3.1 SSI-E For People In Natural Residential Settings

3.1.1 Personal Eligibility

3.1.2 Community Integrated Setting

3.1.3 Not Certified or Licensed

3.1.4 SSI Payment Levels

3.1.5 Applications and Timeline Process

3.1.6 Responsible Agencies

3.1.7 Determining Need For Services

3.1.8 Assessment Worksheet

3.1.9 Determining Need When A Person Resides With A Spouse

3.1.10 Certification Procedure

3.1.11 Denial of Eligibility

3.1.12 Effective Date

3.1.13 Couples and SSI-E

3.1.14 Review of Certification

3.1.15 Case Management

3.1.16 Inter-County Moves

3.1.17 Decertification of Eligibility

3.1.18 Recipient Notice of Decertification

3.1.19 SSI Eligibility Review

3.1.20 Regional Office Monitoring

3.1.21 Appeals

3.1.22 Cost Sharing

3.1.1 Personal Eligibility

To be eligible for SSI-E in a natural residential setting, a person must meet all the following criteria:

1. 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.

2. In order to be eligible for SSI-E, a person living with others must:

1. be paying a proportionate share of the household expenses, including food, rent or mortgage, property taxes and utilities other than telephone; or

2. have an ownership interest in or pay rent for his or her housing; or

3. buy food separately or pay his or her share of food costs. (This requirement does not apply to children under 18 residing with a parent or people residing with a spouse.)

If none of these apply, the SSA considers the person to be receiving in-kind support and reduces the federal benefit level by one-third instead of calculating the actual value of in-kind income received.

Such persons are considered in the SSI-B or SSI-D living arrangements ("household of another") and are not eligible for SSI-E (See 6.1 SSI-E Payment Rates).

Note: If the "household of another" living arrangement does not apply but the person receives unearned in-kind food, shelter or clothing, the SSA will usually assume that the support is worth a set amount called "Presumed Maximum Value" (See 6.1 SSI-E Payment Rates), unless the person proves that it is worth less.

Such persons are eligible for SSI-E provided this additional unearned income does not put them over the income limit, but it will reduce their SSI benefit.

3. The person needs at least 40 hours per month of primary long-term support services ( supportive home care The provision of services, except nursing care, that are intended to maintain persons in independent or supervised living in their own home or the home of their friends or relatives, which help them meet their daily living needs, address their needs for social contact, ensure their well-being and reduce the likelihood that the person will have to move to a nursing home or other alternate living arrangement. Services may include, but are not limited to: Household care. Personal care. Supervision. , daily living skills training or community support program A coordinated care and treatment program which provides a range of treatment, rehabilitation, and support services through an identified treatment program and staff to ensure: 1) ongoing therapeutic involvement 2) individualized treatment 3) rehabilitation 4) support services in the community for persons with chronic mental illness or chronic alcohol or other drug abuse. Services include, but are not limited to: Outreach. Screening. Assessment and treatment planning. Crisis intervention services. Supportive psychotherapy/counseling. Symptom management. Medication prescription, administration, monitoring and documentation. Psychiatric and psychological services. Rehabilitation services such as employment-related services. Social and recreational skill training. Activities of daily living services provided in community-based settings. Assistance to obtain adequate physical health or dental services. Transportation services. Financial benefits. Living accommodations. Case management activities including coordination of treatment and referrals. Monitoring symptom status. Advocacy. Education. Support and consultation to clients’ families and other major supports. services)

4. This is determined by completing a functional assessment and completing the F-20817 Assessment Worksheet for Natural Residential Settings, which confirms the number of hours of qualifying long-term support services needed.

If the person is a minor child residing with a parent, only hours of service needed when the parent is away from the residence for purposes of employment count toward the 40 hour requirement.

In cases where a minor child residing with a parent or parents that are physically or mentally unable to provide care, hours in which the parent or parents are home may be applied toward the 40 hour requirement.

If the person resides with a spouse, only services needed when the spouse is away from the residence for purposes of employment or which the spouse is physically or mentally unable to provide count toward the 40 hour requirement.  (See "Determining Need When a Person Resides With a Spouse.")

