[Federal Register Volume 61, Number 50 (Wednesday, March 13, 1996)]
[Rules and Regulations]
[Pages 10274-10280]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 96-5705]
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SOCIAL SECURITY ADMINISTRATION
20 CFR Part 416
RIN 0960-AC55
Supplemental Security Income for the Aged, Blind, and Disabled;
Continuation of Full Benefit Standard for Persons Temporarily
Institutionalized
AGENCY: Social Security Administration.
ACTION: Final rule.
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SUMMARY: These final rules are being issued to reflect section 3 of the
Employment Opportunities for Disabled Americans Act and section 9115 of
the Omnibus Budget Reconciliation Act of 1987. These statutory
provisions amended the Social Security Act (the Act) to permit certain
recipients to receive payments based on the full supplemental security
income (SSI) benefit rate for a limited period after becoming residents
of medical or psychiatric institutions.
EFFECTIVE DATE: These final rules are effective May 13, 1996.
FOR FURTHER INFORMATION CONTACT: Lawrence V. Dudar, Legal Assistant,
Office of Regulations and Rulings, Social Security Administration, 3-B-
1 Operations Building, 6401 Security Boulevard, Baltimore, MD 21235,
(410) 965-1759.
SUPPLEMENTARY INFORMATION: SSI regulations generally require the
suspension of SSI benefits when a recipient is a resident of a public
institution throughout a month, except that the recipient may receive a
reduced benefit if he or she is a resident throughout a month in a
public or private institution where over 50 percent of the cost of care
is paid for by Medicaid. The following legislative provisions, however,
now allow for benefits based on the full SSI Federal benefit rate to
continue during months of residency in an institution under certain
circumstances.
Benefits Payable Based on Section 1611(e)(1)(E) of the Act
Section 3 of Public Law 99-643 (the Employment Opportunities for
Disabled Americans Act) added subparagraph (E) to section 1611(e)(1) of
the Act. Based on this added provision, a recipient, whose SSI
eligibility is based on section 1619 (a) or (b) of the Act for the
month preceding the first full month of residence in (1) a public
medical or psychiatric institution or (2) a public or private
institution where Medicaid is paying more than 50 percent of the cost
of care, can remain eligible for an SSI benefit based on the full
Federal benefit rate for up to 2 months after entering the institution.
This statutory provision also provides that payment is conditioned on
an agreement by the institution that these benefits are to be retained
by the recipient and cannot be used to defray the cost of institutional
care.
Section 1902(o) of the Act requires that all State Medicaid plans
provide for disregarding any SSI payments paid by reason of section
1611(e)(1)(E) or 1611(e)(1)(G) of the Act in computing the post-
eligibility contribution of the individual to the cost of care.
Therefore, if the institution is receiving Medicaid payments for the
recipients, we will rely on the agreement the institution signed with
the State Medicaid agency to ensure that this condition is met.
Benefits Payable Based on Section 1611(e)(1)(G) of the Act
Section 9115 of Public Law 100-203 (the Omnibus Budget
Reconciliation Act of 1987) added subparagraph (G) to section
1611(e)(1) of the Act. Based on this added provision, a recipient is
eligible for continued benefits for up to 3 full months after entering
the institution if the following conditions are met:
1. A physician certifies that the recipient's stay in the
institution or facility is likely not to exceed 3 months;
2. The recipient demonstrates a need to continue to maintain and
provide for the expenses of a home or other living arrangement to which
he or she may return after leaving the facility; and
3. The recipient was eligible for Federal SSI cash benefits or
federally administered State supplementation in the month before the
month benefits would otherwise be reduced or suspended because of
residence in an institution.
The following policies implement the provisions of section
1611(e)(1)(G) of the Act.
We state in these final rules at Sec. 416.212(b) that, in order for
a recipient to be eligible for these benefits, the physician's
certification and the evidence of the need to pay home or living
arrangement expenses must be submitted to the Social Security
Administration (SSA) no later than the day of discharge or the 90th
full day of confinement, whichever is earlier. We will determine the
date of submission to be the date we receive it or, if mailed, the date
of the postmark. This time frame for submission of the needed evidence
to establish eligibility for continued payments represents what we
believe is the best balance between the statutory language and
Congressional intent that:
[[Page 10275]]
The benefits are payable ``without interruption;''
The physician's statement must be ``anticipatory'' (i.e.,
based on an expectation rather than accomplished fact); and,
The Commissioner will assist recipients in establishing
eligibility for the payments.
We will encourage recipients to submit the necessary evidence as early
as possible to facilitate our administration of the provision.
Section 1611(e)(1)(H) allows, but does not require, the
Commissioner to enter into agreements with outside agencies and
organizations for making the determinations required under section
1611(e)(1)(G) or for providing information or assistance in connection
with making such determinations. We are not exercising the option at
this time.
