A medical treatment facility is an institution, or that part of an institution, licensed or otherwise, approved by a Federal, State, or local government to provide inpatient medical care and services.

For purposes of this section, health insurance means benefits consisting of medical care (provided directly, through insurance or reimbursement, or otherwise and including items and services paid for as medical care) under any hospital or medical service policy or certificate, hospital or medical service plan contract, or health maintenance organization (HMO) contract offered by a health insurance provider.

Health insurance does not include benefits covered under one or any combination of the following insurances:

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  coverage only for accident, disability income insurance, or any combination thereof;

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  coverage issued as a supplement to liability insurance;

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  liability insurance, including general liability insurance, medical malpractice insurance, homeowner liability insurance, and automobile liability insurance;

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  workers' compensation or similar insurance;

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  automobile medical payment insurance;

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  credit-only insurance; or

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  other similar insurance coverage, under which benefits for medical care are secondary or incidental to other insurance benefits.

For purposes of this section, private provider means:

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  any commercial insurance company offering health insurance to recipients or groups;

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  any profit or nonprofit prepaid plan offering either medical services or full or partial payment for medical services (e.g., HMOs, associations such as Blue Cross and Blue Shield, church-sponsored plans); or

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  any organization administering health insurance plans for professional associations, unions, fraternal groups, employer-employee benefit plans, and any similar organization offering these payments or services, including self-insured and self-funded plans.

The Federal SSI benefit is limited to a maximum of $30 per month for an eligible recipient (or $60 per month for certain couples situations as described in this section), minus any countable income, when the recipient is a resident throughout a month in a public or private medical treatment facility, and any of the following applies:

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  Medicaid, including an HMO or other private provider on behalf of an recipient for whom Medicaid is paying the premium, pays or is expected to pay over 50 percent of the cost of care for that month; or

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  Medicare Part A pays or is expected to pay over 50 percent of the cost of care for that month, and the Part A coverage was purchased for the recipient under a State plan approved under Title XIX of the Social Security Act (i.e., “State buy-in”). See example 2 in this section for additional information.

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  For children under age 18, 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; or

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

Medicaid payments made under a home or community based services waiver (as defined by Title XIX of the Social Security Act) usually do not result in imposing the $30 payment limit, even if the Medicaid payment is over 50 percent of the cost of care.

For more information on waivers in these situations, see SI 00520.510D. For information about an exception to this policy, see the second bullet of SI 00520.011C.4.

There are several exceptions to the requirement in SI 00520.011C.1. that residence in the facility must be throughout a month in order for the $30 payment limit to apply.

1. a. 

   The $30 payment limit applies if a recipient:

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     spends part of a month in a public institution where SSI eligibility would be precluded if there throughout a month, and

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     spends the rest of the month in a public or private medical treatment facility where the $30 payment limit would apply if there throughout a month (i.e., the Medicaid payment exceeds 50 percent of the cost of care in that facility during that month; or for children under age 18, Medicaid or private health insurance payments or both exceed 50 percent of the cost of care in that facility during that month).

   In such situations, the $30 payment limit applies regardless of:

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     the order of the types of institutionalization;

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     whether one facility is involved (e.g., different section of a multiple purpose facility, SI 00520.001B.10.);

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     whether two or more institutions of the same type are involved (e.g., two different Medicaid-certified medical treatment facilities and one public non-Medicaid facility); or

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     whether the absence from the public institution is temporary (i.e., 14 days or less).

   EXAMPLE: Mrs. Rush is a resident of Belvedere State Hospital Center, a public institution, where Medicaid does not make any payments toward the cost of her care. On 12/16/18, she entered West County Hospital for surgery. She remained at West County until 01/08/19, when she returned to the state hospital. She remained at the state hospital throughout the rest of January and continued to reside there. During Mrs. Rush's stay at West County, Medicaid paid over 50 percent of the cost of her care in that facility for both the month of December and the month of January. Therefore, she is eligible for the $30 reduced benefit (plus any applicable state supplemental payment) for December and January.

2. b. 

   Medicaid certification or decertification of a facility can result in exceptions to the throughout a month requirement, as follows:

   The $30 payment limit applies when:

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     a recipient is in a public medical treatment facility throughout a month; and

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     the facility is either certified or decertified for Medicaid during the month, and

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     the Medicaid payment exceeds 50 percent of the cost of care in the facility during that month; or

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     for children under 18, Medicaid or private insurance, or both payments exceed 50 percent of the cost of care in the facility during that month.

The $30 payment limit does not apply for the month of certification or decertification if for the balance of the month the institution is a private facility (except for cases where children are already subject to the $30 payment limit because of private health insurance payments).

