Institution Residence - Current MSSICS and SSI Claims System Screens

MS 08110.009 Institution Residence Facsimiles and Screen Shots
The Institution Residence Data (LINS) page reference has changed to MS 08110.009 due to
MSOM updates. When continued payments are payable for temporary institutionalization, SSA
must receive a physician’s certification and home expenses statement by the recipient, no later
than the date of discharge or the 90th day of medical confinement, whichever is earlier.
The SSA Claims Specialist (CS) confirms the recipient and physician provided this required
information by completing the fields ‘Home expense statement date’ field and ‘Physician
certification date’ field on the Screenshot page ‘Institution Residence – TI Benefits Selected’.
These fields tell the SSI system that the CS has obtained the necessary documentation to
determine the SSI recipient is eligible for temporary institutionalization benefits.
These fields serve as a safeguard to prevent the issuance of incorrect payments to a recipient who
does not meet the requirements to receive temporary institutionalization benefits.

FACSIMILE 1: INSTITUTION RESIDENCE – LEVINGS STATE (MEETS LEVINGS
REQUIREMENTS IS YES)
INSTITUTION RESIDENCE
NAME

SOCIAL SECURITY NUMBER(SSN)

SSSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS
SSSS
SSSSSSSSSSSSSSSSSSSSSSSSS

ROLE
SSS-SS-

[1-D]
PERIOD EFFECTIVE DATES SS/SS/SSSS – SS/SS/SSSS
*INDICATES REQUIRED INFORMATION
INSTITUTION FAVORITES
SELECT FROM FAVORITES OR TYPE CONTACT INFORMATION
[2-O]
[˅/˄] SHOW/HIDE FAVORITES
INSTITUTION FAVORITES
[3-O]
[REFRESH]

[4-O]
MANAGE OFFICE LEVEL FAVORITES

1

[5-D]

[6-D]

[7-D]

INSTITUTION NAME

[8-O]

ADDRESS

SS[VARIES]SS

SS[VARIES]SS

PHONE

ACTIONS

SS[VARIES]SS [SELECT]

[9-M]
*INSTITUTION NAME
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX [ ] UNKNOWN
*ADDRESS
[10-M]
*COUNTRY:
-[11-M]
*STREET 1
[16-M]

[12-O]
STREET 2
[17-C]

*CITY/TOWN:
CODE
[20-C]

[14-O]

[15-O]

STREET 3
[18-C]

STREET 4
[19-C]

STATE/TERRITORY

STATE/PROVINCE/REGION

ZIP

[21-O]

POSTAL CODE
[22-O]

[ ] UNKNOWN
[23-O]

[24-O]

PHONE:( )U.S. ( )INTERNATIONALPHONE:
(INTERNATIONAL)

PHONE

PHONE

(999)999-9999 (DOMESTIC) 99[MAX 15 CHARACTERS]99

10-DIGIT NUMBER/COUNTRY CODE + NUMBER
[25-D]
DATE INSTITUTIONALIZATION BEGAN SS/SS/SSSS

2

[26-C]
*MEDICAID, OR MEDICARE PART A WITH STATE BUY-IN, PAYS MORE THAN 50%
( ) YES ( ) NO ( ) UNKNOWN
[27-C]
MONTHLY CHARGE 9999.99

[ ] UNKNOWN

[28-C]
AMOUNT CLAIMANT PAYS 9999.99

[ ] UNKNWON

[29-C]
*INSTITUTION FOR SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)
PURPOSES
( ) YES ( ) NO
[30-C]

[31-O]

*MEETS LEVINGS REQUIREMENTS MORE INFO
(X) YES ( ) NO ( ) DECIDE LATER
[32-O]
[˅/˄] SHOW/HIDE PERSON REMARKS
[33-O]
PERSON REMARKS (PRINTED)
XX[MAXIMUM OF 1000 CHARACTERS]XX
[34-O]
[˅/˄] SHOW/HIDE FILE DOCUMENTATION NOTES
[35-O]
FILE DOCUMENTATION NOTES
XX[MAXIMUM OF 1000 CHARACTERS]XX
[36-O]
[CLEAR PAGE/UNDO CHANGES]
3

4

G. FACSIMILE 2: INSTITUTION RESIDENCE (MEETS LEVINGS REQUIREMENTS
IS NO)
INSTITUTION RESIDENCE
NAME

SOCIAL SECURITY NUMBER(SSN)

SSSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS
SSSS
SSSSSSSSSSSSSSSSSSSSSSSSS

ROLE
SSS-SS-

[1-D]
PERIOD EFFECTIVE DATES SS/SS/SSSS – SS/SS/SSSS
*INDICATES REQUIRED INFORMATION
INSTITUTION FAVORITES
SELECT FROM FAVORITES OR TYPE CONTACT INFORMATION
[2-O]
[˅/˄] SHOW/HIDE FAVORITES
INSTITUTION FAVORITES
[3-O]