Final Rules Applicable to Both Categories of Benefits
These final rules include the following policy provisions that are
applicable to both categories of benefits:
1. We will compute a recipient's benefits under sections
1611(e)(1)(E) and 1611(e)(1)(G) of the Act on the basis of the
permanent living arrangement used to compute benefits for the month
immediately prior to the first month the recipient is otherwise subject
to suspension under Sec. 416.1325 or subject to a reduced benefit
amount under Sec. 416.414 because of residence in an institution. All
the Federal income provisions (including living arrangements, in-kind
support and maintenance, and deeming) applicable to the recipient's
permanent living arrangement will continue to apply for the period in
which benefits are payable while in the institution. This also means
that we will compute the benefits as an eligible couple (instead of as
two eligible individuals) for months in which either benefit is being
paid to one member of the couple.
Section 1611(e)(1)(E) of the Act originally was interpreted and
implemented as requiring the computation of benefits under section
1611(e)(1)(E) to be based on a living arrangement in the institution.
Under such an interpretation, the section 1611(e)(1)(E) benefits were
not subject to the in-kind support and maintenance and deeming of
income provisions that applied before the person was institutionalized
and which apply when computing benefits under section 1611(e)(1)(G).
This computation could increase the benefits paid under section
1611(e)(1)(E) as compared to the benefits paid prior to
institutionalization. To ensure the payment of section 1611(e)(1)(E)
benefits comparable to those paid before institutionalization (and
comparable to benefits payable under section 1611(e)(1)(G)), as of the
effective date of the final regulations, benefits under section
1611(e)(1)(E) will be computed based on the living arrangement existing
prior to institutionalization. Thus, all Federal living arrangement,
in-kind support and maintenance, and deeming provisions will continue
to apply for up to the first 2 full months of institutionalization.
We are delaying the effective date of the final rules for 60 days
after publication in the Federal Register in order to avoid a notice
problem for those individuals who already have been notified of section
1611(e)(1)(E) benefit amounts calculated under our prior practice. If
the effective date were not delayed, those individuals whose first full
month of institutionalization is the month in which the regulations are
published and who have one remaining month of eligibility under section
1611(e)(1)(E) would not be notified timely that their benefits would be
computed differently for each of the 2 months under section
1611(e)(1)(E). For those individuals, benefits for their first full
month of institutionalization will be computed based on a living
arrangement in the institution. Benefits for the second full month of
institutionalization will be computed based on the living arrangement
existing prior to institutionalization. The delayed effective date of
the final rules will enable us to timely notify our field offices of
the regulatory change, and will provide field office personnel with
sufficient time to identify and notify the affected individuals before
the effective date of the change.
We also are amending the rules on temporary absence from a living
arrangement at Sec. 416.1149 to show that these recipients are
``temporarily absent'' from their permanent living arrangement. This
living arrangement as a computation basis will not extend past the last
month that section 1611(e)(1)(E) or section 1611(e)(1)(G) benefits are
payable or, if the recipient is discharged in the month following the
last month of eligibility for section 1611(e)(1)(E) or section
1611(e)(1)(G) benefits, past the date of discharge. In the event the
recipient remains institutionalized and becomes eligible for a reduced
benefit, the temporary absence ends, and we will consider the
institution as the permanent living arrangement. The computation basis
will no longer include factors (e.g., deemed income) which were
applicable in the recipient's last permanent living arrangement.
We are amending Secs. 416.1147, 416.1149, and 416.1167 to reflect
the temporary absence rules applicable to the treatment of in-kind
support and maintenance and deeming of income and resources for these
two types of benefits. We are also amending Secs. 416.410, 416.412,
416.413, and 416.414 both to reference the extension of full benefit
eligibility to institutionalized recipients under sections
1611(e)(1)(E) and 1611(e)(1)(G) and to update and include the full
Federal yearly benefit rate applicable in recent years to an eligible
individual, qualified individual, and an eligible couple. In
Sec. 416.212(a)(1), we substituted the word ``under'' for the phrase
``for benefits based on'' because an individual who is eligible under
section 1619(b) of the Act does not receive cash benefits, but only
acquires a special eligibility status for purposes of establishing or
maintaining eligibility for Medicaid.
2. The new Secs. 416.212(a)(2) and 416.212(c) state the policy
barring reimbursement to an institution for a recipient's current
maintenance (excepting, of course, reimbursement of expenditures for
personal needs) from the benefits authorized under section
1611(e)(1)(E) and section 1611(e)(1)(G) of the Act.
Section 1611(e)(1)(E) prohibits payment of benefits unless the
institution agrees to permit the recipient to retain any benefits paid
under this section. If the institution is receiving Medicaid payments
for the recipient, we rely on the agreement the institution signed with
the State Medicaid agency to ensure this condition is enforced.
