SI 00520: Institutionalization

Effective Dates: 10/21/2013 - Present

TN 37 (09-12)

Citations:

Social Security Act §1611(e)(1)(G) and (H)

20 CFR 416.211, 416.212, 416.410, 416.412, 416.414, 416.640, 416.1147,416.1149, 416.1167, 416.2040.

A. Introduction to Temporary Institutionalization (TI) benefits

Section 1611(e)(1)(G) of the Social Security Act provides that Supplemental Security Income (SSI) recipients, who are temporarily institutionalized for medical care (and who would otherwise receive a reduced benefit or none at all), can get benefits during the first 3 full months of institutionalization to pay expenses to maintain their home or living arrangement where they may return upon discharge. We refer to benefits paid under section 1611(e)(1)(G) as temporary institutionalization (TI) benefits.

B. Eligibility for TI benefits

An SSI recipient (including an eligible child) may continue to receive benefits (including State supplementation) without interruption based on the full federal benefit rate (FBR) for any of the first 3 full months of medical confinement if, for those months the recipient:

otherwise would be subject to the $30 payment limit, or ineligible due to residence in a public medical institution (payment status NO2); and
meets the following 5 requirements.

1. Types of facilities where TI benefits apply

The SSI recipient’s admittance must be to:

a public institution, the primary purpose of which is the provision of medical or psychiatric care, or
a public or private Medicaid-certified medical treatment facility.

NOTE: The TI provision does not apply to residents of penal institutions. (For more information about which TI provisions do not apply to residents in penal institutions, see SI 00520.009E.)

2. Throughout a month residence in an institution

The recipient must continuously reside throughout the affected month in one or more of the facilities described in SI 00520.140B.1. (in this section).

3. SSI eligibility requirement for TI benefits

The recipient must be eligible for an SSI payment (or a federally administered State supplement) in the month prior to the first month the $30 payment limit or ineligibility (payment status N02) would have applied (absent payment of TI benefits or the special benefits for institutionalized 1619 eligibles as described in SI 00520.130B.2.).

4. Physician's certification for TI benefits

A physician must certify in writing that he or she expects that the recipient’s medical confinement will not last for longer than 90 full consecutive days.
The physician (or other appropriate source, see SI 00520.140H.2. in this section) must submit the certification no later than the 90th day of medical confinement, or by the day of release whichever is earlier. For this purpose, “submitted” means received by the Social Security Administration (SSA) or postmarked.

5. Need to maintain a home for TI benefits

To be eligible for TI benefits, the recipient must demonstrate that the recipient needs to pay some or all of the expenses of maintaining the home or living arrangement to which he or she may intend to return. The home or living arrangement to which the recipient may return may or may not be the last permanent living arrangement.

The recipient (or someone on his or her behalf) must submit evidence of this need no later than the 90th day of medical confinement, or the day of release whichever is earlier. For this purpose, “submitted” means received by SSA or postmarked.
The institution cannot require the recipient or the recipient's representative payee to pay the institution any portion of the TI benefits, except nominal sums for the recipient's personal needs (e.g., personal hygiene items, snacks, candy).

C. Months when TI benefits are payable

1. Months of eligibility for TI benefits

TI benefits are payable for any of the first 3 full months of medical confinement where the recipient would be ineligible for SSI due to confinement in a public institution or subject to the $30 payment limit (absent payments under this provision or the special benefits provision for institutionalized 1619 eligibles as described in SI 00520.130).

2. Examples of when SSA pays TI benefits

Example 1: TI benefits apply for 3 full months

Mrs. Johnson, an aged recipient, went into the hospital on July 18. Medicare covered her hospitalization. She provided SSA with a doctor's statement that he expected her to go home on or by October 17. She also provided SSA with a written statement that she had to give her roommate her share of the apartment rent of $100. Mrs. Johnson provided these statements in July.

