210-RICR-50-00-3. SSI-Related Coverage Groups (version Technical Revision, 07/27/2006 to 11/13/2017)

0394 SSI-RELATED COVERAGE GROUPS 0394.05 INSTIT IND, SSI ELIG IN COMM REV:01/2002 This coverage group consists of individuals in a medical or nursing facility who would be eligible for SSI if living in the community. This includes individuals with sufficient income to meet personal needs while in the facility, but not enough income to meet their needs outside the community according to SSI and State Supplement Standards. 0394.10 INSTIT IND, NOT SSI ELIG IN COM REV:01/2002 This coverage group consists of individuals in a medical or nursing facility who would not be eligible for SSI if s/he were living in the community. While in the facility these individuals are MA eligible under a special income level for institutionalized individuals (the Federal Cap). The resources of institutionalized persons in this coverage group must be within SSI limits. 0394.15 12/73 RES OF TITLE XIX FACILIT REV:06/1994 This coverage group (InRHODES Category Code 18) consists of individuals who were eligible for AABD as residents or inpatients of Title XIX facilities or were, on the basis of need for institutional care, considered to be eligible for AABD in the month of December, 1973. The Title XIX facilities are the Eleanor Slater Hospital and Zambarano Hospital. Eligibility for Medical Assistance continues for these individuals as long as they: o Remain residents of the Title XIX facilities; and, o Meet the eligibility conditions of AABD as of December, 1973; and, o Are in need of institutionalized care. Due to the small number of individuals in this coverage group, this category will be entered to InRHODES by the Eligibility Technician using the InRHODES manual determination command (MANL). 0394.20 CONTIN SSI ELIG, SHORT CONFINE REV:01/2002 This coverage group consists of SSI recipients who enter medical facilities, including acute care hospitals and Nursing facilities, and who intend to return to their community residences within ninety (90) days. The Omnibus Budget Reconciliation Act (OBRA) of 1987 provides for the continuation of full SSI benefits for up to three months. The intent of the OBRA provision is to allow individuals to retain their community residences while temporarily confined to a hospital or Long Term Care facility. The eligibility requirements for continued SSI benefits are: o A physician must certify in writing that the individual's medical confinement is not expected to exceed ninety (90) days; and, o The individual must certify in writing that s/he needs the benefit to maintain the home; and, o Documents attesting to the above conditions must be received by the SSA not later than ten (10) days after the end of the month in which the individual entered the hospital. 0394.25 EMPLOYED IND, SSI BY 1619 (B) REV:01/2002 This coverage group consists of disabled persons who are working and who receive special SSI payments under Section 1619b of the Social Security Act. Individuals who received SSI payments in the month prior to institutionalization receive two (2) months of continued benefits when admitted to: o Eleanor Slater Hospital; o Zambarano Hospital. 0394.30 INSTIT IND, AABD ELIG IN 12/73 REV:01/2002 This coverage group consists of individuals who, whether or not they actually received cash assistance in December, 1973 satisfy the following criteria: o Eligibility for cash assistance in December, 1973 because they were blind or disabled under the State's approved AABD plan; and, o For each consecutive month after December, 1973, continued eligibility based on the December, 1973 conditions of blindness or disability, and the other conditions of the plan in effect in December, 1973; and, o Income and resources within current SSI standards. 0394.35 DISABLED CHILD-KATIE BECKETT REV:08/2006 This coverage group consists of certain disabled children under the age of nineteen (19) who are living at home and who would qualify for Medical Assistance if in a medical institution. "Katie Beckett" coverage requires that the child meet special eligibility conditions in addition to financial eligibility. A child under 19 years of age who is living at home but who is in need of the level of care provided in a hospital, Nursing Facility, or Intermediate Care Facility for Mental Retardation, has his/her Medical Assistance financial eligibility determined as if s/he were actually institutionalized. ONLY THE CHILD'S OWN INCOME AND RESOURCES ARE USED IN THE DETERMINATION OF FINANCIAL ELIGIBILITY. THE INCOME AND RESOURCES OF THE CHILD'S PARENTS ARE NOT DEEMED TO BE AVAILABLE TO THE CHILD. A "Katie Beckett" child is deemed Categorically Needy for the full scope of medical services. The purpose of "Katie Beckett" coverage is to make Medical Assistance for home care available to children who might otherwise be disqualified due to the parents' income. 