However, section 1611(e)(1)(G) does not specifically require that the
recipient be permitted to retain the benefits payable under that
section, as does section 1611(e)(1)(E). The legislative history is
clear, however, that Congress intended that the benefits payable under
section 1611(e)(1)(G) be available for maintenance of the recipient's
home or living arrangement and not for paying the institution for the
cost of the recipient's current maintenance except reimbursement of
expenditures for personal needs. Moreover, as noted above, section
1902(o) of the Act requires that all State Medicaid plans provide for
disregarding any SSI payments paid by reason of section 1611(e)(1)(E)
or 1611(e)(1)(G) of the Act in computing the post-eligibility
contribution of the individual to the cost of care. Consequently, to
permit institutions to secure these benefits would appear to negate the
purpose of
[[Page 10276]]
the legislation and, in the case of Medicaid institutions, to be in
conflict with section 1902(o) of the Act. Based on this intent and
section 1902(o), we are extending the prohibition on the payment of
benefits to, or the use of benefits by, an institution to defray
current maintenance costs, except personal needs items, to benefits
payable under section 1611(e)(1)(G). This prohibition concerning
benefits payable under the two sections will be implemented as follows.
In view of Congressional intent that benefits payable under
sections 1611(e)(1)(E) and 1611(e)(1)(G) of the Act be used for meeting
expenses outside the institution, the new Secs. 412.212(a)(2) and
416.212(c) provide that an institution must allow the recipient to
retain those benefits. The institution can only be reimbursed for
nominal costs it may have incurred for the recipient's personal needs
such as personal hygiene items, snacks, and candy to the extent not
covered by Medicaid. We believe that payment to the institution for
these costs is not inconsistent with sections 1611(e)(1)(E) and
1611(e)(1)(G). However, reimbursement is not permitted beyond personal
needs.
The current Sec. 416.640(c) prohibits a representative payee from
reimbursing an institution from SSI benefits for the current
maintenance costs of an institutionalized recipient when Medicaid pays
to the institution more than 50 percent of the cost of the individual's
care. In the previously published notice of proposed rulemaking, we had
proposed to amend Sec. 416.640 (b) and (c) to repeat the prohibition on
reimbursement for current maintenance costs (with the exception of
personal needs) for recipients who are receiving benefits payable under
sections 1611(e)(1)(E) and 1611(e)(1)(G). However, to avoid unnecessary
duplication, we have revised Sec. 416.640 (b) and (c) in these final
regulations simply to include cross references in those sections to the
new Sec. 416.212.
3. We are amending Sec. 416.2040 to reflect that for States whose
supplementation programs are federally administered under the authority
of section 1616(a) of the Act and/or section 212 of Public Law 93-66,
institutionalized recipients receiving benefits under either section
1611(e)(1)(E) or section 1611(e)(1)(G) can continue to be eligible to
receive the optional/mandatory State supplementary payments. In
addition, a recipient who would be eligible for benefits authorized
under Sec. 416.212 but for countable income which reduces his or her
Federal SSI benefit to zero may still be eligible to receive a
federally administered State supplementary payment. Non-federally
administered States will elect whether institutionalized beneficiaries
receiving Federal benefits under either section 1611(e)(1)(E) or
section 1611(e)(1)(G) will receive the same State supplementary payment
they received prior to the first full month of institutionalization or
the payment (if any) normally made in such circumstances.
We are extending eligibility for federally administered State
supplementation to recipients receiving benefits payable under the two
sections. With respect to federally administered optional State
supplementation, section 1616(b)(2) of the Act provides the
Commissioner with broad authority to adopt such ``. . . procedural or
other general administrative provisions, as the Commissioner of Social
Security finds necessary . . . to achieve efficient and effective
administration of both the program which he conducts under this title
and the optional State supplementation.'' The regulation at
Sec. 416.2005(d) provides similar authority for federally administered
mandatory State supplements. These authorities enable SSA to administer
statutory provisions that affect State supplementation in a fashion
fully in accord with their underlying Congressional intent. Congress,
when enacting section 1611(e)(1)(E) and section 1611(e)(1)(G), intended
that recipients not be disadvantaged financially when entering an
institution for a stay of short duration. To implement this intention,
we consider the recipient's living arrangement as not having changed
when computing the amount of the Federal benefit payable under sections
1611(e)(1)(E) and 1611(e)(1)(G). The same policies used for determining
the Federal benefit will be used to determine the State supplementary
payment. Thus, a recipient's living arrangement would not be considered
to have changed for purposes of determining the recipient's State
supplementary payment. This will ensure that the State supplementary
payments payable in the month prior to the first full month of
institutionalization will, subject to the income counting provisions,
continue through the months of institutionalization. Thus, we believe
that the policy will assist the Commissioner in achieving efficient and
effective administration of both the title XVI and State supplementary
payment programs, because continuing the State supplementary payments
will negate the need for field office intervention, with attendant
error potential.