On July 29, Mrs. Johnson moved to a nursing home, Medicaid began paying for her care, and she stayed until November 2. The TI benefits provision applies for August, September, and October, the 3 full months in which Mrs. Johnson was institutionalized as defined in SI 00520.140B.3. (in this section).
Example 2: TI benefits apply for less than 3 months

Mrs. Jones, an aged SSI recipient, broke her hip and went into the hospital on July 15. On the day of Mrs. Jones' admission, the hospital sent the FO a statement from Mrs. Jones' doctor. The doctor expected her to transfer from the hospital to a nursing home with a final discharge to her home by October 14. On July 20, Mrs. Jones submitted a written statement that she needed to pay her rent or she would lose her apartment.

Medicare paid for Mrs. Jones' care in the hospital and the first 3 days of nursing home care, through September 29. On September 30, Medicaid began paying the cost of her care. Mrs. Jones continued in the nursing home through the months of October and November.

TI benefits apply for the month of October only since it is within the first 3 full months of medical confinement and it is the only one of those months for which the $30 payment limit federal living arrangement (FLA) D or ineligibility due to residence in a public medical institution (N02) would otherwise apply.
Example 3: TI benefits do not apply

Mr. Smith, a disabled recipient, suffered a stroke and entered a hospital on July 15. His brother contacted the FO on July 19 to report Mr. Smith's medical confinement. On July 21, the claims representative obtained a certification from Mr. Smith's doctor that he expected the hospital to discharge Mr. Smith by October 14 and a written statement that Mr. Smith was responsible for his mortgage payment while he was in the hospital. Mr. Smith's private insurance paid for his hospitalization until January 10, when he returned home.

Mr. Smith is ineligible for TI benefits under this section since he is not subject to the $30 payment limit or ineligible for SSI due to residence in a public institution. He may be eligible for regular SSI benefits since he was in a private institution.
Example 4: TI benefits do not apply — $30 payment began after the third full month of medical confinement

The same facts as in the preceding example apply except that Mr. Smith did not leave the hospital. On January 11, Medicaid began paying the cost of his care and February was the first month the $30 payment limit applied. Since February is his seventh full consecutive month of medical confinement, the TI benefits provision does not apply.

D. Temporary absence and TI benefits

1. Effect of TI on temporary absence

A recipient, including a member of a couple, is temporarily absent from the last permanent living arrangement for any months he or she is receiving TI benefits. Therefore, a couple continues to be a couple during periods of eligibility for TI payment. The “last permanent living arrangement” refers to the living arrangement used to determine benefits for the month before the month for which the $30 payment limit or payment status N02 would otherwise apply.

2. Determining living arrangements prior to institutionalization

For purposes of determining the living arrangement from which the recipient is temporarily absent, use the permanent living arrangement as of the first moment of the month before the month in which institutionalization began (as defined in SI 00520.140B.3. in this section).

The circumstances that exist in that permanent living arrangement are the circumstances to use in determining:

the federal living arrangement (FLA),
in-kind support and maintenance (ISM),
deeming, and
federally administered State supplementary payments for that same month.

3. Applying other SSI rules in TI cases

All FLA, ISM, deeming, and federally administered State supplementation provisions continue to apply as if the recipient were physically residing in that last permanent living arrangement.

4. When temporary absence ends in TI cases

The temporary absence continues through the last month TI benefits are paid unless the recipient is discharged in the month following the last month TI benefits are paid. In that case, temporary absence continues through the date of discharge.

5. Examples of temporary absence in TI situations

Example 1: TI benefits and deeming

A recipient lives with his ineligible spouse in their daughter's home. On August 15, he went to visit his brother. On August 29, he went into a Medicaid institution and was determined to be eligible for TI benefits for the months of September, October, and November. His daughter's home was his permanent living arrangement on August 1. Therefore, we would continue deeming from his ineligible spouse and we would continue to count any ISM he would have received as if he were physically residing in his daughter's home.
Example 2: When temporary absence ends

In the Mrs. Johnson example in SI 00520.140C.2. (in this section), the permanent living arrangement from which she is absent is the household she shares with her roommate. The temporary absence ended on November 2 when Mrs. Johnson left the nursing home.
Example 3: When temporary absence ends

In the Mrs. Jones example in SI 00520.140C.2. (in this section), the permanent living arrangement from which she is temporarily absent is the hospital. The temporary absence ends on October 31 because it is the third and final month of TI benefits.