Note that if the "household of another" living arrangement does not apply, but the person receives unearned in-kind food, shelter or clothing, SSA will usually assume that the support is worth a set amount called the "presumed maximum value" (See 6.1 SSI-E Payment Rates), unless the person proves that it is worth less.

Such persons are eligible for SSI-E provided this additional unearned income does not put them over the income limit. However, it will reduce their federal SSI benefit.

3.1.2 Community Integrated Setting

The person must live in a home or apartment in a neighborhood where:

1. non-elderly and non disabled people also reside;

2. the person has access to services and community resources (e.g., stores, transportation, theaters, restaurants, etc.) typical of the community; and

3. there are regular and informal opportunities for social integration and interaction with non-elderly and non disabled people.

A residence is not qualified if it is a part of, or on the grounds of, an " Institution A facility required to be regulated as a hospital, nursing home, child caring institution, or a community based residential facility or other board and care facility of 16 or more beds. ."  A natural residential setting may be adjacent to an institution.

A residence is not qualified if it is part of, or on the grounds of, a Community Based Residential Facility (CBRF) consisting entirely of independent apartments.

Effective July 1, 2000, a residence that is part of a certified Residential Care Apartment Complex (RCAC) is qualified. However, a certified RCAC is considered a substitute care living arrangement (See Part 1, SSI-E for People in Substitute Care).

3.1.3 Not Certified or Licensed

A residence is not qualified as a natural residential setting if it requires certification as an Adult Family Home or licensure under Wisconsin Statutes Chapters 48 or 50. Such residences, if they are allowable settings for SSI-E, are covered under Part 1, SSI-E for People in Substitute Care.

3.1.4 SSI Payment Levels

See 6.1 SSI-E Payment Rates

3.1.5 Applications and Timeline Process

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.

For persons receiving SSI at the time they apply for the E Supplement, the effective date for certification 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 certification.

The worker enters the SSI-E Effective Date on the form in item 4. Do not certify based on anticipated events.

If the local agency determines the person is not eligible for SSI-E, it must provide a written notice of denial to the person or guardian and the representative payee, if any, with the reasons for ineligibility and a statement of appeal rights.

See the model denial notice in 5.1 Appeals and Complaints.

3.1.6 Responsible Agencies

The "local authorizing" county agency responsible for completing the certifications for SSI-E depends on the target group description which applies to the person.

However, any one of the above agencies may select another county agency in this group to authorize and monitor SSI-E for certain groups of recipients.

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.  For these situations, 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.  

3.1.7 Determining Need For Services

The authorizing agency must determine whether the candidate for SSI-E needs 40 hours or more of primary long-term support services (i.e., supportive home care, daily living skills training The provision of services to persons whose health or well-being is at risk of deteriorating or for whom development is delayed due to inadequate knowledge or skills in routine daily living tasks. Services are intended to improve a client’s or caretaker’s ability to perform routine daily living tasks and utilize community resources, are educationally focused and are not primarily designed to provide substitute task performance. Services include, but are not limited to: Education and training. Assessment and diagnosis. Case planning, monitoring, and review. Teaching of child rearing skills. Training on the preparation and management of household budget. Maintenance and care of the home and preparation of food. Services provided primarily in natural settings such as those performed by a home trainer for children age birth through 3. Skill training for clients of all ages living in natural settings. or community support services) as defined in the Glossary.

It is the need rather than receipt of services which determines eligibility. For persons already receiving services, the funding source for the service is irrelevant (e.g., MA card, MA waivers, community aids, COP, Family Support, CSP, etc.).

Similarly, it does not matter who provides the service - a paid provider, family, or other informal caregiver--or whether no one currently provides it, as long as it is needed.

However, when the SSI recipient resides with a spouse or is a minor living with a parent, special criteria apply.

Only services needed when the spouse or parent is away from the residence for purposes of employment or which the spouse is physically or mentally unable to provide count toward the 40 hour requirement (s.49.77(3s)(b)1 and 2).

To determine need, three criteria must be met:

1. an assessment must be conducted which meets the requirements of s.46.27 (Community Options Program assessment with a focus on the amount [hours]) of qualifying services needed;

2. the Functional Assessment Worksheet for Natural residential Settings (F-20817)  must be completed to document the service needs identified by the assessment; and,

3. the SSI-E Natural Residential Setting Application Checklist (F-20812) may be completed to confirm that the person is in a qualified living arrangement and meets the other qualifying conditions.