In light of the above, it is reasonable to conclude that the
Commissioner exercise discretion and require, under the authority of
section 1616(b)(2) of the Act, States, whose State supplementary
payments are federally administered, to continue to supplement the full
benefit rate payable for months of hospitalization under both section
1611(e)(1)(E) and section 1611(e)(1)(G).
4. We are also amending Sec. 416.1325 of subpart M in part 416 to
show that benefits will not be suspended for months of residency in a
public institution if the recipient is eligible for benefits payable
under section 1611(e)(1)(E) or section 1611(e)(1)(G) of the Act for
those months. However, this amended rule is not being included in these
regulations and, instead, will be separately published as an interim
final rule in final regulations which recodify Subpart M entitled:
``Suspensions, Terminations, and Advance Notice of Unfavorable
Determinations.''
On September 28, 1992, we published a notice of proposed rulemaking
(NPRM) at 57 FR 44519 reflecting the provisions of the Employment
Opportunities for Disabled Americans Act and the Omnibus Budget
Reconciliation Act of 1987 that are described above. We received two
comments on the proposed regulations from State mental health agencies,
both of which endorsed the regulatory changes. Therefore, the proposed
rules are adopted as final regulations. However, we have made a number
of minor, nonsubstantive changes to the rules as written in the NPRM,
including updates on the amount of benefits payable, the change to
Sec. 416.640 which is discussed above, and a correction to a cross
reference to reflect the numerical redesignation of a section. We also
have deleted the benefit amounts payable in the years prior to 1994
since such information is generally not needed by the public.
Regulatory Procedures
Executive Order 12866
We have consulted with the Office of Management and Budget (OMB)
and determined that these rules do not meet the criteria for a
significant regulatory action under Executive Order 12866. Thus, they
were not subject to OMB review.
Paperwork Reduction Act
These final regulations contain information collection requirements
in Secs. 416.212(b)(1)(iii) and
[[Page 10277]]
416.212(b)(1)(iv). The Social Security Administration would normally
request clearance of this requirement (under the Paperwork Reduction
Act) by the Office of Management and Budget (OMB). However, we are not
doing so in this situation because we have already obtained OMB
clearance to collect this information under OMB control number 0960-
0516.
Public reporting burden for each of these collections of
information is estimated to average 5 minutes per response. This
includes the time it will take to read the instructions, gather the
necessary facts, and provide the information requested. The respondents
to the collection in paragraph (b)(1)(iii) will be physicians. The
respondents to the requirement in paragraph (b)(1)(iv) will be
recipients of SSI payments. We estimate that 60,000 people will provide
this information yearly. The total annual burden for both information
collections is therefore estimated to be 5,000 hours.
Regulatory Flexibility Act
We certify that these final regulations will not have a significant
economic impact on a substantial number of small entities because they
affect individuals. Therefore, a regulatory flexibility analysis, as
provided in Public Law 96-354, the Regulatory Flexibility Act, is not
required.
(Catalog of Federal Domestic Assistance Program No. 93.807,
Supplemental Security Income)
List of Subjects in 20 CFR Part 416
Administrative practice and procedure, Aged, Blind, Disability
benefits, Public Assistance programs, Supplemental Security Income
(SSI), Reporting and recordkeeping requirements, Social security.
Dated: February 28, 1996.
Shirley Chater,
Commissioner of Social Security.
For the reasons set forth in the preamble, subparts B, D, F, K, and
T of part 416 of chapter III of title 20 of the Code of Federal
Regulations are amended as follows:
PART 416--SUPPLEMENTAL SECURITY INCOME FOR THE AGED, BLIND, AND
DISABLED
Subpart B--Eligibility
1. The authority citation for subpart B of part 416 continues to
read as follows:
Authority: Secs. 702(a)(5), 1110(b), 1602, 1611, 1614, 1615(c),
1619(a), 1631, and 1634 of the Social Security Act (42 U.S.C.
902(a)(5), 1310(b), 1381a, 1382, 1382c, 1382d(c), 1382h(a), 1383,
and 1383c); secs. 211 and 212, Pub. L. 93-66, 87 Stat. 154 and 155
(42 U.S.C. 1382 note); sec. 502(a), Pub. L. 94-241, 90 Stat. 268 (48
U.S.C. 1681 note); sec. 2, Pub. L. 99-643, 100 Stat. 3574 (42 U.S.C.
1382h note).
2. Section 416.202 is amended by revising paragraph (b)(4) to read
as follows:
Sec. 416.202 Who may get SSI benefits.
* * * * *
(b) * * *
(4) A child of armed forces personnel living overseas as described
in Sec. 416.216.
* * * * *
3. Section 416.211 is amended by revising paragraphs (a)(1) and (b)
to read as follows:
Sec. 416.211 You are a resident of a public institution.
