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Supplemental Security Income Exceptional Expense (SSI-E) Handbook Release 10-01 August 25, 2010 |
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Supplemental Security Income Exceptional Expense (SSI-E) Handbook Release 10-01 August 25, 2010 |
2.1.2 Qualified Substitute Care Facility
2.1.3 Community-Integrated Setting
2.1.11 Review of Certification
2.1.13 Decertification of Eligibility
To be eligible for SSI-E in substitute care, a person must meet all the following criteria:
The person must be eligible for SSI.
If the Social Security Administration denies the person for SSI, the person may not receive the E Supplement unless the denial is successfully appealed or if conditions change such that the person subsequently becomes eligible for SSI.
If conditions change, the authorizing agency must submit a new certification to the Department of Health Services.
To qualify for SSI-E, the person must have monthly expenses greater than the SSI-E payment level. Such expenses include monthly costs borne by the person for the facility rate, personal needs, and cost-sharing for social and health services. For MA Community Waiver recipients, only the room and board portion of the rate is included along with personal needs and cost-sharing.
SSI-E recipients in substitute care are entitled to a monthly personal needs allowance of at least $65, or if they have more than $65 of monthly earnings, at least the first $65 of earnings and one half of the remainder.
The local agency may set a higher personal needs allowance.
The person must be in the least restrictive and most home-like living arrangement that can meet the person’s needs, as determined by the certifying agency.
The person must live in a qualified substitute care facility in a community-integrated setting.
The person’s residence must be one of the following:
Licensed Family Foster Home for children;
Licensed Group Foster Home for children;
Community Based Residential Facility licensed for no more than 20 beds.
Licensed or Certified Adult Family Home;
CBRF, grandfathered, or
Certified Residential Care Apartment Complex (RCAC).
Grandfathered CBRFs are facilities that are larger than 20 beds which are qualified on the basis of previous eligibility standards.
A list of such facilities is in 6.2 Grandfathered Facilities, which also explains the different categories of grandfathered facilities and the conditions under which facilities lose grandfather status.
Only individuals living in one of the above types of substitute care arrangements may be initially certified for SSI-E. However, persons currently receiving SSI-E while not in one of these settings are permitted to continue receiving SSI-E under one of three circumstances:
If a person receives SSI-E in a CBRF with 20 or fewer beds which then increases its licensed bed capacity to more than 20 beds, the person continues to be eligible while living in the facility. No other residents may be certified after the increase in bed capacity.
When a grandfathered CBRF (see Appendix C) loses its grandfather status because it increases its licensed bed capacity, SSI-E recipients residing in the facility at the time grandfathered-in status is revoked continue to be eligible for SSI-E, but no additional persons may be certified for the SSI-E payment in the facility.
If a person was receiving SSI-E on January 1, 1984 while living in a facility that was not a qualified substitute care setting, the person continues to receive SSI-E as long as he or she continues to reside in the same facility.
When that person moves to a new living arrangement, the certification may be continued only if, in the new residence, the person meets the current eligibility criteria.
The facility may not be adjacent to, a part of, or on the grounds of an "institution"
The facility must be in a neighborhood where:
non-elderly and non disabled people also reside;
the person has access to services and community resources (e.g., transportation, stores, theaters, restaurants, etc.) typical of the community; and
there are regular and informal opportunities for social integration and interaction with non-elderly and non disabled people.
The "local authorizing" county agency (Appendix A, "Definitions") responsible for completing the certification for SSI-E depends on the target group description which applies to the person.
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AGENCIES AUTHORIZED TO CERTIFY SSI-E RECIPIENTS |
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DSS |
DHS |
DCP |
CAU |
DDS |
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Elderly |
X |
X |
X |
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Alzheimer’s Disease |
X |
X |
X |
X |
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Blind |
X |
X |
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Chronically Mentally Ill |
X |
X |
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Developmentally Disabled |
X |
X |
X |
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Physically Disabled |
X |
X |
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Alcohol or Drug Abuse |
X |
X |
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SSI-E shall be authorized only after careful review by agency staff or a contractor agency. Both the needs of the recipient and the level of support service provided must be taken into account in deciding if SSI-E is to be approved.
When a person applies for SSI-E, the agency must determine eligibility for that person within 30 days of when the person first expresses an intent to apply.
Do not certify for the future based on anticipated situations. You may be planning a living arrangement that meets SSI-E criteria and plan to certify, but do not send in the certification until the plan is implemented. Complete the certification only after the person meets all the eligibility criteria.