E. Determining the dollar amount of TI benefits

We compute payments for recipients eligible for TI benefits using the full FBR and the applicable federally administered State supplement (if any). For information on State supplementation, see SI 00520.140E.4. (in this section).

1. Length of stay exceeds the expected 90 days

Payments made under the TI provision are not overpayments due to the recipient's actual stay exceeding the expected stay of 90 days or less.

2. Changes in physician’s certification

After initially providing a statement that he or she expected the confinement not to exceed 90 days, if the physician subsequently provides a new certification that indicates he or she now expects the confinement to exceed 90 days, TI benefits continue to be payable since the original certification established eligibility.

Example 1: Confinement exceeds 90 days

On March 10, Mr. Thompson, an 85-year-old recipient, went into a hospital for surgery. On March 12, the physician certified that she expected the period of medical confinement, including post-operative care in a nursing home, would not exceed 90 days. On March 13, Mr. Thompson provided a statement that he needed to continue to pay his rent. The FO initiated continued payments effective April. On June 7, Mr. Thompson's physician provided a new statement indicating that Mr. Thompson had suffered complications and she now believed that the period of medical confinement would likely exceed 90 days. This change does not affect eligibility for TI benefits since the initial certification established eligibility.

After initially providing a statement that the physician expects the confinement to exceed 90 days, the physician provides a new certification indicating she now expects the recipient to be in the a medical facility no longer than 90 days and the physician submits the new certification before the 91st day of confinement or by the day of release. TI benefits are payable.
Example 2: Confinement does not exceed 90 days

On February 9, Mrs. Rose went into a hospital for surgery on her broken hip. Her physician certified on February 12 that she would go to the rehabilitation wing of the hospital and that her stay would likely exceed 90 days. We denied Mrs. Rose TI benefits based on the physician's certification. After the surgery on February 14, her physician sent written notification to the FO that he now expects to release Mrs. Rose by the end of April. The FO, which already had Mrs. Rose's statement of need to maintain her home, initiated TI benefit payments effective March 1.

NOTE: If the FO did not have Mrs. Rose's statement of need, it would have to obtain the statement before her release (or the 91st day of confinement) for her to be eligible for TI benefit payments.

3. Overpayments of TI benefits

Overpayments may occur as a result of misapplication of the TI provision if it is later learned that:

a requirement for the receipt of TI benefits was not met; or
we paid the recipient incorrectly due to another payment or eligibility reason.

NOTE: Overstaying the expected 90 days is not a failure to meet a requirement.

4. Effect of TI on State supplementation

For federally administered State supplementary payments (mandatory and optional), the State supplement payable for the months of TI benefits is the same as that which would be payable if the recipient were physically residing in his or her last permanent living arrangement.

5. Special benefits for institutionalized 1619 eligibles

An SSI recipient may be eligible under the special benefits provision for institutionalized 1619 eligibles for the first 2 full months of institutionalization and also be eligible (if all applicable requirements are met) for TI benefits for the same 2 months, or the third full month of institutionalization. See SI 00520.130 for information about special benefits for 1619 eligibles.

F. Assisting recipients to establish TI eligibility

SSA actively assists recipients in establishing eligibility for TI benefits. This includes FOs maintaining close working relationships with medical institutions to assure prompt notification of a recipient's admission.

When informed of a recipient's admission to a medical facility, the FO staff will contact the recipient (or knowledgeable source) to assist in obtaining the physician's certification and the statement of need as quickly as possible.