[4-O]

[REFRESH]
[5-D]

MANAGE OFFICE LEVEL FAVORITES
[6-D]

INSTITUTION NAME
SS[VARIES]SS

[7-D]

[8-O]

ADDRESS
SS[VARIES]SS

PHONE

ACTIONS

SS[VARIES]SS [SELECT]

[9-M]
*INSTITUTION NAME
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX [ ] UNKNOWN
*ADDRESS
[10-M]
*COUNTRY:
--

5

[11-M]
*STREET 1
[16-M]
*CITY/TOWN:
CODE
[20-C]
POSTAL CODE

[12-O]

[14-O]

STREET 2
[17-C]

[15-O]

STREET 3

STREET 4

[18-C]

[19-C]

STATE/TERRITORY

STATE/PROVINCE/REGION

ZIP

[21-O]
[ ] UNKNOWN

[22-O]

[23-O]

[24-O]

PHONE: ( )U.S. ( )INTERNATIONAL PHONE:

PHONE

PHONE

(999)999-9999 (DOMESTIC)
99 [MAX 15
CHARACTERS] 99 (INTERNATIONAL) 10-DIGIT NUMBER/COUNTRY CODE +
NUMBER
[25-D]
DATE INSTITUTIONALIZATION BEGAN SS/SS/SSSS
[26-C]
*MEDICAID, OR MEDICARE PART A WITH STATE BUY-IN, PAYS MORE THAN 50%
( ) YES ( ) NO ( ) UNKNOWN
[27-C]
MONTHLY CHARGE 9999.99

[ ] UNKNOWN

[28-C]
AMOUNT CLAIMANT PAYS 9999.99

[ ] UNKNWON

[29-C]
*INSTITUTION FOR SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)
PURPOSES
( ) YES ( ) NO
[30-C]

[31-O]

*MEETS LEVINGS REQUIREMENTS MORE INFO
6

( ) YES (X) NO ( ) DECIDE LATER
[40-D]
ADMISSION DATE SS/SS/SSSS

[41-C]
*ADMISSION DATE VERIFIED
( ) YES
( ) NO

[42-O]
[X] DISCHARGED FROM THE INSTITUTION
[43-C]
*DISCHARGE DATE 99/99/9999
MM/DD/YYY

[44-C]
*DISCHARGE DATE VERIFIED
( ) YES
( ) NO

[45-C]
*INSTITUTION TYPE
( ) PUBLIC ( ) PRIVATE ( ) UNKNOWN
[46-C]
*CONFINEMENT REASON
[47-C]
*PRIVATE HEALTH INSURANCE, OR A COMBINATION OF PRIVATE HEALTH
INSURANCE AND MEDICAID, IS PAYING OR IS EXPECTED TO PAY MORE THAN 50
PERCENT
( ) YES ( ) NO ( ) UNKNOWN
[32-O]
[˅/˄] SHOW/HIDE PERSON REMARKS
[33-O]
PERSON REMARKS (PRINTED)
XX[MAXIMUM OF 1000 CHARACTERS]XX
[34-O]
[˅/˄] SHOW/HIDE FILE DOCUMENTATION NOTES
[35-O]
7

FILE DOCUMENTATION NOTES
XX[MAXIMUM OF 1000 CHARACTERS]XX
[36-O]
[CLEAR PAGE/UNDO CHANGES]

8

9

I.

FACSIMILE 3: INSTITUTION RESIDENCE (NON-LEVINGS STATE)

INSTITUTION RESIDENCE
NAME

SOCIAL SECURITY NUMBER(SSN)

SSSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS
SSSS
SSSSSSSSSSSSSSSSSSSSSSSSS

ROLE
SSS-SS-

[1-D]
PERIOD EFFECTIVE DATES SS/SS/SSSS – SS/SS/SSSS
*INDICATES REQUIRED INFORMATION
INSTITUTION FAVORITES
SELECT FROM FAVORITES OR TYPE CONTACT INFORMATION
[2-O]
[˅/˄] SHOW/HIDE FAVORITES
INSTITUTION FAVORITES
[3-O]

[4-O]

[REFRESH]
[5-D]

MANAGE OFFICE LEVEL FAVORITES
[6-D]

INSTITUTION NAME
SS[VARIES]SS

[7-D]

[8-O]

ADDRESS
SS[VARIES]SS

PHONE

ACTIONS

SS[VARIES]SS [SELECT]

[9-M]
*INSTITUTION NAME
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX [ ] UNKNOWN
*ADDRESS
[10-M]
*COUNTRY:
--

10

[11-M]

[12-O]

*STREET 1

[14-O]

STREET 2

[15-O]

