|
B
|
D
|
68.05
|
899.34
|
967.39
|
Medicaid Facility
|
D
|
Z
|
---
|
60.00
|
60.00
|
IN DOMCARE 2/
|
A
|
G
|
947.40
|
1011.00
|
1958.40
|
In PCBH 2/
|
A
|
H
|
957.40
|
1011.00
|
1968.40
|
1/ For individuals/couples whose FCI precludes a Federal payment, the amounts in the
"O/S Amount" column will vary depending on income. See SI 02005.001.
2/ Couples can reside in a noninstitutional care arrangement such as DOMCARE. The
couple is considered to be living in their own household. See SI 00835.790A.2.
The payment level for couples in a PCBH will apply only in certain situations; i.e.,
the month of move. If a “couple” on the first of the month, each member should receive
1/2 of the couple's FBR for the month of move. The state supplement amount to the
member(s) who move(s) into the PCBH is 1/2 of the couple's rate for OS-H for the month
of move. The state supplement amount for the member who remains in a household situation
is 1/2 of the couple's rate for OS-A or OS-B for the month of move. Both are treated
as individuals the month following the month of move. MSSICS cannot handle the eligibility
and payment computations for this situation. Follow instructions in MSOM BUSSR 002.004,
MSOM BUSSR 002.005 and MSOM BUSSR 002.006.
CODING AND PAYMENT LEVELS (01/2008 - 12/2008)
Living Arrangement
|
L/A Code
|
O/S Code
|
O/S Amount
|
Federal Payment Amount
|
Total Payment Amount
|
INDIVIDUALS 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
Z
|
$ 00.00
|
$637.00
|
$637.00
|
1 EP
|
A
|
C
|
43.70
|
956.00
|
999.70
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
Z
|
00.00
|
424.67
|
424.67
|
1 EP
|
B
|
D
|
43.70
|
637.34
|
681.04
|
In Parental Household
|
C
|
Z
|
00.00
|
637.00
|
637.00
|
Medicaid Facility
|
D
|
Z
|
---
|
30.00
|
30.00
|
IN DOMCARE
|
A
|
G
|
434.30
|
637.00
|
1071.30
|
In PCBH
|
A
|
H
|
439.30
|
637.00
|
1076.30
|
COUPLES 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
Z
|
00.00
|
$956.00
|
$956.00
|
1 EP
|
A
|
C
|
68.05
|
1275.00
|
1343.05
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
Z
|
00.00
|
637.34
|
637.34
|
1 EP
|
B
|
D
|
68.05
|
850.00
|
918.05
|
Medicaid Facility
|
D
|
Z
|
---
|
60.00
|
60.00
|
IN DOMCARE 2/
|
A
|
G
|
947.40
|
956.00
|
1903.40
|
In PCBH 2/
|
A
|
H
|
957.40
|
956.00
|
1913.40
|
CODING AND PAYMENT LEVELS (10/2007 - 12/2007)
Living Arrangement
|
L/A Code
|
O/S Code
|
O/S Amount
|
Federal Payment Amount
|
Total Payment Amount
|
INDIVIDUALS 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
Z
|
$ 00.00
|
$623.00
|
$623.00
|
1 EP
|
A
|
C
|
43.70
|
935.00
|
978.70
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
Z
|
00.00
|
415.34
|
415.34
|
1 EP
|
B
|
D
|
43.70
|
623.34
|
667.04
|
In Parental Household
|
C
|
Z
|
00.00
|
623.00
|
623.00
|
Medicaid Facility
|
D
|
Z
|
---
|
30.00
|
30.00
|
IN DOMCARE
|
A
|
G
|
434.30
|
623.00
|
1057.30
|
In PCBH
|
A
|
H
|
439.30
|
623.00
|
1062.30
|
COUPLES 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