0394.35.05 Special Elig Conditions REV:08/2006 To be eligible for Katie Beckett coverage, it must be determined that: o The child requires the level of care provided in a hospital, a Nursing Facility, or an ICF-MR. The DHS worker must assure that a completed assessment of the child's needs is sent to the Center for Child and Family Health (CCFH). This unit has the responsibility of determining the level of care and disability status for the child and the specific time frame for re-evaluation. o The level of care provided at home is appropriate for the child; o The estimated cost to Medical Assistance for providing the appropriate level of care at home does not exceed the cost to Medical Assistance for providing care in an institutional setting. If the child meets these special eligibility conditions and is otherwise eligible, the DHS worker authorizes medical coverage. Children eligible for Medical Assistance under this coverage group may be enrolled in a Rite Care Health Plan in accordance with provisions contained in Section 0348, if they are not otherwise covered by a third party health insurance plan. 0394.35.10 Instit, Home Cost Comparison REV:08/2006 The estimated cost to MA of providing care for the child at home cannot exceed the estimated cost to MA of providing care in an institution. To make this determination, the DHS worker compares the gross monthly cost for the required level of care (hospital, NF, or ICF-MR, as appropriate) to the total gross monthly cost for allowed home care services), using the Waivered Services Panel in the InRHODES eligibility function. 0394.35.10.05 Allowed Home Care Services REV:09/2003 Allowed home care services are: o Certified home health agency services, including skilled nursing; physical, speech and occupational therapy and home health aid services; and, o Purchase or rental of durable medical equipment; o Home based therapeutic services; and, o Minor assistive devices, minor home modifications, and other special equipment. Certain services may be provided by school systems for school age children, by family members and/or by volunteers and are not to be considered in estimating the cost of care at home. It should be noted, however, that for school age children these services are the legal responsibility of the school system. 0394.35.10.10 Determ Costs of Instit Care REV:08/2006 The DHS worker determines if the costs of services required to provide an appropriate level of care in the home are within the costs of care in the appropriate institution. If eligible, there is no income applied to the cost of services. The child is allowed to retain all income for community living expenses. If the total estimated cost of care in the home is less than the total estimated cost of care in the appropriate institution, the child meets this special condition and, if otherwise eligible, is eligible for the full scope of MA benefits. If the total estimated cost of services required to allow the child to be cared for at home exceeds the cost of institutional care, the child is ineligible, even if the child meets all other eligibility requirements. 0394.35.15 Financial Eligibility Requirements REV:08/2006 To establish financial eligibility for "Katie Beckett" coverage, the DHS worker determines if the child would be eligible for Medical Assistance, as either Categorically Needy or Medically Needy, if the child were institutionalized. Under the law, if the child meets the "Katie Beckett" requirements, s/he, for MA purposes only, is deemed to be receiving an SSI cash payment, and is therefore CATEGORICALLY NEEDY. Only the income and resources of the child are considered. Any payment provided under Title XX or other federal, state or local government programs for in-home supportive services is excluded from income. The DHS worker determines if the child would be financially eligible for Medical Assistance if institutionalized. An institutionalized child is financially eligible for Medical Assistance if s/he is in one of the following groups: o If s/he would be eligible for SSI if institutionalized, i.e., has resources within the SSI limit of $2,000, and income LESS THAN $70.00 MONTHLY. These individuals receive cash SSI payments even when they are institutionalized and are therefore Categorically Needy; o If s/he had resources within the $2,000 limit and income of at least $70.00 but NOT MORE THAN THE Federal Cap set forth in Section 0386.05. These individuals lose their SSI cash payment when they are institutionalized because their gross personal income is $70 or more per month. However, because their income is less than the Federal Cap they remain eligible for Medical Assistance as Categorically Needy; o If s/he has with resources less than the Medically Needy resource level of $4,000 and income less than the cost of care in the institution. These individuals are eligible as Medically Needy. The income and resources of the parents are not considered in the determination of eligibility, and are not used to reduce the cost of Medical Assistance services.