3.1.8 Assessment Worksheet

The Functional Assessment Worksheet for Natural Residential Settings is used to document that the person needs at least 40 hours per month of qualifying services.

For a person residing with a spouse, see 3.1.9 Determining Need When a Person Resides With a Spouse before completing the form.

The Worksheet establishes need based on an assessment.  However, if the person is currently receiving primary long-term support services from the authorizing agency, need may be established based upon hours of qualifying services included in the person’s case plan, plus any unpaid services and any unmet need.

For a child residing with a parent, the SSI-E statute requires that the authorizing agency count only services needed when the parent is away from the residence for employment.

This also includes hours of service needed or received when the child is in school or otherwise out of the home if the parent is away from the home for employment during these periods.

The Community Support Program part of the Assessment Worksheet  (F-20817) may be used only for persons whose primary disability is mental health related or chronic alcohol or other drug abuse. When the Community Support Program category is used it must be used exclusively, that is, it may not be combined with the Supportive Home Care or Daily Living Skills Training categories from the F-20817. This is because the service need requirement is a mechanism for targeting limited state funds to persons with higher support needs.

Since the CSP category is both broader than, and inclusive of, some of the service areas covered under Supportive Home Care and Daily Living Skills Training, it is reasonable targeting to require persons whose eligibility is based on such needs to qualify solely on the basis of the CSP category.  However, if a person whose primary disability is mental illness or drug abuse does not meet the 40 hour eligibility threshold under the CSP category, but has a secondary physical or developmental disability, you may attempt to qualify the person using the Functional Assessment Worksheet for Natural Residential Settings (F-20817).

3.1.9 Determining Need When A Person Resides With A Spouse

A person residing with a spouse meets the 40 hour requirement if any one of the following applies:

1. If a person receives 40 or more hours of primary long-term support services per month which are included in the person’s case plan. This is sufficient evidence that the spouse is incapable of providing the service. Document services received on the Assessment Worksheet.

2. If the person needs 40 or more hours of qualifying services according to an assessment, and the person’s spouse is age 75 or older, or the spouse has been determined disabled for SSI, Social Security Disability Insurance (SSDI) or SSI-related MA. Document qualifying hours on the Assessment Worksheet.

3. If the hours of qualifying service needed by the person which the spouse cannot provide total 40 or more per month. Add the hours in the following categories (do not double count):

   1. when the spouse is outside the home for employment (see "Definitions", Appendix A);

   2. when the spouse is providing basic care to self or other family members besides the applicant;

   3. when the spouse is sleeping;

   4. which a physician determines inappropriate for the spouse to provide due to the nature of the applicant’s condition or needs;

   5. which in the worker’s judgment the spouse cannot provide due to the spouse’s physical limitations;

   6. which in the worker’s judgment the spouse cannot provide due to the spouse’s mental limitations.

Document qualifying hours on the Assessment Worksheet.

3.1.10 Certification Procedure

When you determine a person meets all the criteria for eligibility, complete the Application for SSI-E Certification form  (F-20818) Natural Residential Settings (F-20817), and the SSI-E Natural Residential Setting Application Checklist (F-20812).

The Certification form must be signed by the applicant or the applicant’s representative (who may not be the county worker unless the county agency is the representative payee) and by the county director or by her/his authorized representative.

See 6.3 Forms for more information.  Private contract agencies may prepare SSI-E Certification for the designated county agency, but the county agency director or a designee must review, approve and sign the form.

Base eligibility on the current situation. Do not certify persons based on anticipated plans. 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.

Within 30 days of the application date on the F-20818, send the original of the Certification form (white and green copies) to the Department of Health Services.  Notify the person (or guardian) and the representative payee, if any, in writing. See the model approval letters in 5.1 Appeals and Complaints.

The Department of Health Services will notify the person or the representative payee when the payment level changes. DHS will return the green copy of theF-20818 Certification form to the local authorizing agency A department of social services under s.46.215 or s.46.22, a department of human services under s.46.23, a county aging unit under s.46.82 which is an agency of county government, a department of community programs under 51.42 or a department of developmental disabilities services under 51.437 [all citations via Wisconsin Statutes (exit DHFS)]. as confirmation of action taken (see reverse side of the green copy).