Z
|
00.00
|
$934.00
|
$934.00
|
1 EP
|
A
|
C
|
68.05
|
1246.00
|
1314.05
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
Z
|
00.00
|
622.67
|
622.67
|
1 EP
|
B
|
D
|
68.05
|
830.67
|
898.72
|
Medicaid Facility
|
D
|
Z
|
---
|
60.00
|
60.00
|
IN DOMCARE 2/
|
A
|
G
|
947.40
|
934.00
|
1881.40
|
In PCBH 2/
|
A
|
H
|
957.40
|
934.00
|
1891.40
|
CODING AND PAYMENT LEVELS (01/2007 - 09/2007)
Living Arrangement
|
L/A Code
|
O/S Code
|
O/S Amount
|
Federal Payment Amount
|
Total Payment Amount
|
INDIVIDUALS 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
Z
|
$ 00.00
|
$623.00
|
$623.00
|
1 EP
|
A
|
C
|
43.70
|
935.00
|
978.70
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
Z
|
00.00
|
415.34
|
415.34
|
1 EP
|
B
|
D
|
43.70
|
623.34
|
667.04
|
In Parental Household
|
C
|
Z
|
00.00
|
623.00
|
623.00
|
Medicaid Facility
|
D
|
Z
|
---
|
30.00
|
30.00
|
IN DOMCARE
|
A
|
G
|
389.30
|
623.00
|
1012.30
|
In PCBH
|
A
|
H
|
439.30
|
623.00
|
1062.30
|
COUPLES 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
Z
|
00.00
|
$934.00
|
$934.00
|
1 EP
|
A
|
C
|
68.05
|
1246.00
|
1314.05
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
Z
|
00.00
|
622.67
|
622.67
|
1 EP
|
B
|
D
|
68.05
|
830.67
|
898.72
|
Medicaid Facility
|
D
|
Z
|
---
|
60.00
|
60.00
|
IN DOMCARE 2/
|
A
|
G
|
857.40
|
934.00
|
1791.40
|
In PCBH 2/
|
A
|
H
|
957.40
|
934.00
|
1891.40
|
CODING AND PAYMENT LEVELS (07/2006 - 12/2006)
Living Arrangement
|
L/A Code
|
O/S Code
|
O/S Amount
|
Federal Payment Amount
|
Total Payment Amount
|
INDIVIDUALS 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
Z
|
$ 00.00
|
$603.00
|
$603.00
|
1 EP
|
A
|
C
|
43.70
|
905.00
|
948.70
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
Z
|
00.00
|
402.00
|
402.00
|
1 EP
|
B
|
D
|
43.70
|
603.34
|
647.04
|
In Parental Household
|
C
|
Z
|
00.00
|
603.00
|
603.00
|
Medicaid Facility
|
D
|
Z
|
---
|
30.00
|
30.00
|
IN DOMCARE
|
A
|
G
|
389.30
|
603.00
|
992.30
|
In PCBH
|
A
|
H
|
439.30
|
603.00
|
1042.30
|
COUPLES 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
Z
|
00.00
|
$904.00
|
$904.00
|
1 EP
|
A
|
C
|
68.05
|
1,206.00
|
1,274.05
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
Z
|
00.00
|
602.67
|
602.67
|
1 EP
|
B
|
D
|
68.05
|
804.00
|
872.05
|
Medicaid Facility
|
D
|
Z
|
---
|
60.00
|
60.00
|
IN DOMCARE 2/
|
A
|
G
|
857.40
|
904.00
|
1,761.40
|
In PCBH 2/
|
A
|
H
|
957.40
|
904.00
|
1,861.40
|
CODING AND PAYMENT LEVELS (01/2006 - 06/2006)
Living Arrangement
|
L/A Code
|
O/S Code
|
O/S Amount
|
Federal Payment Amount
|
Total Payment Amount
|
INDIVIDUALS 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
Z
|
$ 00.00
|
$603.00
|
$603.00
|
1 EP
|
A
|
C
|
43.70
|
905.00
|
948.70
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
Z
|
00.00
|
402.00
|
402.00
|
1 EP
|
B
|
D
|
43.70
|
603.34
|
647.04
|
In Parental Household
|
C
|
Z
|
00.00
|
603.00
|
603.00
|
Medicaid Facility
|
D
|
Z
|
---
|
30.00
|
30.00
