405.2 Supplemental Security Income (SSI) Categories

If an individual gets Supplemental Security Income (SSI) benefits and is in either an LTC facility or a HCBS setting, the CAO must use one of the following categories for MA LTC payments:       

   55 Pa. Code § 299.1(a)      55 Pa. Code § 299.36 (e)   

• A—age 65 or older.

• J—under age 65 and disabled according to Social Security Administration (SSA) requirements.

• M—under age 65 and blind according to SSA requirements.

The CAO will use the SSI category only if the individual will continue to receive SSI benefits while receiving LTC services. The individual will remain in the SSI category as long as one of the following conditions is met:

• The individual is receiving HCBS.

• The individual has no other income, or the individual’s countable income is less than the current SSI Personal Needs Allowance (PNA). The CAO will either contact the SSA or ask the individual or their representative to inform the SSA that he has entered an LTC facility and will be receiving Title XIX funds.

NOTE:  An individual who is receiving SSI only and is admitted to an LTC facility can keep getting an SSI payment of $30 and a Supplement for Personal Needs (SPN) maximum payment of $22.10. SSI recipients will keep $30.00 SSI and the $22.10 SPN to equal $52.10 total income while in an LTC facility, but still are entitled to a $60 PNA from their countable income.

An individual may receive their regular SSI benefit for up to 3 months of institutionalization to pay for expenses to maintain their home or living arrangement if their stay in a medical facility is 90 days or less. The SSA refers to this as a “temporary institutionalization benefit”. The following will need to be provided to the SSA in order to continue to receive their SSI benefit once institutionalized:

• A physician must certify in writing that the individual’s stay in a facility will not last for more than 90 consecutive days.  This note must either be a comment on the MA 51 or a separate note.  Simply notating short-term stay less than 180 days on the MA 51 is not sufficient.
• An individual or their representative must provide a statement that they need to make payments to maintain a home or living arrangement in the community to which they intend to return.

The AAA will assist the Dom Care individual with providing these statements to the SSA. During this 3-month period the individual does not need to pay anything toward their cost of care.

The SSA must give the individual and the CAO written notice of any decision about the individual’s eligibility status. The CAO must create an alert to review the individual’s status at the end of the three months. The CAO must keep using the A, J, or M category until notified by the SSA that the individual’s SSI benefits have ended.

NOTE:  See the Medical Assistance Eligibility Handbook, Chapter 387 for information about the SSI program.

Updated December 23, 2024, Replacing January 31, 2022