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Review each eligibility factor following the regulations in the appropriate manual sections. Document all factors of eligibility on form DAAS-8190S for applicant/recipients of SSI, or form DAAS-8190NS for non-applicant/recipients of SSI.
A. Visits
Make a visit to the applicant’s residence or the SA facility if the applicant is unable to visit the agency unless one of the exceptions below applies:
1. The applicant resides in a state institution (mental hospital or retardation center or prison). In this case, information shall be obtained from a responsible person or staff member of the institution.
2. The applicant resides in an SA facility in a county other than the county of legal residence from which he/she was admitted to assisted living level of care. A visit is not required, if a responsible person can act, and agrees to act on the applicant’s behalf. If no responsible person can be found to act on the applicant’s behalf, the county of legal residence may ask the county where the facility is located to complete the required forms within time standards.
1. If the application has been made and a home or facility visit is necessary to obtain additional information, do not deny the application if applicant is unavailable during an unannounced visit.
B. FL-2/MR-2 Requirements
For instructions regarding the requirment to have a valid FL-2 and/or MR-2 see SA-3100, Eligibility.
C. Verification and Documentation
1. Thoroughly complete each item on the DAAS-8190NS booklet for non-SSI recipients applying for SA. Thoroughly complete the DAAS-8190S booklet for applicants receiving SSI and applying for SA. Verify and document each of the following factors on the appropriate application booklet.
a. Eligibility Requirements: SA-3100
b. Age: SA-3230
c. Disability or blindness if under age 65. See SA3110, Application Process, VIII; and EIS-1105, III. C.
(1) For SSI a/r’s, view SDX Disability Onset, which indicates if there is a date of disability onset as alleged by the claimant during the period in which the case is awaiting a medical determination, or if the case has been medically denied.
(2) After a final disability or blindness determination has been made, the date of onset will be either the date of disability onset established for Title II (RSDI) purposes in a concurrent Title II/Title XVI allowance or the date of onset established for Title XVI only medical allowances.
(3) This date will be no earlier than the effective month of the SSI application unless information in the medical file supports an earlier onset.
d. Automated Inquiry and Match Procedures: SA-3400
g. Residence: SA-3250.
h. Resources: SA-3200.
(1) For SSI recipients
(a) View SDX Resources, showing the resource information that the applicant has provided to Social Security. Recipients of SSI automatically meet the resource requirements of SA; however, SSI resource information could provide eligibility leads that need further exploration. For example, if the SDX reflects ownership of a home which is excluded for SSI, document the SA case file with the physical location of the home for purposes of state/county residency.
(b) SDX also provides information on transfer of assets for SSI recipients.
(2) For non-SSI recipients review SOLQ/BENDEX thoroughly for leads on resources. An example of resource lead is a direct deposit indicator (“S” for savings, “C” for checking account).
i. Transfer of Resources: SA-3205
j. Income: SA-3210
k. Budgeting: SA-3220
l. Health Insurance: MA-2400.
For SSI recipients, view Third Party Insurance, which is an indicator of third party liability for health care expenses, and the effective date of the recipient’s third party liability enrollment.
m. SA facility information required:
(1) Verify in EIS that the facility is an SA eligible facility. There will be a “Y” in the SA Eligible Indicator for the facility if it is a facility approved to accept SA. For information on facilities that are designated “Y”, see SA 3100 II.3.
(2) Print the EIS facility inquiry (FI) screen for the facility of the applicant’s physical residence.
(3) Use the printed EIS FI screen to verify/document the facility’s correct name, physical location, licensure status, correct facility code and other important eligibility data.
(4) Document applicant’s date of admission to the facility on the DAAS-8190S or DAAS-8190NS as applicable.
(5) Update SA recipient case files with the above facility/physical residence information each time the applicant/recipient moves to a different SA facility.
(6) File the FI screen printout with the application booklet.
n. Enter the applicant’s physical location address (from the EIS FI screen) on the DSS-8124 application form or document why the applicant’s mailing address is different from the physical address of the facility in which he or she resides. See EIS-1063. For SSI recipients/applicants, view SDX to verify the mailing address and residence address. The SSI check and Medicaid card are mailed to this address unless a payee exists.
o. Carolina Access/Managed Care Program. (Refer to DMA-Admin. Letter No. 28-01).