|
IN DOMCARE
|
A
|
G
|
389.30
|
603.00
|
992.30
|
In PCBH
|
A
|
H
|
394.30
|
603.00
|
997.30
|
COUPLES 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
Z
|
00.00
|
$904.00
|
$904.00
|
1 EP
|
A
|
C
|
68.05
|
1,206.00
|
1,274.05
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
Z
|
00.00
|
602.67
|
602.67
|
1 EP
|
B
|
D
|
68.05
|
804.00
|
872.05
|
Medicaid Facility
|
D
|
Z
|
---
|
60.00
|
60.00
|
IN DOMCARE 2/
|
A
|
G
|
857.40
|
904.00
|
1,761.40
|
In PCBH 2/
|
A
|
H
|
867.40
|
904.00
|
1,771.40
|
CODING AND PAYMENT LEVELS (01/2005 - 12/2005)
Living Arrangement
|
L/A Code
|
O/S Code
|
O/S Amount
|
Federal Payment Amount
|
Total Payment Amount
|
INDIVIDUALS 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
Z
|
$ 00.00
|
$579.00
|
$579.00
|
1 EP
|
A
|
C
|
43.70
|
869.00
|
912.70
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
Z
|
00.00
|
386.00
|
386.00
|
1 EP
|
B
|
D
|
43.70
|
579.34
|
623.04
|
In Parental Household
|
C
|
Z
|
00.00
|
579.00
|
579.00
|
Medicaid Facility
|
D
|
Z
|
---
|
30.00
|
30.00
|
IN DOMCARE
|
A
|
G
|
389.30
|
579.00
|
968.30
|
In PCBH
|
A
|
H
|
394.30
|
579.00
|
973.30
|
COUPLES 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
Z
|
00.00
|
$869.00
|
$869.00
|
1 EP
|
A
|
C
|
68.05
|
1,159.00
|
1,227.05
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
Z
|
00.00
|
579.00
|
579.00
|
1 EP
|
B
|
D
|
68.05
|
772.67
|
840.72
|
Medicaid Facility
|
D
|
Z
|
---
|
60.00
|
60.00
|
IN DOMCARE 2/
|
A
|
G
|
857.40
|
869.00
|
1,726.40
|
In PCBH 2/
|
A
|
H
|
867.40
|
869.00
|
1,736.40
|
CODING AND PAYMENT LEVELS (01/2004 - 12/2004)
Living Arrangement
|
L/A Code
|
O/S Code
|
O/S Amount
|
Federal Payment Amount
|
Total Payment Amount
|
INDIVIDUALS 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
A
|
$ 27.40
|
$564.00
|
$591.40
|
1 EP
|
A
|
C
|
$43.70
|
$846.00
|
$889.70
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
B
|
$27.40
|
$376.00
|
$403.40
|
1 EP
|
B
|
D
|
$43.70
|
$564.00
|
$607.70
|
In Parental Household
|
C
|
A
|
$27.40
|
$564.00
|
$591.40
|
Medicaid Facility
|
D
|
Z
|
---
|
$30.00
|
$30.00
|
IN DOMCARE
|
A
|
G
|
$389.30
|
$564.00
|
$953.30
|
In PCBH
|
A
|
H
|
$394.30
|
$564.00
|
$958.30
|
COUPLES 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
A
|
$ 43.70
|
$846.00
|
$889.70
|
1 EP
|
A
|
C
|
$68.05
|
$1,128.00
|
$1,196.05
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
B
|
$43.70
|
$564.00
|
$607.70
|
1 EP
|
B
|
D
|
$68.05
|
$752.00
|
$820.05
|
Medicaid Facility
|
D
|
Z
|
---
|
$60.00
|
$60.00
|
In DOMCARE 2/
|
A
|
G
|
$857.40
|
$846.00
|
$1,703.40
|
In PCBH 2/
|
A
|
H
|
$867.40
|
$846.00
|
$1,1713.40
|
CODING AND PAYMENT LEVELS (01/2003 - 12/2003)
Living Arrangement
|
L/A Code
|
O/S Code
|
O/S Amount
|
Federal Payment Amount
|
Total Payment Amount
|
INDIVIDUALS 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
A
|
$ 27.40
|
$552.00
|
$579.40
|
1 EP
|
A
|
C
|
$43.70
|
$829.00
|
$872.70
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