3.1.11 Denial of Eligibility

If you determine that the SSI recipient does not meet the SSI-E eligibility criteria, the local agency shall send a written notice to the person or guardian and the representative payee, if any, including the reason for denial and a statement of the right to appeal.  See the model denial notice in 5.1 Appeals and Complaints.  Do not complete any certification form.

3.1.12 Effective Date

The effective date for SSI-E 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 Application for SSI-E Certification form  (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 where the person continues to be eligible for SSI-E is the first of the month after the change takes place.

3.1.13 Couples and SSI-E

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.

However, even though the needs assessment is done separately for each person, where needs are measured for services that would be provided to and benefit them jointly, the service time must be apportioned between them so that the same time is not counted twice.

For example, if a couple requires 8 hours of grocery shopping a month, the hours should be split between them, usually evenly, unless some other division better reflects the proportionate benefit. 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).

3.1.14 Review of Certification

The person’s SSI-E eligibility must be reviewed when:

1. The person changes residence.

While it is the responsibility of the SSI recipient to report a change of address to the local Social Security office, it is also necessary for the local certifying agency to verify that the person in the new address still meets the SSI-E certification requirements.

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.

The authorizing agency shall report changes of address to the Department of Health Services on the Certification form as a "Continue" (see the instructions in Appendix D). Use the Certification form (F-20818 (PDF 11 KB)) to report such a change:

1. If the person moves from one qualifying natural residential setting to another, send the original (white) copy of the form to DHS. Hours of service needed are not recounted if the person moves from one natural residential setting to another, so a new Functional Assessment Worksheet for Natural residential Settings (F-20817) is not completed.

2.  If the person moves to a qualified substitute care facility, report this as a "Continue" and "NRSC" (i.e., move from natural residential to substitute care) on the Certification form. Send the original (white) copy of the form to DHS. Follow the instructions in 6.3 SSI Forms.

3. 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, report this as a "Continue" and "SCR" (i.e., move from substitute care to natural residential) on the Certification form.

2. The local authorizing agency becomes aware that the person no longer needs at least 40 hours per month of qualifying services. The basis for this can be that the certifying agency has reduced or terminated the purchase or provision of such services to the person because of declining need, or has reassessed the person’s needs, or some other basis.

Persons certified prior to September 1, 1988 based on the receipt of primary long-term support services continue to be eligible so long as they receive the services by which they originally qualified.

This means that a child who qualified prior to that date by receiving at least 40 hours of service continues to be eligible even if the child would not be eligible if applying now because the parent is home with the child.

This provision applies as long as the child continues to receive at least 40 hours of the services that originally qualified her or him.

3.1.15 Case Management

Case management services may be provided to SSI-E recipients as a covered service under Medicaid Health care coverage authorized by Title XIX of the federal Social Security Act and provided to all recipients of SSI in Wisconsin. Also known as Title 19, Title XIX, T-19, Medical Assistance. , 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.

3.1.16 Inter-County Moves

The SSI-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 a natural residential setting in its county to either substitute care or a natural residential setting in another county, rather than doing 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 DHS.)  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 Application for SSI-E Certification form  (F-20818).

Send the form to the Department of Health Services. (See the instructions in 6.3 SSI Forms) If the new arrangement does not qualify for SSI-E, the receiving county does a decertification (see immediately below).

3.1.17 Decertification of Eligibility

When the person become ineligible for SSI-E, complete the Certification form as a decertification. Follow the instructions in 6.3 SSI Forms.

For decertifications based on requirements of this policy, hold the form for 10 calendar days after notifying the recipient before submitting the form to the Department of Health  Services.

The 10 day holding period applies only to those decertifications where the basis of the action is that the person is not in a living arrangement that qualifies as a natural residential setting under this policy, or that the person does not need at least 40 hours per month of qualifying services.

This gives the recipient time to notify the local authorizing agency that he or she has appealed (with or without agency assistance) and wishes the benefit to continue pending the outcome of the appeal.

