Revision 09-4; Effective December 1, 2009

SSI persons who enter a Medicaid long-term care facility can continue to receive their community-based SSI payment in the following situations:

• Section 1619 eligibility
  
  Disabled individuals with earnings greater than the SSI benefit rate can continue to receive SSI or Medicaid benefits or both under Section 1619 of the Social Security Act (Public Law 99-643, effective July 1, 1987). These individuals can receive the community-based SSI payment for two months after the month of entry to a Medicaid facility.
   
• Temporary institutionalization
  
  Effective July 1, 1988, Public Law 100-203 allows SSI persons who meet certain requirements to continue receiving their SSI benefits while they are temporarily confined to a medical facility.
  
  These continued benefits may be made for up to three months after the month of entry if:
  • the individual notifies the SSA that he expects to be in a medical facility for at least a full calendar month but for fewer than 90 days;
  • SSA receives a physician's certification within 10 days after the close of the month of admission. The physician certifies that the individual is likely to leave the facility no later than the 91st consecutive day after admission; and
  • SSA receives evidence within 10 days after the close of the month of admission that the individual needs to maintain and provide for the expenses of the home or living arrangement to which he may return.

In each situation, the SSI person is allowed to keep SSI benefits for the first two or three calendar months, respectively, after the month of entry. Neither law affects the SSI benefit for the month of entry. Because the Nursing Home Billing System generally does not consider the SSI benefit toward calculating the co-payment for months after the month of entry, do not process Form H1259, Correction of Applied Income, for these cases.

H-6210 Manual Certification Procedures

Revision 16-3; Effective September 1, 2016

Some SSI recipients do not appear on the SDX tapes and therefore are not shown as Medicaid eligible on HHSC's computer system. Cases that are provided Medicaid coverage by means of a manual certification include the following:

• Prior SSI recipients who are not currently eligible and who were never certified for Medicaid on HHSC's computer system;
• SSI recipients who are issued a check manually by the Social Security district office;
• SSI recipients shown on the Social Security master file but not shown on HHSC's computer system; and
• SSI applicants with unpaid or reimbursable medical bills in Texas who move out of the state before SSI eligibility is approved.

The Social Security district office must initiate the manual certification procedure. When applicable, the Social Security district office completes a manual certification form and mails it to HHSC's Data Integrity department. Data Integrity certifies these persons for ME – Temporary Manual SSI. These persons are sent a Your Texas Benefits Medicaid ID card by the state office. A person remains certified for ME – Temporary Manual SSI Medicaid until the person's information appears on the SDX tape or until SSA submits a manual request to deny the eligibility. Cases for persons certified for ME – Temporary Manual SSI must be manually updated by the Social Security district office.

If an SSI recipient contacts a Social Security office requesting assistance in obtaining a Your Texas Benefits Medicaid ID card, the recipient's current Medicaid status must be determined before a manual certification form is initiated. When a request is received by the SSA representative regarding the current eligibility status of the SSI recipient, the eligibility specialist provides the requested information by verifying the recipient's status through system inquiry or via regional procedures.

If Medicaid status cannot be determined locally, the Social Security representative submits a manual certification form, assuming that the SSI recipient is not certified for Medicaid. (If the SSI recipient is currently certified as Medicaid eligible, the form is retained in state office for future reference.)

If an SSI recipient contacts HHSC requesting assistance in obtaining a Your Texas Benefits Medicaid ID card, obtain the name, address and Social Security number. Perform inquiry through the automated systems to verify Medicaid status. If the SSI recipient is not certified for Medicaid, or if current status cannot be determined, inform the Social Security district office that a manual certification is needed.

If an SSI recipient is certified for Medicaid but circumstances exist that may have stopped the receipt of the Your Texas Benefits Medicaid ID card, refer the recipient to the Social Security district office. If no change in circumstances occurred, send an email to Data Integrity, ME Unit.

Data Integrity attempts to resolve the problem and reports the action taken. Notify the Social Security district office (using Form H1016, Supplemental Security Income Referral) of any change reported by SSI recipients.

Reminder: Manual certifications are sent to state office by SSA when SSA cannot process the SSI certification on the SDX due to systems limitations. Do not issue a Form H1027 for manual certifications unless authorized by Data Integrity in state office.

H-6220 Emergency Manual Certification

Revision 16-3; Effective September 1, 2016

In some instances, it may be necessary for a newly certified SSI recipient to obtain emergency medical services before the receipt of the Your Texas Benefits Medicaid ID card. The SSA representative determines if the recipient's situation is considered a medical emergency. If the representative determines that a medical emergency does exist, the following procedures are followed by the department and SSA to ensure that the recipient has access to the appropriate services.