B
|
$27.40
|
$368.00
|
$395.40
|
1 EP
|
B
|
D
|
$43.70
|
$552.67
|
$596.37
|
In Parental Household
|
C
|
A
|
$27.40
|
$552.00
|
$579.40
|
Medicaid Facility
|
D
|
Z
|
---
|
$30.00
|
$30.00
|
IN DOMCARE
|
A
|
G
|
$389.30
|
$552.00
|
$941.30
|
In PCBH
|
A
|
H
|
$394.30
|
$552.00
|
$946.30
|
COUPLES 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
A
|
$ 43.70
|
$829.00
|
$872.70
|
1 EP
|
A
|
C
|
$68.05
|
$1,106.00
|
$1,174.05
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
B
|
$43.70
|
$552.67
|
$596.37
|
1 EP
|
B
|
D
|
$68.05
|
$737.34
|
$805.39
|
Medicaid Facility
|
D
|
Z
|
---
|
$60.00
|
$60.00
|
IN DOMCARE 2/
|
A
|
G
|
$857.40
|
$829.00
|
$1,686.40
|
In PCBH 2/
|
A
|
H
|
$867.40
|
$829.00
|
$1,696.40
|
CODING AND PAYMENT LEVELS (01/2002 - 12/2002)
Living Arrangement
|
L/A Code
|
O/S Code
|
O/S Amount
|
Federal Payment Amount
|
Total Payment Amount
|
INDIVIDUALS 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
A
|
$ 27.40
|
$545.00
|
$572.40
|
1 EP
|
A
|
C
|
$43.70
|
$818.00
|
$861.70
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
B
|
$27.40
|
$363.34
|
$390.74
|
1 EP
|
B
|
D
|
$43.70
|
$545.34
|
$589.04
|
In Parental Household
|
C
|
A
|
$27.40
|
$545.00
|
$572.40
|
Medicaid Facility
|
D
|
Z
|
---
|
$30.00
|
$30.00
|
IN DOMCARE
|
A
|
G
|
$389.30
|
$545.00
|
$934.30
|
In PCBH
|
A
|
H
|
$394.30
|
$545.00
|
$939.30
|
COUPLES 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
A
|
$ 43.70
|
$817.00
|
$860.70
|
1 EP
|
A
|
C
|
$68.05
|
$1,090.00
|
$1,158.05
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
B
|
$43.70
|
$544.67
|
$588.37
|
1 EP
|
B
|
D
|
$68.05
|
$726.67
|
$794.72
|
Medicaid Facility
|
D
|
Z
|
---
|
$60.00
|
$60.00
|
IN DOMCARE 2/
|
A
|
G
|
$857.40
|
$817.00
|
$1,674.40
|
In PCBH 2/
|
A
|
H
|
$867.40
|
$817.00
|
$1,684.40
|
CODING AND PAYMENT LEVELS (01/2001 - 12/2001)
Living Arrangement
|
L/A Code
|
O/S Code
|
O/S Amount
|
Federal Payment Amount
|
Total Payment Amount
|
INDIVIDUALS 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
A
|
$ 27.40
|
$530.00
|
$557.40
|
1 EP
|
A
|
C
|
$43.70
|
$796.00
|
$839.70
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
B
|
$27.40
|
$353.34
|
$380.74
|
1 EP
|
B
|
D
|
$43.70
|
$530.67
|
$574.37
|
In Parental Household
|
C
|
A
|
$27.40
|
$530.00
|
$557.40
|
Medicaid Facility
|
D
|
Z
|
---
|
$30.00
|
$30.00
|
IN DOMCARE
|
A
|
G
|
$329.30
|
$530.00
|
$859.30
|
In PCBH
|
A
|
H
|
$334.30
|
$530.00
|
$864.30
|
COUPLES 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
A
|
$ 43.70
|
$796.00
|
$839.70
|
1 EP
|
A
|
C
|
$68.05
|
$1,062.00
|
$1,130.05
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
B
|
$43.70
|
$530.67
|
$574.37
|
1 EP
|
B
|
D
|
$68.05
|
$708.00
|
$776.05
|
Medicaid Facility
|
D
|
Z
|
---
|
$60.00
|
$60.00
|
IN DOMCARE 2/
|
A
|
G
|
$737.40
|
$796.00
|
$1,533.40
|
In PCBH 2/
|
A
|
H
|
$747.40
|
$796.00
|
$1,543.40
|
CODING AND PAYMENT LEVELS (01/2000 - 12/2000)
Living Arrangement