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.

The Effective Date for decertifying an SSI-E recipient is the first of the month AFTER you know the person is no longer eligible, except that if it is less than ten (10) calendar days to the first of the month, the effective date should be the first of the following month.

This provides the person with time to appeal the decision without the E Supplement being stopped and without accruing an overpayment. Never specify a retroactive effective date. The one exception to this policy is that if the recipient dies, use the date of death as the effective date.

Send the form to the Department of Health  Services, P.O. Box 6680, Madison, WI 53716-0680.

3.1.18 Recipient Notice of Decertification

When the decertification is prepared, the local authorizing agency sends a written notice to the person or guardian and the representative payee, if any. The notice shall include:

1. the effective date of the action;

2. the reason for the decertification;

3. a statement of the right to appeal;

4. information that if the person files and informs the local authorizing agency of an appeal within 10 calendar days of the date on the notice that the benefit will continue while the appeal is pending; and,

5. a statement of the process for submitting an appeal, including the time limit, the address where it is sent, and the availability of assistance from the authorizing agency in formulating it in writing.

See the model notice of decertification in 5.1 Appeals and Complaints.   If the recipient is blind or otherwise visually impaired or has communication difficulties, the local agency shall take due care to ensure that notice has been effectively communicated to the recipient.

3.1.19 SSI Eligibility Review

The SSA, DHS State SSI Unit and the Disability Determination Bureau 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 non-financial 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.

3.1.20 Regional Office Monitoring

DHS Regional Offices have the responsibility to monitor the local authorizing agency’s general management of SSI-E for natural residential settings. The Regional Office will coordinate efforts to provide technical assistance and general oversight of the SSI-E program at the local level.

3.1.21 Appeals

Applicants and recipients of SSI-E in natural residential settings have the right to a fair hearing if they believe they have been wrongly denied or discontinued from the program.  The right to a state fair hearing applies only with respect to denials and decertifications taken by the local authorizing agency under this policy. It does not apply with respect to federal requirements for SSI and actions taken by the SSA under them.

The Social Security Administration has its own appeal process. Appeals of actions under this policy should be sent to:

Department of Administration

Division of Administrative Hearings

P.O. Box 7875

Madison, WI 53707-7875

(608) 266-3038

The local authorizing agency shall provide written notice to the recipient or guardian and to the representative payee, if any, of discontinuances and denials. The notice shall contain the information specified in "Decertification of Eligibility" above.

If the basis for a decertification is that the person no longer resides in a living arrangement that meets the qualifications for a natural residential setting under this policy or that the person no longer needs at least 40 hours per month of qualifying primary long-term support services, the worker holds the decertification for 10 calendar days after notifying the recipient.

This provides the recipient with the opportunity to request that the benefit be continued while an appeal is pending. Otherwise, it is submitted to the DHS immediately.  The appeal must be made within forty-five (45) calendar days of the effective date of decertifications or denials.

For persons on SSI-E subject to discontinuance due to requirements of this policy, if the person, person’s guardian or representative payee files an appeal within 10 calendar days of the date on the notice and informs and/or sends a copy of the appeal to the local authorizing agency, the person continues to receive the SSI-E payment until a hearing decision is made.

This applies as long as the person remains eligible for the basic SSI payment (i.e., is not also terminated from SSI by the Social Security Administration). The person may waive her/his right to continued payments.

In the event of an appeal request within those 10 days, the local authorizing agency shall hold the decertification pending the outcome of the appeal.

When an appeal determination has been made, the agency shall either void the decertification or submit it to the Department of Health Services, depending on the outcome of the appeal.  If the appeal request is not received within 10 days after notifying the person, the agency shall submit the decertification to the Social Security office.

If the person subsequently appeals within the 45 day time limit, the benefit is terminated while the appeal is pending. If the recipient prevails, he or she will receive a retroactive payment back to the decertification date.

3.1.22 Cost Sharing

For those SSI-E recipients who are receiving human services through local agencies, the SSI-E income must be considered the same as regular SSI income when calculating a person’s obligation to pay toward the cost of such services.

Except for the categories of persons below, cost-sharing is governed by the Uniform Fee System, Administrative Rule HSS 1. 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 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