An eligible SSI recipient who has not received his Medicaid number and the Your Texas Benefits Medicaid ID card and has a medical emergency may request immediate assistance in obtaining an emergency Medicaid certification. In this situation, the local SSA representative contacts a local Medicaid eligibility specialist or supervisor.

When the SSA representative contacts you regarding the current eligibility status of the SSI recipient, provide the requested information by verifying the recipient's status through system inquiry or regional procedures. The SSA representative informs HHSC staff:

• that an emergency manual certification is being sent to the Data Integrity in state office and about the nature of the recipient's emergency; and
• identification information for the recipient, including:
  • name;
  • Social Security number;
  • address;
  • telephone number; and
  • special instructions needed for contact.

Data Integrity staff expedite the processing of the emergency Medicaid certification. Section staff also contacts local HHSC staff to authorize completion of the appropriate Form H1027.

When authorization is received from Data Integrity staff, expedite the delivery of the form to the recipient and, if necessary, notify the provider of the recipient's Medicaid eligibility.

Reminder: Emergency manual certifications are orally expedited to HHSC for the purpose of issuing an appropriate Form H1027. A newly certified SSI recipient usually does not yet have a Medicaid number. Do not issue Form H1027-A until authorized to do so by Data Integrity in state office. 

H-6230 SSI Payment Placed in Suspense by SSA

Revision 11-1; Effective March 1, 2011

An SSI recipient may be eligible to receive an SSI payment, but does not receive it because of some problem. Problems may occur because of a change of address, returned check, change of payee or other reasons that cause the payment to be placed in suspense.

A suspense code on the SDX tape is interpreted as a denial of Medicaid because the person is not receiving an SSI payment. When the person is reinstated in a current pay status, Medicaid eligibility is also reinstated.

Cases placed in suspense and the reasons for suspension may be recognized by the denial code shown on the SSI case screen. The codes are:

Code	Eligibility	Reason
S04	Suspended	Disability decision pending
S05	Suspended	Substantial, gainful activity development pending
S06	Suspended	Recipient's address unknown
S07	Suspended	Returned checks for other than address, payee change or death of payee
S08	Suspended	Representative payee development pending
S09	Suspended	Recipient refuses to cooperate
S20	Suspended	Potential rollback case or no disability payment made before 7-73
S21	Suspended	The recipient is presumptively disabled and has already received payments

If an SSI recipient whose case is in a suspense status contacts HHSC, ask the recipient to contact SSA so that the cause of the suspense action may be promptly resolved. Unless an emergency situation exists, do not contact SSA to initiate a manual certification for the recipient. If SSA verifies that the recipient has been denied SSI assistance because of entry into a Medicaid facility, take an MEPD application for assistance. 

H-6240 Residence in a Public Institution or Acute Care Hospital

Revision 13-1; Effective March 1, 2013

Eligibility for recipients in acute care hospitals is determined using the SSI federal benefit rate.

Generally, a person is not eligible for SSI if he/she is a resident of a public institution throughout the calendar month. The following definitions apply for purposes of this policy:

Institution — An establishment that makes available some treatment or services, besides food and shelter, to four or more persons who are not related to the proprietor.

Public institution — An establishment that is operated or controlled by federal or state or government unit, or a political subdivision, such as the city or county.

Except for patients in Medicaid facilities and certain persons described in this section, persons who are inmates and live in public institutions throughout the calendar month are not eligible for medical assistance:

• A person is considered a resident of a public institution if he receives the substantial portion of his food and shelter while living in the institution. This is true whether he is receiving treatment and services available in the institution or whether he or someone else is paying for his food, shelter and services. A person is not considered a resident of a public institution if he lives in a public educational institution and is enrolled in or registered for the institution's educational or vocational training.
• A person is considered to be living in an institution throughout the calendar month if she lives there from the first day of a month through the last day of that month. SSA considers a person to be living in an institution continuously if she transfers from one institution to another or is temporarily absent without being discharged. A person is also considered a resident of an institution throughout a month if she:
  • is born in the institution and remains throughout the rest of the month of her birth; or
  • lives in an institution on the first day of a month and dies in the institution during that month.
• A person who is placed in a Medicaid-certified facility (Medicare-SNF, NF or ICF/IID) after permanent release from a jail, prison, reformatory, or other correctional or holding facility is not considered to be under the control of that institution. In these cases, the person could be eligible for Medicaid if he meets all eligibility criteria.