(a) General rule. (1) Subject to the exceptions described in
paragraphs (b), (c), and (d) of this section and Sec. 416.212, you are
not eligible for SSI benefits for any month throughout which you are a
resident of a public institution as defined in Sec. 416.201. In
addition, if you are a resident of a public institution when you apply
for SSI benefits and meet all other eligibility requirements, you
cannot be eligible for benefits until the day of your release from the
institution. The amount of your SSI benefits for the month of your
release will be prorated (see subpart D of this part) beginning with
the date of your release.
* * * * *
(b) Exception--SSI benefits payable at a reduced rate. You may be
eligible for SSI benefits at a reduced rate described in Sec. 416.414,
if--
(1)(i) The public institution in which you reside throughout a
month is a medical care facility for which Medicaid (title XIX of the
Social Security Act) pays a substantial part (more than 50 percent) of
the cost of your care; or
(ii) You reside for part of a month in a public institution and the
rest of the month in a public institution or private medical facility
where Medicaid pays more than 50 percent of the cost of your care; and
(2) You are ineligible in that month for a benefit described in
Sec. 416.212 that is payable to a person temporarily confined in a
medical facility.
* * * * *
Secs. 416.212-416.215 [Redesignated as Secs. 416.213-416.216]
4. Sections 416.212 through 416.215 are redesignated as
Secs. 416.213 through 416.216 respectively and a new Sec. 416.212 is
added to read as follows:
Sec. 416.212 Continuation of full benefits in certain cases of medical
confinement.
(a) Benefits payable under section 1611(e)(1)(E) of the Social
Security Act. Subject to eligibility and regular computation rules (see
subparts B and D of this part), you are eligible for the benefits
payable under section 1611(e)(1)(E) of the Social Security Act for up
to 2 full months of medical confinement during which your benefits
would otherwise be suspended because of residence in a public
institution or reduced because of residence in a public or private
institution where Medicaid pays over 50 percent of the cost of your
care if--
(1) You were eligible under either section 1619(a) or section
1619(b) of the Social Security Act in the month before the first full
month of residence in an institution;
(2) The institution agrees that no portion of these benefits will
be paid to or retained by the institution excepting nominal sums for
reimbursement of the institution for any outlay for a recipient's
personal needs (e.g., personal hygiene items, snacks, candy); and
(3) The month of your institutionalization is one of the first 2
full months of a continuous period of confinement.
(b) Benefits payable under section 1611(e)(1)(G) of the Social
Security Act. (1) Subject to eligibility and regular computation rules
(see subparts B and D of this part), you are eligible for the benefits
payable under section 1611(e)(1)(G) of the Social Security Act for up
to 3 full months of medical confinement during which your benefits
would otherwise be suspended because of residence in a public
institution or reduced because of residence in a public or private
institution where Medicaid pays over 50 percent of the cost if--
(i) You were eligible for SSI cash benefits and/or federally
administered State supplementary payments for the month immediately
prior to the first full month you were a resident in such institution;
(ii) The month of your institutionalization is one of the first 3
full months of a continuous period of confinement;
(iii) A physician certifies, in writing, that you are not likely to
be confined for longer than 90 full consecutive days following the day
you entered the institution, and the certification is submitted to SSA
no later than the day of discharge or the 90th full day of confinement,
whichever is earlier; and
(iv) You need to pay expenses to maintain the home or living
arrangement to which you intend to return after institutionalization
and
[[Page 10278]]
evidence regarding your need to pay these expenses is submitted to SSA
no later than the day of discharge or the 90th full day of confinement,
whichever is earlier.
(2) We will determine the date of submission of the evidence
required in paragraphs (b)(1) (iii) and (iv) of this section to be the
date we receive it or, if mailed, the date of the postmark.
(c) Prohibition against using benefits for current maintenance. If
the recipient is a resident in an institution, the recipient or his or
her representative payee will not be permitted to pay the institution
any portion of benefits payable under section 1611(e)(1)(G) excepting
nominal sums for reimbursement of the institution for any outlay for
the recipient's personal needs (e.g., personal hygiene items, snacks,
candy). If the institution is the representative payee, it will not be
permitted to retain any portion of these benefits for the cost of the
recipient's current maintenance excepting nominal sums for
reimbursement for outlays for the recipient's personal needs.
Subpart D--Amount of Benefits
5. The authority citation for subpart D of part 416 is continues to
read as follows:
Authority: Secs. 702(a)(5), 1611 (a), (b), (c), and (e), 1612,
1617, and 1631 of the Social Security Act (42 U.S.C. 902(a)(5), 1382
(a), (b), (c), and (e), 1382a, 1382f, and 1383).
6. Section 416.410 is revised to read as follows:
Sec. 416.410 Amount of benefits; eligible individual.