|
L/A Code
|
O/S Code
|
O/S Amount
|
Federal Payment Amount
|
Total Payment Amount
|
INDIVIDUALS 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
A
|
$ 27.40
|
$512.00
|
$539.00
|
1 EP
|
A
|
C
|
43.70
|
769.00
|
812.70
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
B
|
27.40
|
341.34
|
368.74
|
1 EP
|
B
|
D
|
43.70
|
512.67
|
556.37
|
In Parental Household
|
C
|
A
|
27.40
|
512.00
|
539.40
|
Medicaid Facility
|
D
|
Z
|
---
|
30.00
|
30.00
|
IN DOMCARE
|
A
|
G
|
329.30
|
512.00
|
841.30
|
In PCBH
|
A
|
H
|
334.30
|
512.00
|
846.30
|
COUPLES 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
A
|
$ 43.70
|
$769.00
|
$812.70
|
1 EP
|
A
|
C
|
68.05
|
1,026.05
|
1,094.05
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
B
|
43.70
|
512.67
|
556.37
|
Medicaid Facility
|
D
|
Z
|
---
|
60.00
|
60.00
|
IN DOMCARE 2/
|
A
|
G
|
737.40
|
769.00
|
1,506.40
|
In PCBH 2/
|
A
|
H
|
747.40
|
769.00
|
1,516.40
|
CODING AND PAYMENT LEVELS (01/1999 - 12/1999)
Living Arrangement
|
L/A Code
|
O/S Code
|
O/S Amount
|
Federal Payment Amount
|
Total Payment Amount
|
INDIVIDUALS 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
A
|
$ 27.40
|
$500.00
|
$ 527.40
|
1 EP
|
A
|
C
|
43.70
|
751.00
|
794.70
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
B
|
27.40
|
333.34
|
360.74
|
1 EP
|
B
|
D
|
43.70
|
500.00
|
543.70
|
In Parental Household
|
C
|
A
|
27.40
|
500.00
|
527.40
|
Medicaid Facility
|
D
|
Z
|
---
|
30.00
|
30.00
|
IN DOMCARE
|
A
|
G
|
329.30
|
500.00
|
829.30
|
In PCBH
|
A
|
H
|
334.30
|
500.00
|
834.30
|
COUPLES 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
A
|
$ 43.70
|
$751.00
|
$ 794.70
|
1 EP
|
A
|
C
|
68.05
|
1001.00
|
1069.05
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
B
|
43.70
|
500.67
|
544.37
|
Medicaid Facility
|
D
|
Z
|
---
|
60.00
|
60.00
|
IN DOMCARE 2/
|
A
|
G
|
737.40
|
751.00
|
1488.40
|
In PCBH 2/
|
A
|
H
|
747.40
|
751.00
|
1498.40
|
CODING AND PAYMENT LEVELS (01/1998 - 12/1998)
Living Arrangement
|
L/A Code
|
O/S Code
|
O/S Amount
|
Federal Payment Amount
|
Total Payment Amount
|
INDIVIDUALS 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
A
|
$ 27.40
|
$494.00
|
$ 521.40
|
1 EP
|
A
|
C
|
43.70
|
741.00
|
784.70
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
B
|
27.40
|
329.34
|
356.74
|
1 EP
|
B
|
D
|
43.70
|
494.00
|
537.70
|
In Parental Household
|
C
|
A
|
27.40
|
494.00
|
521.40
|
Medicaid Facility
|
D
|
Z
|
---
|
30.00
|
30.00
|
IN DOMCARE
|
A
|
G
|
329.30
|
494.00
|
823.30
|
In PCBH
|
A
|
H
|
334.30
|
494.00
|
828.30
|
COUPLES 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
A
|
$ 43.70
|
$741.00
|
$ 784.70
|
1 EP
|
A
|
C
|
68.05
|
988.00
|
1056.05
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
B
|
43.70
|
494.00
|
537.70
|
Medicaid Facility
|
D
|
Z
|
---
|
60.00
|
60.00
|
IN DOMCARE 2/
|
A
|
G
|
737.40
|
741.00
|
1478.40
|
In PCBH 2/
|
A
|
H
|
747.40
|
741.00
|
1488.40
|
CODING AND PAYMENT LEVELS (01/1997 - 12/1997)
