H-6000, Co-Payment for SSI Cases

Revision 24-1; Effective March 1, 2024

A person is eligible for the full standard payment amount in the month of entry to a Medicaid certified long-term care facility under SSI policy. The person must have been living in a non-institutional setting or in a private institution where Medicaid made no substantial payments for any part of that month before entry to the Medicaid facility. HHSC uses the reduced SSI payment standard to calculate the co-payment for any future month where the person continues to live in the facility throughout the month.

An SSI recipient who lives in an approved Medicaid long-term care facility remains eligible for SSI if their countable income does not exceed the SSI reduced standard payment amount.

The Social Security Administration (SSA) determines eligibility for these recipients and HHSC staff must explore the co-payment amount.

Determine the co-payment for SSI recipients based on the SSI payment amount the person is entitled to and not the actual SSl payment received. SSA will recoup any erroneous payments.

Note: The reduced SSI payment standard is $30.

The reduced SSI payment standard applies to all future months if the person continues to live in the Medicaid long-term care facility throughout the month. A person is entitled to the reduced SSI payment standard for the month of entry into a Medicaid long-term care facility only if:

• the person was living in a public institution or in a Medicaid medical treatment facility for every day of the month before the date of admission to the long-term care facility; or
• Medicaid was paying more than half of the person’s cost of care.

Note: HHSC supplements the reduced SSI payment standard by $45 per month to ensure SSI recipients also have a $75 personal needs allowance.

A couple may be eligible under the full couple SSI payment standard during the month one or both spouses live in a Medicaid certified medical treatment facility where Medicaid is expected to make substantial payments.

If only one spouse enters a facility and remains there throughout the subsequent month(s), SSA separates the payments for the subsequent month(s) to reflect the living arrangements of each spouse. If both spouses enter the Medicaid medical facility and Medicaid makes substantial payments for each spouse, SSA lowers the SSI payment standard to the reduced standard for a couple ($60) for the months after the month of entry.

Monitor SSI recipients who enter a facility to determine if the recipient has other income. Calculate the co-payment as appropriate and notify Provider Claims Services.

The following amounts are the SSI federal benefit rate for the periods shown:

From Jan.1, 1974, to June 30, 1988, the reduced SSI standard payment amount was $25 for a person and $50 for a couple.