The benefit under this part for an eligible individual (including
the eligible individual receiving benefits payable under the
Sec. 416.212 provisions) who does not have an eligible spouse, who is
not subject to either benefit suspension under Sec. 416.1325 or benefit
reduction under Sec. 416.414, and who is not a qualified individual (as
defined in Sec. 416.221) shall be payable at the rate of $5,640 per
year ($470 per month) effective for the period beginning January 1,
1996. This rate is the result of a 2.6 percent cost-of-living
adjustment (see Sec. 416.405) to the December 1995 rate. For the period
January 1, through December 31, 1995, the rate payable, as increased by
the 2.8 percent cost-of-living adjustment, was $5,496 per year ($458
per month). For the period January 1, through December 31, 1994, the
rate payable, as increased by the 2.6 percent cost-of-living
adjustment, was $5,352 per year ($446 per month). The monthly rate is
reduced by the amount of the individual's income which is not excluded
pursuant to subpart K of this part.
7. Section 416.412 is revised to read as follows:
Sec. 416.412 Amount of benefits; eligible couple.
The benefit under this part for an eligible couple (including
couples where one or both members of the couple are receiving benefits
payable under the Sec. 416.212 provisions), neither of whom is subject
to suspension of benefits based on Sec. 416.1325 or reduction of
benefits based on Sec. 416.414 nor is a qualified individual (as
defined in Sec. 416.221) shall be payable at the rate of $8,460 per
year ($705 per month), effective for the period beginning January 1,
1996. This rate is the result of a 2.6 percent cost-of-living
adjustment (see Sec. 416.405) to the December 1995 rate. For the period
January 1, through December 31, 1995, the rate payable, as increased by
the 2.8 percent cost-of-living adjustment, was $8,224 per year ($687
per month). For the period January 1, through December 31, 1994, the
rate payable, as increased by the 2.6 percent cost-of-living
adjustment, was $8,028 per year ($669 per month). The monthly rate is
reduced by the amount of the couple's income which is not excluded
pursuant to subpart K of this part.
8. Section 416.413 is revised to read as follows:
Sec. 416.413 Amount of benefits; qualified individual.
The benefit under this part for a qualified individual (defined in
Sec. 416.221) is payable at the rate for an eligible individual or
eligible couple plus an increment for each essential person (defined in
Sec. 416.222) in the household, reduced by the amount of countable
income of the eligible individual or eligible couple as explained in
Sec. 416.420. A qualified individual will receive an increment of
$2,820 per year ($235 per month), effective for the period beginning
January 1, 1996. This rate is the result of the 2.6 percent cost-of-
living adjustment (see Sec. 416.405) to the December 1995 rate, and is
for each essential person (as defined in Sec. 416.222) living in the
household of a qualified individual. (See Sec. 416.532.) For the period
January 1, through December 31, 1995, the rate payable, as increased by
the 2.8 percent cost-of-living adjustment, was $2,748 per year ($229
per month). For the period January 1, through December 31, 1994, the
rate payable, as increased by the 2.6 percent cost-of-living
adjustment, was $2,676 per year ($223 per month). The total benefit
rate, including the increment, is reduced by the amount of the
individual's or couple's income that is not excluded pursuant to
subpart K of this part.
9. Section 416.414 is amended by revising the introductory text of
paragraph (a) to read as follows:
Sec. 416.414 Amount of benefits; eligible individual or eligible
couple in a medical care facility.
(a) General rule. Except where the Sec. 416.212 provisions provide
for payment of benefits at the rates specified under Secs. 416.410 and
416.412, reduced SSI benefits are payable to persons and couples who
are in medical care facilities where more than 50 percent of the cost
of their care is paid by a State plan under title XIX of the Social
Security Act (Medicaid). This reduced SSI benefit rate also applies to
persons who are in medical care facilities where more than 50 percent
of the cost would have been paid by an approved Medicaid State plan but
for the application of section 1917(c) of the Social Security Act due
to a transfer of assets for less than fair market value. Persons and
couples to whom these reduced benefits apply are--
* * * * *
Subpart F--Representative Payment
10. The authority citation for subpart F of part 416 continues to
read as follows:
Authority: Secs. 702(a)(5), 1631 (a)(2) and (d)(1) of the Social
Security Act (42 U.S.C. 902(a)(5) and 1383 (a)(2) and (d)(1)).
11. Section 416.640 is amended by revising paragraphs (b) and (c)
to read as follows:
Sec. 416.640 Use of benefit payments.
* * * * *
(b) Institution not receiving Medicaid funds on beneficiary's
behalf. If a beneficiary is receiving care in a Federal, State, or
private institution because of mental or physical incapacity, current
maintenance will include the customary charges for the care and
services provided by an institution, expenditures for those items which
will aid in the beneficiary's recovery or release from the institution,
and nominal expenses for personal needs (e.g., personal hygiene items,
snacks, candy) which will improve the beneficiary's condition. Except
as provided under Sec. 416.212, there is no restriction in using SSI
benefits for a beneficiary's current maintenance in an institution. Any
payments remaining from SSI benefits may be used for a temporary period
to maintain the
[[Page 10279]]
beneficiary's residence outside of the institution unless a physician
has certified that the beneficiary is not likely to return home.