For more information about Medicaid certification and decertification, and how they affect the $30 payment limit, see SI 00520.700.

The $30 payment limit also applies:

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  to certain recipients who are ineligible for Medicaid payment of their institutional care because they have transferred a resource (see SI 00520.012);

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  to certain severely disabled children who are living at home and who qualify for Medicaid under a state “home care” plan and who would not be otherwise eligible for SSI under the regular parental deeming rules. (See SI 01310.201B.3.)

We discuss exceptions to the $30 payment limit in SI 00520.140, “Temporary Institutionalization Benefits,” and SI 00520.130, “Special Benefits for Institutionalized 1619 Eligibles.”

Children under age 18 who are subject to the $30 payment limit because of private health insurance payments (i.e., Medicaid alone does not pay over 50 percent of the cost of their care) will receive the Optional State Supplement (OSS) amount that would apply to them if they were not subject to the $30 payment limit.

In cases where the $30 payment limit applies, the system automatically computes payments. In many cases the system automatically sends notices and identifies or controls these cases.

Until full systems support is available, you need to send manual notices for institutionalized children under age 18 who are subject to the $30 payment limit because of private health insurance payments (i.e., Medicaid alone does not pay over 50 percent of the cost of care).

Determine if the $30 payment limit applies as follows and record the information obtained and its source on a DROC screen. Also, document the file with a copy of any manual notice required in SI 00520.011G.

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  Use reports from medical treatment facilities, representative payees, and other payment sources, as necessary, in determining expected Medicaid or private health insurance payments.

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  Reopen determinations if you receive information rebutting a determination of the applicability or inapplicability of the $30 payment limit. For example, if the original source of payment (e.g., Medicaid) later determines an overpayment or lack of liability, apply the changed facts. For rules on administrative finality, see SI 04070.010.

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  Consider the exceptions to “throughout a month” in SI 00520.011C.3.

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  Consider a statement from the state Medicaid agency or its designated representative that a facility is not certified for Medicaid payments as sufficient to establish that Medicaid is not paying or expected to pay more than 50 percent of the cost of care.

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  If an institution expects to receive (or has received) payments only from Medicaid, consider those payments to be more than 50 percent of the cost of care. However, in states where the Medicaid plan will pay for only a limited number of days of the recipient’s stay in the medical treatment facility (and private insurance is not involved), apply the $30 payment limit only if the actual amount of the Medicaid payments for the month is substantial, i.e., more than 50 percent of the cost of care.

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  If Medicaid is paying more than 50 percent of the cost of care, whether or not private health insurance is involved, input FLA-D.

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  If Medicaid is not paying over 50 percent of the cost of care for an institutionalized child under age 18, determine whether private health insurance is involved.

1. a. 

   Determine whether private health insurance alone, or in combination with Medicaid payments, is paying over 50 percent of the cost of care.

2. b. 

   If the child's representative payee is the institution, accept the payee's allegation regarding private health insurance payments without further development.

3. c. 

   If the child's representative payee is not the institution:

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     Accept the payee's allegations regarding private health insurance without further development if the information would preclude eligibility or result in a reduction of the payment amount. For example, the payee reports that the child is in a public medical facility and neither Medicaid nor private health insurance, alone or in combination, pays more than 50 percent.

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     Obtain verification from the institution) if the information reported by the payee would be advantageous to the recipient. For example, obtain verification if the payee reports that the child is in a public medical facility and Medicaid, or private health insurance, or both, pays over 50 percent of the cost of care.

     When working KB critical birthday diaries (when the recipient attains age 18) for institutionalized children, redevelop private insurance issues that may affect payment or eligibility. Be alert to situations where a child will lose eligibility beginning with the month after the month of attainment of age 18 (i.e., in a public institution and Medicaid not paying over 50 percent), as well as situations where a child's payments will no longer be subject to the $30 limit.

   See details

   SI 02309.003 - Attainment of Age 18 - KB Diary - Supplemental Security Income (SSI)

   SI 00520.011C.1 - Determination of Applicability of $30 Payment Limit

1. a. 

   When the child’s payment is reduced because the $30 payment limit applies, use DPS to prepare an SSA-L8155, including paragraphs PICM01 (includes caption) and PICM02 under caption 1907, “CHILD'S NAME (POSSESSIVE) Payment is Based on These Facts.”

2. b. 

   When the child’s payment increases (i.e., goes from N02 to FLA-D), prepare a manual SSA-L8151, Notice of Change of Payment, including paragraphs PICM01 and PICM02.