SSR 78-9: Rescinded 1982

SSR 78-9

PURPOSE:

To state new policy requiring separate computations of Federal

supplemental security income (SSI) benefits for an eligible individual and

his eligible spouse when one is in a hospital, skilled nursing facility,

or intermediate care facility which is receiving payments under a State

plan approved under title XIX.

CITATIONS (AUTHORITY):

Sections 1611(b), 1611(e)(1)(B)(ii) as amended by Section 502 of Public

Law 94-566, 1612, 1631(a)(2) of the Social Security Act; Sections

416.120(c)(5), 416.231(a)(2), 416.231(b)(5), 416.248(c), 416.424, 416.430,

416.432(b), 416.432(c), 416.1040(a), 416.1040(c(1) and 416.1146 of

Regulations No. 16 (20 CFR Chap. III).

PERTINENT HISTORY:

In determining SSI benefits for an eligible individual and his eligible

spouse, one of whom is throughout any month in an institution receiving

payments under a State plan approved under title XIX (hereinafter referred

to as a "Medicaid facility") the reduction in the rate of payment required

by section 1611(e)(1)(B)(ii) of the Act due to such confinement, has

heretofore applied to the couple as an entity, and there have been no

separate computations for each member. That is, the maximum rate of

payment for a couple under section 1611(b)(2) of the Act (currently

$3,021.60 per year) was reduced to the sum of the maximum payable to an

individual under section 1611(b)(1) of the Act (currently $2,013.60 per

year) plus $300 ($25 per month), the maximum payable to an individual in a

Medicaid facility in a year, and the total thus produced became the

maximum rate of payment per year for such eligible individual with an

eligible spouse. This, in turn, was subject to reduction by the countable

income chargeable to them as a couple. The total was then disbursed in

amounts of not more than $25 per month to the member in the Medicaid

facility, and the remainder to the other member, or in equal amounts if

the total did not exceed $50.

he

maximum rate of payment per year for such eligible individual with an

eligible spouse. This, in turn, was subject to reduction by the countable

income chargeable to them as a couple. The total was then disbursed in

amounts of not more than $25 per month to the member in the Medicaid

facility, and the remainder to the other member, or in equal amounts if

the total did not exceed $50.

In the event the noninstitutionalized member of the couple was living

throughout a month in the household of another from whom he was receiving

support and maintenance, computation of the rate of payment as described

above was modified so as to reduce the rate of payment to such member of

the couple as an individual under section 1611(b)(1) by one-third, in

accordance with section 1612(a)(2)(A) of the Act and section 416.432(c) of

the regulations. In the event an essential person was living with the

couple, the payment increment attributable to the essential person was

added to the rate of payment for the couple. Where there was a separation,

retention of essential person status depended on whether the essential

person continued to reside with a qualified individual. However, where the

qualified individual is temporarily absent from home (as would be the case

where confined to a Medicaid facility for not more than 6 months), the

increment to the rate of payment because of the presence of the essential

person is, under the regulations (section 416.248(c)), allowed to continue

until 6 full months elapse or earlier where evidence indicates that the

qualified individual does not intend to return to the home. Consequently,

confinement in a Medicaid facility did not necessarily terminate the

essential person increment or affect the rate of payment to the couple.

he presence of the essential

person is, under the regulations (section 416.248(c)), allowed to continue

until 6 full months elapse or earlier where evidence indicates that the

qualified individual does not intend to return to the home. Consequently,

confinement in a Medicaid facility did not necessarily terminate the

essential person increment or affect the rate of payment to the couple.

In all such cases of confinement to which the reduced rates of payment

applied, such reduction was predicated by law (section 1611(e)(1)(B)) and

regulation (see section 416.231(b)(5) of the regulations) on the receipt

by the institution of more than 50 percent of the cost of services being

provided by title XIX funds on behalf of the individual so confined.

The policies described above are applicable to the computation of payment

rates for such an eligible couple for all months prior to October 1976.

However, Section 502 of Public Law 94-566 amended Section

1611(e)(1)(B)(ii) of the Social Security Act to provide a new method of

computation and payment for an eligible individual with an eligible spouse

when one of them is so confined throughout a month.