Counties Where Family Care is Available
For Family Care populations in Family Care counties, at the county’s option, the county or the Aging and Disability Resource Center (ADRC) may determine SSI-E eligibility.
For non-Family Care populations, i.e. people with mental illness and children, the county can complete the SSI-E determination or contract with a private contract agency or ADRC.
For SSI-E determinations performed by ADRCs, the county agency director is not required to review and approve SSI-E certifications. In these cases, the ADRC director or designee may review and approve SSI-E certifications.
In counties where Family Care is available, there will be cases where individuals will become eligible for SSI-E after initial enrollment in Family Care due to change(s) in the individual’s condition and/or circumstances. In these cases, the Managed Care Organization will complete the initial SSI-E determination and certification, since the Managed Care Organization is familiar with these individuals and their functional condition. Which ever entity the county designated responsible for the initial SSI-E determination (a county agency or ADRC), that same entity would be responsible for the certification of individuals who become eligible for SSI-E after enrollment in IRIS.
When you determine a person meets all the criteria for eligibility, complete the Application for SSI-E Certification form (F-20818 ). The form must be signed by the agency director or by her/his authorized representative (as noted in 2.1.6, SSI-E certifications in areas where Family Care is available may be signed by ADRC directors or designees that have determined SSI-E eligibility).
The applicant for SSI-E or a representative (which for substitute care certifications only may be the case worker completing the form) must sign the form at the bottom. See Appendix D for instructions on completing the form.
Private contract agencies may complete the SSI-E certification for the designated county agency, but the county agency director or a designee must review, approve and sign the form (item 16).
The Department of Health Services will notify the SSI recipient when the payment increase takes effect.
In the event the individual who is certified is not currently receiving SSI, the Department will return all copies of the certification form to the authorizing agency with a notation made on the reverse of the form.
The effective date for the start of SSI-E payment is the first of the month after the person has met all of the eligibility criteria and the local agency representative completes the form, i.e., the first of the month after the form completion date entered in item 14 on the F-20818 .
The worker enters the SSI-E Effective Date on the form in item 5. Do not certify based on anticipated events. The effective date for a Change of Living Arrangement for someone receiving SSI-E and continuing eligibility in the new arrangement is the first of the month after the change takes place. For example, if an SSI recipient moves from a CBRF to an Adult Family Home on June 10, make the effective date July 1.
SSI recipients are certified for SSI-E as individuals, even if they receive SSI as a couple. One or both members of the couple may be certified depending on their needs as individuals.
If both members of the couple are certified for SSI-E, the payment level is the couple rate for SSI-E (See 6.1 SSI-E Payment Rates.).
The local authorizing agency must establish a method for monitoring that the person continues to reside in a qualified substitute care setting with costs to the person at least equal to the E payment level. Agency monitoring must be sufficient for the agency to report to the Department of Health Services in a timely manner changes of address or living arrangement, decertifications and moves from substitute care to natural residential settings.
The authorizing agency may provide the recipient or guardian and the recipient’s representative payee, if any, with a form on which to report changes of address and other changes to the authorizing agency.
Case management services may be provided to SSI-E recipients as a covered service under Medicaid , to the extent allowed by the State MA Administrative Code or the MA Community Waivers Manual. Such services must meet all applicable standards of those funding sources.
Monitoring in Counties where Family Care is Available
For Family Care populations, the Managed Care Organization is responsible for the annual Family Care eligibility recertification for its members. The ADRC is responsible for the annual eligibility recertification of clients in the IRIS self-directed supports waiver.
It is most efficient for the monitoring of SSI-E eligibility to be coupled with the annual Family Care/IRIS recertification given the recertification process involves a comprehensive review of a client’s needs and living situation. For this reason, for Family Care populations, Managed Care Organizations will be responsible for monitoring SSI-E eligibility for their members and ADRCs will be responsible for monitoring SSI-E eligibility for IRIS members, as part of the annual recertification of each group. To fulfill the monitoring requirement, the Managed Care Organization or ADRC would only need to provide notification to HP Enterprise Services if a client no longer met SSI-E eligibility by completing Form F-20818 (http://dhs.wisconsin.gov/forms1/f2/f20818.pdf or http://dhs.wisconsin.gov/forms1/f2/f20818.doc). This form is used to both certify or decertify individuals (see item #12 to give reason for decertification). No additional action or paperwork would be needed in cases where the client continues to meet eligibility criteria for SSI-E, which will be the majority of cases.
