SSA - POMS: SI 00835.043 - Temporary Absence from a Federal LA Due to Confinement in a Medicaid Facility

A. When to Use

Use the instructions in this section to determine temporary absence from a Federal LA unless the individual qualifies for continuation of benefits because of temporary institutionalization (SI 00520.140) for any portion of the same confinement.

B. Policy— When an Absence is Temporary

1. Conditions for a Temporary Absence

A temporary absence exists, without time limit, if an individual:

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has been in his permanent living arrangement for at least 1 full calendar month prior to his absence;
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intends to return to the permanent living arrangement; and
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throughout each calendar month of absence is subject to the $30 payment limit because he is in a medical care facility where Medicaid pays more than 50 percent of the cost of the individual's care. This also includes situations where the payment limit applies when Medicaid does not pay because of a transfer of resources.

2. ISM During a Temporary Absence

We value ISM as if an individual were physically in his permanent living arrangement for the month of entry into the facility and the month in which the temporary absence ends. However, we do not charge food or shelter as income for any month the $30 payment limit applies.

C. Policy— Ending a Temporary Absence

1. What Ends a Temporary Absence

A temporary absence due to confinement in a Medicaid facility ends when:

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the individual returns to the permanent residence;
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the individual's intent to return changes;
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the individual leaves the Medicaid facility and does not return to the permanent residence (see 2. below to determine if a new period of temporary absence may be established); or
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Medicaid does not or is not expected to pay more than half the cost of care for the month. (The temporary absence ends sometime after the first moment of the affected month.)

2. What Establishes a New Residence

At the moment a temporary absence due to confinement in a Medicaid facility ends (for a reason other than return to the permanent living arrangement), the individual is abandoning his previous permanent living arrangement unless there is a new period of temporary absence. A new period of temporary absence is possible as long as the individual still intends to return to the permanent living arrangement.

EXAMPLE: Mrs. Hull lives alone in an apartment she rents, and she receives no ISM. On May 15 she leaves her apartment to enter a nursing home. Medicaid pays for her care, and she is subject to the $30 Federal payment limit for June. (SI 00520.140 does not apply because her doctor expected her stay in the home to exceed 90 days.) Mrs. Hull leaves the nursing home on August 30 and goes to her daughter's home, where she plans to stay for a few weeks until she has regained enough strength to manage by herself. Her daughter accepts no payment from Mrs. Hull for staying there. Mrs. Hull returns to her apartment on September 23. When her temporary absence due to confinement in a Medicaid facility ends in August, she starts a new period of temporary absence. The second period (August 30 through Septemper 23) is a temporary absence for reasons other than confinement in a Medicaid facility or school attendance. Since her stay at her daughter's home was also temporary, we do not charge Mrs. Hull with ISM for September.

D. Procedure— Eligible Individual Absent

Use this procedure any time an eligible individual reports entering or physically residing in a Medicaid- certified facility for more than a calendar month and is subject to the $30 payment limit.

1. Development

STEP	ACTION
1	Ask whether the individual intends (or intended) to return home (i.e., his permanent living arrangement).
	• If yes, go to step 2. • If no, determine there is no temporary absence and see 2.a. below.
2	Ask how long the individual had lived at home prior to the absence.
	• If more than a full calendar month, go to step 3. • If less than a full calendar month, determine there is no temporary absence and see 2.a. below.
3	Contact the Medicaid-certified facility to find out if Medicaid paid or is expected to pay more than half the cost of care. This will have to be documented for purposes of determining application of the $30 payment limit in most cases anyway (SI 00520.011).
	• If Medicaid pays for more than half the cost of care or if the reason Medicaid does not pay is because of a transfer of resources, then determine that the absence is temporary and see 2.b. below. • If Medicaid does not pay for more than half the cost of care and the reason is not because of a transfer of resources, then determine that the absence is not temporary and see 2.a. below.

2. Documentation

Document the circumstances surrounding the absence to support your determination as follows.

a. Intent

Obtain the individual's or representative payee's statement, signed or on DROC, concerning the individual's intent to return to the permanent living arrangement. The representative payee's statement of intent is controlling.

b. Length of Time in Permanent Living Arrangement

Obtain the individual's or representative payee's statement, signed or on DROC, regarding length of time the individual resided in the permanent living arrangement prior to the absence.

c. Medicaid Payment

Record a contact with the facility regarding Medicaid's payment of more than half the cost of care for the calendar months of confinement.

E. Procedure— Ineligible Household Member Absent

1. When to Develop

Develop the issue of a temporary absence for another member of the household, who is neither currently on the rolls nor filing for SSI, when:

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the absence is alleged to be temporary; and
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if not temporary, the absence would affect an eligible individual's eligibility or payment amount by changing the results of the LA/ISM determination (see SI 00835.510 on breakpoints).

2. How to Develop

Use the rules in SI 00835.041 to develop an ineligible individual's temporary absence due to confinement in a Medicaid facility. Such an absence, if in excess of one calendar month, cannot be temporary because an ineligible individual cannot be subject to the $30 payment limit.

F. References

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SI 00520.011, rules regarding medical treatment facilities, Medicaid payments, and calendar month evaluations
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SI 00520.012, rules regarding the applicability of the $30 payment limit when Medicaid does not pay for costs because of a resource transfer

Social Security

Program Operations Manual System (POMS)

SI 00835.043 Temporary Absence from a Federal LA Due to Confinement in a Medicaid Facility