Some persons may be eligible for SSI although they are residents of a public institution throughout the month. These exceptions are as follows:

• A person lives throughout the calendar month in a medical care facility, and Medicaid pays or is expected to pay more than 50% of the person's cost of care.
• A person lives for:
  • part of the month in a public institution; and
  • the rest of the month in a public or private medical care facility in which Medicaid pays or is expected to pay more than 50% of the person's cost of care.
• A person lives in a publicly operated community residence that serves no more than 16 residents. Community residences, for this purpose, do not include medical care facilities, educational or vocational training institutions, jails or other facilities for restraint of prisoners or persons being held pending disposition of legal charges. 

H-6250 Residence in a Medical Care Facility

Revision 11-1; Effective March 1, 2011

SSI uses a reduced federal benefit rate of $30 for individuals and $60 for couples if:

• they live in a public or private medical care facility; and
• Medicaid pays, or is expected to pay, more than 50% of the cost of the individual's or couple's care; or
• a child under age 18 lives in a medical care facility where a substantial part (more than 50%) of the cost of his care is paid by a health insurance policy issued by a private provider of such insurance, or where a substantial part (more than 50%) of the cost of his care is paid for by a combination of Medicaid payments and payments made under a health insurance policy issued by a private provider of such insurance.

Note: The reduced federal benefit rate applies for an SSI recipient during the penalty period when there has been a transfer of assets. (See Chapter I, Transfer of Assets.)

Reduced benefits apply in the following situations:

• An individual or couple lives in one or more medical care facilities throughout the calendar month, and Medicaid pays, or is expected to pay, more than 50% of the cost of care in each facility.
• An individual or couple lives for a part of the month in a public institution and the rest of the month in a public or private medical care facility in which Medicaid pays, or is expected to pay, more than 50% of the cost of care.
• A child under age 18 lives for part of a month in a public institution and for the rest of the month in a public or private medical care facility where a substantial part (more than 50%) of the cost of care is being paid under a health insurance policy issued by a private provider or by a combination of Medicaid and payments under a health insurance policy issued by a private provider.

If an individual or couple lives in more than one private medical facility throughout a calendar month, and Medicaid pays less than 50% of the cost of care in at least one of the facilities, the individual or couple may be entitled to the full SSI federal benefit rate.

In some instances, Medicaid liability may exist for only part of a month, even though the individual or couple lives in one private Medicaid facility throughout that month. The variables that would affect Medicaid liability include, but are not limited to, the medical effective date, level-of-care/medical necessity determination effective date and the 30-day limit on hospital services. If these limitations would cause Medicaid to pay for less than 50% of the cost of care, the affected individual or couple may be entitled to the full SSI federal benefit rate.

Medicaid also does not pay for nursing facility care when the PASARR assessment indicates that placement is not appropriate. 

H-6260 Facility Administrator Responsibilities

Revision 13-1; Effective March 1, 2013

If an individual who is receiving or who is potentially eligible to receive SSI benefits enters a Medicaid facility (Medicare-SNF, NF or ICF/IID), refer the administrator to the Nursing Facility Requirements for Licensure and Medicaid Certification Handbook for appropriate procedures. The administrator should notify SSA that an SSI recipient has entered the facility. For potential SSI recipients, the administrator is responsible for contacting SSA to secure a protected date of filing for SSI and to ensure that an eligibility determination is completed.

H-6270 SSI Monitoring

Revision 12-1; Effective March 1, 2012

Upon notification or discovery of a person receiving SSI entering an institutional setting, determine if the SSI will continue upon entry or if the SSI will be denied.

If the recipient's SSI benefits are anticipated to continue, send Form H1224, SSI Monitoring Letter, to the recipient, spouse or authorized representative.

Do not send Form H1224 if the recipient's SSI benefits are anticipated to be denied as a result of entry into the facility.

Reference: See B-7200, SSI Cash Benefits Denied Due to Entry into a Medicaid Facility.

Note: In addition to providing verification of the recipient's income and resources, Form H1224 is used to obtain information regarding transfers of assets by an SSI recipient.

After eligibility for ME-SSI benefits is reported to HHSC and admission forms and medical necessity or level of care are processed, the Service Authorization System Online (SASO) is updated with a co-payment. Review the SASO co-payment for accuracy. (See Chapter H, Co-Payment.) If correct, no action is needed. If incorrect, complete Form H1259, Correction of Applied Income (The Amount You Pay to the Facility), and enter changes into SASO. Remember to hold for 12 days if the co-payment is being increased. When Form H1259 is processed to correct co-payment, the co-payment change requires a "force" action in SASO. If ongoing co-payment has a force, future updates will not reflect in SASO. If the recipient does not have income other than SSI, no further monitoring is required. Check co-payment in SASO for accuracy. If the recipient has variable income along with SSI, monitor the case every six months.

If the recipient has other non-variable income along with SSI, a periodic review is required to ensure that the payment plan is correct. Conduct the periodic review at least every 12 months. Use the same procedure for reviews as is used for initial monitoring.