A person’s certification must be reviewed by the local authorizing agency when the person changes residence. Use the Certification Form (F20818), to report changes to the Department of Health Services.
If the person continues to be eligible in the new residence, the authorizing agency shall report the change of address to the Department of Health Services on the Certification form as a "Continue" (see 6.3 SSI Forms)
If the person moves from a qualified substitute care arrangement to his or her own home and meets the eligibility criteria for persons in natural residential settings, the agency shall report this as a "Continue" and "SCNR" (i.e., move from substitute care to natural residential) on the Certification form. Send the form to the Department of Health Services for processing.
The E Supplement is a statewide benefit which eligible persons should not lose solely because they move to another county.
If the authorizing agency knows that a person has moved from substitute care in its county to either substitute care or a natural residential setting in another county, rather than completing a decertification, the case manager in the first county should inform appropriate staff in the receiving county of the person’s move.
This policy only applies if the first county does not retain legal or fiscal responsibility under Ch. 51 or Ch. 55. (Where the first county is still responsible it reports the change to the Department of Health Services.)
The case manager in the receiving county shall determine within 30 days of receiving the referral whether the new living arrangement qualifies for SSI-E.
If it does, staff in the receiving county shall process as a "Continue" on the F-20818 and send the form to the Department of Health Services. If the new arrangement does not qualify for SSI-E, the receiving county completes a decertification (see immediately below).
If the person becomes ineligible for SSI-E, complete the Certification form as a decertification. See the instructions in 6.3 SSI Forms.
Send a written notice to the person or guardian and the person’s representative payee, if any (though not if the county agency is the payee). Include the reason for the decertification.
Exception: If the person enters a medical treatment facility (hospital or nursing home) for which Medicaid pays more than half the cost of care, do not decertify the person until 3 full calendar months have elapsed.
Federal law allows a recipient to continue receiving his or her full SSI benefit including state supplementation if a physician certifies that the person’s stay is not likely to exceed 3 months and the person needs to maintain a home to return to.
At the end of three calendar months you may either submit a decertification or defer to DHS which will terminate the person from basic SSI (and therefore SSI-E as well) if he or she remains in the institution.
The effective date for decertifying an SSI-E recipient is the first of the month AFTER you know the person is no longer eligible, with one exception: if the recipient dies, use the date of death as the effective date.
Do not retroactively decertify unless it is because of the death of the recipient.
The SSA, the Department of Health Services State SSI Unit and the DDB periodically review SSI cases to determine recipients’ continuing eligibility. SSA reviews for continuing financial eligibility; the frequency and type (in-person or mail) of such reviews is based on the likelihood of error.
The DDB reviews to determine whether persons eligible because of disability are still disabled. The frequency depends upon the likelihood of medical improvement, whether the person attempts to work and the DDB’s initial claims workload.
The State SSI Unit reviews financial and nonfinancial eligibility for state only SSI recipients annually. Such reviews of financial eligibility or continuing disability may result in a cessation of benefits, including cessation of the SSI-E payment.
There is no state appeal process for the local authorizing agency’s decision on eligibility for SSI-E in substitute care.
The personal allowance for an SSI-E recipient shall be at least $65 per month. The $65 represents the minimum amount of discretionary income which must be available to the person. However, if the recipient has more than $65 per month of earnings, the personal needs allowance shall be at least the first $65 and one half of the remainder of earnings. The authorizing agency may set a higher personal needs allowance.
For cost-sharing purposes, persons in substitute care are treated as one-person households. Cost-sharing is based on subsections HSS 1.03(2) and (3) of the Uniform Fee System. For adults in CBRFs or Adult Family Homes, refer to Bulletin 3.23 of the Collection User’s Manual. For children, refer to the Collection User’s Manual, Bulletins 3.20-3.25.
If the person is a recipient of services under the Community Options Program (COP) or if the local authorizing agency uses the COP cost-sharing for other long-term support programs serving the person, refer to the COP Guidelines and Procedures for cost-sharing instructions. If the person is a recipient of services under any Medicaid Waiver for home and community-based services, refer to the MA Community Waivers Manual for cost-sharing instructions.
This page last updated in Release Number: 09-02
Release Date: 11/19/09
Effective Date: 11/19/09