(1) For SAD recipients who have Medicare in a Carolina Access county, an exempt code of “9999903” is system generated in EIS if it is not keyed on the DSS-8125, EIS Data Sheet
(2) All SAD recipients without Medicare must choose a Carolina Access provider or have one appointed and provider number entered on the DSS-8125, EIS Data Sheet. Ensure that the primary care provider is located conveniently to the facility in which the recipient resides, which may be in a different county from the county of financial responsibility.
(3) All SAA recipients are exempt from Carolina Access (Code 9999901).
p. Verification of SSI benefits: Use SDX to verify the SSI status of the SA applicant.
Instructions on using SDX are included in the EIS Manual EIS-1105.
(1) The State Data Exchange (SDX) provides critical information about individuals receiving SSI. When a recipient of SSI applies for SA, SDX SSI information must be reviewed for use in correctly determining SA eligibility.
(2) View the SDX for SSI recipients as it may provide an indication of the applicant’s competency status. Reference SA-3110 I.
(3) The Competency Code indicates the representative payee's status as to legal guardianship and/or competency of the recipient.
(4) Check to see if there is a payee indicated for the SSI check.
(5) SDX provides the SSI Eligible Date, the date the recipient was first determined eligible or most recently redetermined eligible after a period of ineligibility. This is the effective date of the first SSI payment. SSA also calls this the Application Effective Date.
(6) View the SDX Federal Eligibility Code which identifies eligibility for SSI payment in the current month.
(7) SDX Payment Status, consists of two data elements:
(c) The first position reflects the status of the SSI payment.
(d) The second and third positions reflect the reason for the status.
(8) Assess whether applicant is receiving federal benefit rate (FBR) or a reduced rate. The applicant may be receiving a reduced SSI rate due to one or more of the following reasons:
(a) One-Third Reduced SSI (SDX Unearned Income Information). If the SDX reflects unearned income code “J” for the SA applicant/recipient this indicates that the applicant’s SSI payment is based on the applicant residing in the home of another person.
The IMC must inform the SSA via DMA-5049 (Referral to Local Social Security Office) of the change in living arrangements in order to reinstate the FBR. SSI recipients or their payees are responsible for reporting changes to SSA within 10 calendar days. There is a form, SSA-8150-EV that they can use. Refer to SA 3210 for budgeting instructions.
(b) SDX Federal Living Arrangement Code. If the SDX reflects the SSI recipient resides in a Title XIX (Medicaid) institution (federal living arrangement code “D”) instead of an SA facility (field is blank), the SSI payment is reduced to $30/month or terminated if the SSI applicant has other countable income greater than $30.
As an SA applicant, this SSI recipient would need the SSI FBR reinstated because Medicaid does not pay cost of care in an SA facility. The IMC must inform the SSA via DMA-5049 (Referral to Local Social Security Office) of the change in living arrangements in order for SSA to reinstate the FBR. SSI recipients or their payees are responsible for reporting changes to SSA within 10 calendar days. There is a form, SSA-8150-EV that they can use Refer to SA 3210 for budgeting instructions.
(c) SSA Recoupment of Overpayment/s: SSA recoupment of SSI benefits or
Social Security (RSDI) benefits reduce the recipient’s monthly payment to an amount less than the monthly entitlement amount due the recipient. This reduction is reflected in a dollar amount assessed each month to collect the overpayment/s. The recoupment amount must be adjusted to the lowest possible monthly amount.
For further instructions on applicants with an SSA/SSI recoupment see SA-3210 Income.
(9) SDX Denial Code-Date provides the reason and date a claimant was initially denied for SSI. This will indicate whether the SSI applicant was denied for the reason of excess income. If the applicant was denied SSI for any reason other than income, the SA application must also be denied.
(10) The IMC should track and verify that necessary changes have been made by SSA/SSI in order for the SA beneficiary to receive the maximum federal benefits to which he or she may be entitled. Changes made by SSA will reflect on the SDX for SSI applicant/recipients.
2. Document in the case record all applicant, collateral, and telephone contacts. Always include the name of contacts providing information and the date of the contact.
3. Stamp all information with date of receipt in DSS.
4. Document the exact date that an applicant/recipient leaves a adult care facility and moves to the next adult care facility, or, moves to a higher level of care, moves to a public institution, or moves to PLA. This information is very important for keeping accurate track of the SA recipient’s physical location and provides information needed in applying the 5/10 day rule when applicable.
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For questions or clarification on any of the policy contained in these manuals, please contact your local county office.
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