POLICY DIRECTIVE STATEMENT:

Effective October 1976, for the purposes of computing and paying SSI

benefits to an eligible individual with an eligible spouse when one of

them is throughout a month in an institution which is receiving payments

of more than 50 percent of the cost of services under a State plan

approved under title XIX, each member of the couple will be treated as an

individual; for each of these months the benefit payment to each

individual will be computed separately in accordance with the following

formula:

eligible spouse when one of

them is throughout a month in an institution which is receiving payments

of more than 50 percent of the cost of services under a State plan

approved under title XIX, each member of the couple will be treated as an

individual; for each of these months the benefit payment to each

individual will be computed separately in accordance with the following

formula:

- From the maximum rate prescribed for an individual under section

1611(b)(1) of the Act, there will be deducted the countable income of the

member of the couple who is not in a Medicaid facility, computed as if he

were an eligible individual who does not have an eligible spouse and

without regard to any income of the other eligible member of the couple.

That is, the amount specified in section 1611(b)(1) of the Act (after

reduction by one-third, if such noninstitutionalized individual is living

in the household of another as required by section 1612(a)(2)(A) of the

Act) will be reduced by the amount of such individual's income, if any,

that is not excludable under section 1612(b) of the Act (Subpart K of

Regulations No. 16 generally), or excludable under any other Federal

statute. (Section 416.1146 of such Subpart K). The difference, if any,

will be the amount of the Federal SSI payment to the eligible spouse who

is not confined in a Medicaid facility.

- From the maximum rate prescribed for an individual in a Medicaid facility

under section 1611(e)(1)(B)(ii) of the Act, there will be deducted the

countable income of the member who is confined throughout any month in a

Medicaid facility, computed as if such member were an individual and

without regard to any income of the institutionalized eligible member of

the couple. That is, the rate specified in 1611(e)(1)(B)(ii), namely $300

per year, will be reduced by the amount of such individual's income, if

any, that is not excludable under section 1612(b) of the Act (Subpart K of

the Regulations No

h in a

Medicaid facility, computed as if such member were an individual and

without regard to any income of the institutionalized eligible member of

the couple. That is, the rate specified in 1611(e)(1)(B)(ii), namely $300

per year, will be reduced by the amount of such individual's income, if

any, that is not excludable under section 1612(b) of the Act (Subpart K of

the Regulations No. 16, generally) or excludable under any other Federal

statute (Section 416.1146 of such Subpart K). The difference, if any, will

be the amount of the Federal SSI payment to the eligible spouse confined

in a Medicaid facility.

- In the event an essential person(s) is living with the couple at the time

the eligible individual or spouse enters the Medicaid facility, and the

separation is temporary (section 416.1040(c)(1), the income deemed from

the essential person(s), if any, will be added to the income of the

noninstitutionalized individual, and the essential person(s) increment(s)

will be added to the benefit rate for the noninstitutionalized individual.

The above is applicable even though the confined member is the sole

qualified person.

- Federally administered State supplementary payments and State

administered mandatory minimum supplements will be computed in the same

manner as stated in this Policy Directive Statement, that is, when Public

Law 94-566 applies, the State supplementary payment level (combined

Federal plus State) applicable for an individual is used for the

noninstitutionalized member.

- The computation and payment polices prescribed in the preceding

paragraphs of this Policy Directive Statement are applicable for each

month in which an eligible individual or eligible spouse remain in a

Medicaid facility throughout a month.

ies, the State supplementary payment level (combined

Federal plus State) applicable for an individual is used for the

noninstitutionalized member.

- The computation and payment polices prescribed in the preceding

paragraphs of this Policy Directive Statement are applicable for each

month in which an eligible individual or eligible spouse remain in a

Medicaid facility throughout a month.

From the maximum rate prescribed for an individual under section

1611(b)(1) of the Act, there will be deducted the countable income of the

member of the couple who is not in a Medicaid facility, computed as if he

were an eligible individual who does not have an eligible spouse and

without regard to any income of the other eligible member of the couple.