Living Arrangement
|
L/A Code
|
O/S Code
|
O/S Amount
|
Federal Payment Amount
|
Total Payment Amount
|
INDIVIDUALS 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
A
|
$ 27.40
|
$484.00
|
$ 511.40
|
1 EP
|
A
|
C
|
43.70
|
726.00
|
769.70
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
B
|
27.40
|
322.67
|
350.07
|
1 EP
|
B
|
D
|
43.70
|
484.00
|
527.70
|
In Parental Household
|
C
|
A
|
27.40
|
484.00
|
511.40
|
Medicaid Facility
|
D
|
Z
|
---
|
30.00
|
30.00
|
IN DOMCARE
|
A
|
G
|
329.30
|
484.00
|
813.30
|
In PCBH
|
A
|
H
|
334.30
|
484.00
|
818.30
|
COUPLES 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
A
|
$ 43.70
|
$726.00
|
$ 769.70
|
1 EP
|
A
|
C
|
68.05
|
968.00
|
1036.05
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
B
|
43.70
|
484.00
|
527.70
|
Medicaid Facility
|
D
|
Z
|
---
|
60.00
|
60.00
|
IN DOMCARE 2/
|
A
|
G
|
737.40
|
726.00
|
1463.40
|
In PCBH 2/
|
A
|
H
|
747.40
|
726.00
|
1473.40
|
CODING AND PAYMENT LEVELS (01/1996 - 12/1996)
Living Arrangement
|
L/A Code
|
O/S Code
|
O/S Amount
|
Federal Payment Amount
|
Total Payment Amount
|
INDIVIDUALS 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
A
|
$ 27.40
|
$470.00
|
$ 497.40
|
1 EP
|
A
|
C
|
43.70
|
705.00
|
748.70
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
B
|
27.40
|
313.34
|
340.74
|
1 EP
|
B
|
D
|
43.70
|
470.00
|
513.70
|
In Parental Household
|
C
|
A
|
27.40
|
470.00
|
497.40
|
Medicaid Facility
|
D
|
Z
|
---
|
30.00
|
30.00
|
IN DOMCARE
|
A
|
G
|
329.30
|
470.00
|
799.30
|
In PCBH
|
A
|
H
|
334.30
|
470.00
|
804.30
|
COUPLES 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
A
|
$ 43.70
|
$705.00
|
$ 748.70
|
1 EP
|
A
|
C
|
68.05
|
940.00
|
1008.05
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
B
|
43.70
|
470.00
|
513.70
|
Medicaid Facility
|
D
|
Z
|
---
|
60.00
|
60.00
|
IN DOMCARE 2/
|
A
|
G
|
737.40
|
705.00
|
1442.40
|
In PCBH 2/
|
A
|
H
|
747.40
|
705.00
|
1452.40
|
CODING AND PAYMENT LEVELS (01/1995 - 12/1995)
Living Arrangement
|
L/A Code
|
O/S Code
|
O/S Amount
|
Federal Payment Amount
|
Total Payment Amount
|
INDIVIDUALS 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
A
|
$ 32.40
|
$458.00
|
$ 490.40
|
1 EP
|
A
|
C
|
48.70
|
687.00
|
735.70
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
B
|
32.40
|
305.34
|
337.74
|
1 EP
|
B
|
D
|
48.70
|
458.00
|
506.70
|
In Parental Household
|
C
|
A
|
32.40
|
458.00
|
490.40
|
Medicaid Facility
|
D
|
Z
|
---
|
30.00
|
30.00
|
IN DOMCARE
|
A
|
G
|
329.30
|
458.00
|
787.30
|
In PCBH
|
A
|
H
|
334.30
|
458.00
|
792.30
|
COUPLES 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
A
|
$ 48.70
|
$687.00
|
$ 735.70
|
1 EP
|
A
|
C
|
73.05
|
916.00
|
989.05
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
B
|
48.70
|
458.00
|
506.70
|
Medicaid Facility
|
D
|
Z
|
---
|
60.00
|
60.00
|
IN DOMCARE 2/
|
A
|
G
|
737.40
|
687.00
|
1424.40
|
In PCBH 2/
|
A
|
H
|
747.40
|
687.00
|
1434.40
|