Example: A hospitalized disabled beneficiary is entitled to a
monthly benefit of $264. The beneficiary, who resides in a boarding
home, has resided there for over 6 years. It is doubtful that the
beneficiary will leave the boarding home in the near future. The
boarding home charges $215 per month for the beneficiary's room and
board.
The beneficiary's representative payee pays the boarding home
$215 (assuming an unsuccessful effort was made to negotiate a lower
rate during the beneficiary's absence) and uses the balance to
purchase miscellaneous personal items for the beneficiary. There are
no benefits remaining which can be conserved on behalf of the
beneficiary. The payee's use of the benefits is consistent with our
guidelines.
(c) Institution receiving Medicaid funds on beneficiary's behalf.
Except in the case of a beneficiary receiving benefits payable under
Sec. 416.212, if a beneficiary resides throughout a month in an
institution that receives more than 50 percent of the cost of care on
behalf of the beneficiary from Medicaid, any payments due shall be used
only for the personal needs of the beneficiary and not for other items
of current maintenance.
Example: A disabled beneficiary resides in a hospital. The
superintendent of the hospital receives $30 per month as the
beneficiary's payee. The benefit payment is disbursed in the
following manner, which would be consistent with our guidelines:
Miscellaneous canteen items........................................ $10
Clothing........................................................... 15
Conserved for future needs of the beneficiary...................... 5
* * * * *
Subpart K--Income
12. The authority citation for subpart K of part 416 continues to
read as follows:
Authority: Secs. 702(a)(5), 1602, 1611, 1612, 1613, 1614(f),
1621, and 1631 of the Social Security Act (42 U.S.C. 902(a)(5),
1381a, 1382, 1382a, 1382b, 1382c(f), 1382j, and 1383); sec. 211,
Pub. L. 93-66, 87 Stat. 154 (42 U.S.C. 1382 note).
13. Section 416.1147 is amended by revising paragraphs (b) and (d)
to read as follows:
Sec. 416.1147 How we value in-kind support and maintenance for a
couple.
* * * * *
(b) One member of a couple lives in another person's household and
receives food and shelter from that person and the other member of the
couple is in a medical institution. (1) If one of you is living in the
household of another person who provides you with both food and
shelter, and the other is temporarily absent from the household as
provided in Sec. 416.1149(c)(1) (in a medical institution that receives
substantial Medicaid payments for his or her care (Sec. 416.211(b))),
and is ineligible in the month for either benefit payable under
Sec. 416.212, we compute your benefits as if you were separately
eligible individuals (see Sec. 416.414(b)(3)). This begins with the
first full calendar month that one of you is in the medical
institution. The one living in another person's household is eligible
at an eligible individual's Federal benefit rate and one-third of that
rate is counted as income not subject to any income exclusions. The one
in the medical institution cannot receive more than the reduced benefit
described in Sec. 416.414(b)(3)(i).
(2) If the one member of the couple in the institution is eligible
for one of the benefits payable under the Sec. 416.212 provisions, we
compute benefits as a couple at the rate specified under Sec. 416.412.
However, if that one member remains in the institution for a full month
after expiration of the period benefits based on Sec. 416.212 can be
paid, benefits will be computed as if each person were separately
eligible as described under paragraph (c)(1) of this section. This
begins with the first calendar month after expiration of the period
benefits based on Sec. 416.212 can be paid.
* * * * *
(d) One member of a couple is subject to the presumed value rule
and the other member is in a medical institution.
(1) If one of you is subject to the presumed value rule and the
other is temporarily absent from the household as provided in
Sec. 416.1149(c)(1) (in a medical institution that receives substantial
Medicaid payments for his or her care (Sec. 416.211(b))), and is
ineligible in that month for either benefit payable under Sec. 416.212,
we compute your benefits as if both members of the couple are
separately eligible individuals (see Sec. 416.414(b)(3)). This begins
with the first full calendar month that one of you is in the medical
institution (see Sec. 416.211(b)). We value any food, clothing, or
shelter received by the one outside of the medical institution at one-
third of an eligible individual's Federal benefit rate, plus the amount
of the general income exclusion (Sec. 416.1124(c)(12)), unless you can
show that their value is less as described in Sec. 416.1140(a)(2). The
member of the couple in the medical institution cannot receive more
than the reduced benefit described in Sec. 416.414(b)(3)(i).
(2) If one of you is subject to the presumed value rule and the
other in the institution is eligible for one of the benefits payable
under Sec. 416.212, we compute the benefits as a couple at the rate
specified under Sec. 416.412. However, if the one in the institution
remains in the institution after the period benefits based on
Sec. 416.212 can be paid, we will compute benefits as if each member of
the couple were separately eligible as described in paragraph (d)(1) of
this section.