That is, the amount specified in section 1611(b)(1) of the Act (after

reduction by one-third, if such noninstitutionalized individual is living

in the household of another as required by section 1612(a)(2)(A) of the

Act) will be reduced by the amount of such individual's income, if any,

that is not excludable under section 1612(b) of the Act (Subpart K of

Regulations No. 16 generally), or excludable under any other Federal

statute. (Section 416.1146 of such Subpart K). The difference, if any,

will be the amount of the Federal SSI payment to the eligible spouse who

is not confined in a Medicaid facility.

From the maximum rate prescribed for an individual in a Medicaid facility

under section 1611(e)(1)(B)(ii) of the Act, there will be deducted the

countable income of the member who is confined throughout any month in a

Medicaid facility, computed as if such member were an individual and

without regard to any income of the institutionalized eligible member of

the couple. That is, the rate specified in 1611(e)(1)(B)(ii), namely $300

per year, will be reduced by the amount of such individual's income, if

any, that is not excludable under section 1612(b) of the Act (Subpart K of

the Regulations No

h in a

Medicaid facility, computed as if such member were an individual and

without regard to any income of the institutionalized eligible member of

the couple. That is, the rate specified in 1611(e)(1)(B)(ii), namely $300

per year, will be reduced by the amount of such individual's income, if

any, that is not excludable under section 1612(b) of the Act (Subpart K of

the Regulations No. 16, generally) or excludable under any other Federal

statute (Section 416.1146 of such Subpart K). The difference, if any, will

be the amount of the Federal SSI payment to the eligible spouse confined

in a Medicaid facility.

In the event an essential person(s) is living with the couple at the time

the eligible individual or spouse enters the Medicaid facility, and the

separation is temporary (section 416.1040(c)(1), the income deemed from

the essential person(s), if any, will be added to the income of the

noninstitutionalized individual, and the essential person(s) increment(s)

will be added to the benefit rate for the noninstitutionalized individual.

The above is applicable even though the confined member is the sole

qualified person.

Federally administered State supplementary payments and State

administered mandatory minimum supplements will be computed in the same

manner as stated in this Policy Directive Statement, that is, when Public

Law 94-566 applies, the State supplementary payment level (combined

Federal plus State) applicable for an individual is used for the

noninstitutionalized member.

The computation and payment polices prescribed in the preceding

paragraphs of this Policy Directive Statement are applicable for each

month in which an eligible individual or eligible spouse remain in a

Medicaid facility throughout a month.

DOCUMENTATION:

supplementary payment level (combined

Federal plus State) applicable for an individual is used for the

noninstitutionalized member.

The computation and payment polices prescribed in the preceding

paragraphs of this Policy Directive Statement are applicable for each

month in which an eligible individual or eligible spouse remain in a

Medicaid facility throughout a month.

DOCUMENTATION:

Evidence that one member of a couple is in a hospital, skilled nursing

facility or intermediate care facility throughout a month, and that such

institution is receiving payments of more than 50 percent of the cost of

services on behalf of the individual under a State plan approved under

title XIX will be obtained.

FURTHER INFORMATION:

The amended rules, as described above, for computing benefits where a

member of a couple is in a Medicaid facility are not applicable to a

determination of initial eligibility for such couple; the rules for

determinations of eligibility applicable prior to the enactment of Section

502 of Public Law 94-566 will continue in effect. In other words, upon

application, a couple's eligibility will be determined based on a

couple's benefit amount and a couple's resource limit, and where

applicable computation and payment to the eligible individual and eligible

spouse will be based on the formula set out in the above Policy Directive

Statement. The application resources limit continues to be that of a

couple ($2,250.00). The effect of Section 502 of Public Law 94-566 was to

amend title XVI for computation and payment purposes when one member of an

eligible couple is confined throughout a month in an institution and the

institution is receiving payments of more than 50 percent of the cost of

services on behalf of the individual under a State plan approved under

title XIX

be that of a

couple ($2,250.00). The effect of Section 502 of Public Law 94-566 was to

amend title XVI for computation and payment purposes when one member of an

eligible couple is confined throughout a month in an institution and the

institution is receiving payments of more than 50 percent of the cost of

services on behalf of the individual under a State plan approved under

title XIX. Policies related to such areas as liability for overpayments

are not changed by the above policy statement in view of the fact that

this section of the law as amended does not change eligibility status of

the couple.