CODING AND PAYMENT LEVELS (01/1994 - 12/1994)
Living Arrangement
|
L/A Code
|
O/S Code
|
O/S Amount
|
Federal Payment Amount
|
Total Payment Amount
|
INDIVIDUALS 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
A
|
$ 32.40
|
$446.00
|
$ 478.40
|
1 EP
|
A
|
C
|
48.70
|
669.00
|
717.70
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
B
|
32.40
|
297.34
|
329.74
|
1 EP
|
B
|
D
|
48.70
|
446.00
|
494.70
|
In Parental Household
|
C
|
A
|
32.40
|
446.00
|
478.40
|
Medicaid Facility
|
D
|
Z
|
---
|
30.00
|
30.00
|
IN DOMCARE
|
A
|
G
|
329.30
|
446.00
|
775.30
|
In PCBH
|
A
|
H
|
334.30
|
446.00
|
780.30
|
COUPLES 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
A
|
$ 48.70
|
$669.00
|
$ 717.70
|
1 EP
|
A
|
C
|
73.05
|
892.00
|
965.05
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
B
|
48.70
|
446.00
|
494.70
|
Medicaid Facility
|
D
|
Z
|
---
|
60.00
|
60.00
|
IN DOMCARE 2/
|
A
|
G
|
737.40
|
669.00
|
1406.40
|
In PCBH 2/
|
A
|
H
|
747.40
|
669.00
|
1416.40
|
CODING AND PAYMENT LEVELS (01/1993 - 12/1993)
Living Arrangement
|
L/A Code
|
O/S Code
|
O/S Amount
|
Federal Payment Amount
|
Total Payment Amount
|
INDIVIDUALS 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
A
|
$ 32.40
|
$434.00
|
$ 466.40
|
1 EP
|
A
|
C
|
48.70
|
651.00
|
699.70
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
B
|
32.40
|
289.34
|
321.74
|
1 EP
|
B
|
D
|
48.70
|
434.00
|
482.70
|
In Parental Household
|
C
|
A
|
32.40
|
434.00
|
466.40
|
Medicaid Facility
|
D
|
Z
|
---
|
30.00
|
30.00
|
IN DOMCARE
|
A
|
G
|
329.30
|
434.00
|
763.30
|
In PCBH
|
A
|
H
|
334.30
|
434.00
|
768.30
|
COUPLES 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
A
|
$ 48.70
|
$652.00
|
$ 700.70
|
1 EP
|
A
|
C
|
73.05
|
869.00
|
942.05
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
B
|
48.70
|
434.67
|
483.37
|
Medicaid Facility
|
D
|
Z
|
---
|
60.00
|
60.00
|
IN DOMCARE 2/
|
A
|
G
|
737.40
|
652.00
|
1389.40
|
In PCBH 2/
|
A
|
H
|
747.40
|
652.00
|
1399.40
|
CODING AND PAYMENT LEVELS (01/1993 - 06/1993)
Living Arrangement
|
L/A Code
|
O/S Code
|
O/S Amount
|
Federal Payment Amount
|
Total Payment Amount
|
INDIVIDUALS 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
A
|
$ 32.40
|
$434.00
|
$ 466.40
|
1 EP
|
A
|
C
|
48.70
|
651.00
|
699.70
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
B
|
32.40
|
289.34
|
321.74
|
1 EP
|
B
|
D
|
48.70
|
434.00
|
482.70
|
In Parental Household
|
C
|
A
|
32.40
|
434.00
|
466.40
|
Medicaid Facility
|
D
|
Z
|
---
|
30.00
|
30.00
|
IN DOMCARE
|
A
|
G
|
147.30
|
434.00
|
581.30
|
In PCBH
|
A
|
H
|
152.30
|
434.00
|
586.30
|
COUPLES 1/
In Own Household
|
|
|
|
|
|
No EP
|
A
|
A
|
$ 48.70
|
$652.00
|
$ 700.70
|
1 EP
|
A
|
C
|
73.05
|
869.00
|
942.05
|
In Another's Household
|
|
|
|
|
|
No EP
|
B
|
B
|
48.70
|
434.67
|
483.37
|
Medicaid Facility
|
D
|
Z
|
---
|
60.00
|
60.00
|
IN DOMCARE 2/
|
A
|
G
|
373.40
|
652.00
|
1025.40
|
In PCBH 2/
|
A
|
H
|
383.40
|
652.00
|
1035.40
|