14. Section 416.1149 is amended by revising paragraphs (a) and
(c)(1) to read as follows:
Sec. 416.1149 What is a temporary absence from your living
arrangement.
(a) General. A temporary absence may be due to employment,
hospitalization, vacations, or visits. The length of time an absence
can be temporary varies depending on the reason for your absence. For
purposes of valuing in-kind support and maintenance under
Secs. 416.1130 through 416.1148, we apply the rules in this section. In
general, we will find a temporary absence from your permanent living
arrangement if you (or you and your eligible spouse)-
(1) Become a resident of a public institution, or a public or
private medical care facility where over 50 percent of the cost of care
is paid by Medicaid, and are eligible for the benefits payable under
Sec. 416.212; or
(2) Were in your permanent living arrangement for at least 1 full
calendar month prior to the absence and intend to, and do, return to
your permanent living arrangement in the same calendar month in which
you (or you and your spouse) leave, or in the next month.
* * * * *
(c) Rules for temporary absence in certain circumstances.
(1)(i) If you enter a medical care facility that receives
substantial Medicaid payments for your care (as described in
Sec. 416.211(b)) and you are not eligible for either benefit payable
under Sec. 416.212 (and you have not received such benefits during your
current period of confinement) and you intend to return to your prior
living arrangement (and you are eligible for the reduced benefits
payable under Sec. 416.414 for full months in the facility), we
consider this a temporary absence regardless of the length of your stay
in the facility. We use the rules that apply to your permanent living
arrangement to value any food, clothing, or shelter you receive during
the month (for which reduced benefits under Sec. 416.414 are not
payable) you enter or leave the facility.
[[Page 10280]]
During any full calendar month you are in the medical care facility,
you cannot receive more than the Federal benefit rate described in
Sec. 416.414(b)(1). We do not consider food or shelter provided during
a medical confinement to be income.
(ii) If you enter a medical care facility and you are eligible for
either benefit payable under Sec. 416.212, we also consider this a
temporary absence from your permanent living arrangement. We use the
rules that apply to your permanent living arrangement to value any
food, clothing, or shelter you receive during the month you enter the
facility and throughout the period you are eligible for these benefits.
We consider your absence to be temporary through the last month
benefits under Sec. 416.212 are paid unless you are discharged from the
facility in the following month. In that case, we consider your absence
to be temporary through the date of discharge.
* * * * *
15. Section 416.1167 is amended by revising paragraph (a) to read
as follows:
Sec. 416.1167 Temporary absences and deeming rules.
(a) General. During a temporary absence, we continue to consider
the absent person a member of the household. A temporary absence occurs
when--
(1) You, your ineligible spouse, parent, or an ineligible child
leaves the household but intends to and does return in the same month
or the month immediately following; or
(2) You enter a medical care facility and are eligible for either
benefit payable under Sec. 416.212. We consider your absence to be
temporary through the last month benefits under Sec. 416.212 were paid
unless you were discharged from the facility in the following month. In
that case, we consider your absence to be temporary through the date of
discharge.
* * * * *
Subpart T--State Supplementation Provisions; Agreement; Payments
16. The authority citation for subpart T of part 416 continues to
read as follows:
Authority: Secs. 702(a)(5), 1616, 1618, and 1631 of the Social
Security Act (42 U.S.C. 902(a)(5), 1382e, 1382g, and 1383); sec.
212, Pub. L. 93-66, 87 Stat. 155 (42 U.S.C. 1382 note); sec. 8 (a),
(b)(1)-(b)(3), Pub. L. 93-233, 87 Stat. 956 (7 U.S.C. 612c note,
1431 note and 42 U.S.C. 1382e note); secs. 1 (a)-(c) and 2(a),
2(b)(1), 2(b)(2), Pub. L. 93-335, 88 Stat. 291 (42 U.S.C. 1382 note,
1382e note).
17. Section 416.2040 is amended by revising paragraph (a) and
adding a new paragraph (c) to read as follows:
Sec. 416.2040 Limitations on eligibility.
* * * * *
(a) Inmate of public institution. A person who is a resident in a
public institution for a month, is ineligible for a Federal benefit for
that month under the provision of Sec. 416.211(a), and does not meet
the requirements for any of the exceptions in Sec. 416.211 (b), (c), or
(d), or Sec. 416.212, also shall be ineligible for a federally
administered State supplementary payment for that month.
* * * * *
(c) Recipient eligible for benefits under Sec. 416.212. A recipient
who is institutionalized and is eligible for either benefit payable
under Sec. 416.212 for a month or months may also receive federally
administered State supplementation for that month. Additionally, a
recipient who would be eligible for benefits under Sec. 416.212 but for
countable income which reduces his or her Federal SSI benefit to zero,
may still be eligible to receive federally administered State
supplementation.
[FR Doc. 96-5705 Filed 3-12-96; 8:45 am]
BILLING CODE 4190-29-P