Example: Assisting the recipient

Mrs. Freedman, an aged recipient, enters a hospital with pneumonia on August 22. On September 2, the FO receives notification from the hospital of Mrs. Freedman's admission. The FO must contact Mrs. Freedman (or a knowledgeable source) as soon as possible. The FO contacts the facility on September 6 and obtains a statement from the social worker in the facility that Mrs. Freedman's file reflects the physician's expectation that the hospital will discharge her before the 91st day after the day of admission. Mrs. Freedman's sister goes to the FO and signs a statement that Mrs. Freedman has to pay her rent or she will lose her apartment. (Mrs. Freedman was in intensive care and could not talk on the phone when the FO called.)

G. Recipient declines TI benefits

Any recipient who meets the requirements to receive TI benefits may decline them and, instead, have eligibility and payment computed under the regular rules. For example, if we would treat a recipient as a member of a couple subject to deeming rules under continued benefits, it might be advantageous to the recipient to choose an eligibility and payment amount determination under the regular rules.

H. Procedure for TI development

Consider and explain how SSA applies TI benefits whenever a recipient goes into an institution.

1. Determine whether TI potentially applies

Immediately upon learning that a recipient has entered a medical facility, request a physician's certification and a statement of need to maintain the home or living arrangement.
Do not input a TI benefits allowance or denial or make any change in payment or eligibility status because of the recipient's institutionalization until the issue of eligibility for TI benefits is resolved.
Take all appropriate steps to resolve the issue as quickly as possible.

2. Obtain physician’s certification for TI

Obtain a physician's written certification stating whether he or she expects the recipient’s medical confinement to last less than 90 full consecutive days, beginning with the day after the recipient entered the institution.

If the recipient entered a medical facility on August 1, the certification must establish that the physician expects the facility to discharge the recipient on October 30 or earlier. The 90 full consecutive days would be August 2 through October 30.

Document the physician's certification of a 90 day or less stay as follows:

accept the physician's written statement; or
use the facility's admissions or other records which reflect a physician's written statement; or
use information from the attending physician's written records; or
use information from a reliable source (e.g., hospital staff) that such written certification exists.

3. Develop the need to maintain a home

Ask the recipient whether he or she needs to pay some or all of the expenses to maintain the home or living arrangement to which he or she intends to return. In determining the recipient’s need to maintain a home or living arrangement:

Accept, absent evidence to the contrary, a written statement from the recipient (or from a person knowledgeable about the recipient’s expenses and permanent living arrangement) that the recipient needs to maintain and provide for some or all of the expenses of the home or living arrangement to which the recipient intends to return.
Consider the following (not all-inclusive) examples as contrary evidence:
- an indication that the recipient was homeless; or
- a statement from a knowledgeable person that the recipient is not required to pay any of the expenses of the home or living arrangement to which he or she intends to return; or
- an indication that the recipient is returning to a domiciliary or congregate care facility and is not required to continue to pay the facility to “hold the bed.”
Do not consider the fact that a recipient was subject to the value of the one-third reduction (VTR) in the month of entry into the institution as evidence to the contrary. The recipient may be paying something less than his or her pro rata share, or may be paying some expense which was not considered to be a household operating expense for purposes of the ISM determination.
If evidence to the contrary exists, undertake whatever development is necessary to determine whether the recipient needs to maintain and provide for some or all of the expenses of the home or living arrangement to which he or she may return.

4. Servicing FO contacts with local institutions

Contact appropriate institutions:

to establish a process to assure that institutions alert SSA promptly upon admissions of SSI recipients; and
to determine the feasibility of obtaining information from the facility to meet the physician certification requirement.

5. Documenting that TI benefits apply

Document the file with:

a determination of the recipient's need to maintain the home or living arrangement to which he or she intends to return (the recipient's or knowledgeable source's statement is sufficient documentation when evidence to the contrary does not exist);
a report of contact reflecting the physician's statement or the actual written certification from the physician that the recipient is expected to be institutionalized for no more than 90 full consecutive days (see SI 00520.140B.4. in this section); and
the manual TI notice posted in the online notice retrieval system (ONRS), or if unable to post it in ONRS, send it to the electronic folder. When a TI benefits notice is required, see SI 00520.141.

6. Documenting that TI benefits do not apply