STREET 3

STREET 4

PP[MAXIMUM OF 22 CHARACTERS]PP PP[MAXIMUM OF 22 CHARACTERS]PP
PP[MAXIMUM OF 22 CHARACTERS]PP PP[MAXIMUM OF 22 CHARACTERS]PP
[16-M]

[17-C]

*CITY/TOWN:
[20-C]

18-C]

[19-C]

STATE/TERRITORY STATE/PROVINCE/REGION

ZIP CODE

[21-O]

POSTAL CODE
[22-O]

[ ] UNKNOWN
[23-O]

[24-O]

PHONE:( )U.S. ( )INTERNATIONALPHONE:
(INTERNATIONAL)

PHONE

PHONE

(999)999-9999 (DOMESTIC) 99[MAX 15 CHARACTERS]99

10-DIGIT NUMBER/COUNTRY CODE + NUMBER
[25-D]
DATE INSTITUTIONALIZATION BEGAN SS/SS/SSSS
[29-C]
*INSTITUTION FOR SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)
PURPOSES
( ) YES ( ) NO
[40-D]

[41-C]

ADMISSION DATE SS/SS/SSSS
[42-O]

*ADMISSION DATE VERIFIED

( ) YES ( ) NO

[X] DISCHARGED FROM THE INSTITUTION
[43-C]

[44-C]

*DISCHARGE DATE 99/99/9999
MM/DD/YYYY

*DISCHARGE DATE VERIFIED
( ) YES ( ) NO

11

[45-C]
*INSTITUTION TYPE
( ) PUBLIC ( ) PRIVATE ( ) UNKNOWN
[46-C]
*CONFINEMENT REASON:
-[26-C]
*MEDICAID, OR MEDICARE PART A WITH STATE BUY-IN, PAYS MORE THAN 50%
( ) YES ( ) NO ( ) UNKNOWN
[47-C]
*PRIVATE HEALTH INSURANCE, OR A COMBINATION OF PRIVATE HEALTH
INSURANCE AND MEDICAID, IS PAYING OR IS EXPECTED TO PAY MORE THAN 50
PERCENT
( ) YES ( ) NO ( ) UNKNOWN
[32-O]
[˅/˄] SHOW/HIDE PERSON REMARKS
[33-O]
PERSON REMARKS (PRINTED)
XX[MAXIMUM OF 1000 CHARACTERS]XX
[34-O]
[˅/˄] SHOW/HIDE FILE DOCUMENTATION NOTES
[35-O]
FILE DOCUMENTATION NOTES
XX[MAXIMUM OF 1000 CHARACTERS]XX
[36-O]
[CLEAR PAGE/UNDO CHANGES]
12

13

K. FACSIMILE 4: INSTITUTION RESIDENCE - SPECIAL 1619/1611 BENEFITS SELECTED
[48-C]
*INSTITUTION TEMPORARY
(X) YES ( ) NO ( ) DECIDE LATER
1619/1611E SPECIAL BENEFITS
INDIVIDUALS WITH EARNINGS AT OR OVER THE SUBSTANTIAL GAINFUL
ACTIVITY (SGA) LIMIT WHO BECOME INSTITUTIONALIZED MAY BE ELIGIBLE
FOR BENEFIT CONTINUATION FOR UP TO THE FIRST TWO FULL MONTHS OF
INSTITUTIONALIZATION
[49-C]
*EARNINGS AT OR OVER THE SUBSTANTIAL GAINFUL ACTIVITY (SGA) LIMIT BUT
REMAINS ELIGIBLE FOR SSI PAYMENT OR MEDICAID UNDER SECTION 1619(A) OR
(B)
(X) YES ( ) NO ( ) DECIDE LATER
[50-C]
*ELIGIBLE FOR SSI UNDER SECTION 1619(A) OR (B) IN THE MONTH PRIOR TO THE
FIRST FULL MONTH OF INSTITUTIONALIZATION
(X) YES ( ) NO ( ) DECIDE LATER
[51-C]
*INSTITUTION PERMITS CLAIMANT TO RETAIN ANY SSI PAYMENT MADE UNDER
THIS PROVISION
(X) YES ( ) NO ( ) DECIDE LATER
[52-C]
*ELIGIBLE FOR AND CHOOSES UP TO 2 MONTHS OF BENEFIT CONTINUATION
(X) YES ( ) NO ( ) DECIDE LATER
[32-O]
[˅/˄] SHOW/HIDE PERSON REMARKS

14

[33-O]
PERSON REMARKS (PRINTED)
XX[MAXIMUM OF 1000 CHARACTERS]XX
[34-O]
[˅/˄] SHOW/HIDE FILE DOCUMENTATION NOTES
[35-O]
FILE DOCUMENTATION NOTES
XX[MAXIMUM OF 1000 CHARACTERS]XX
[36-O]
[CLEAR PAGE/UNDO CHANGES]

15

M. FACSIMILE 5: INSTITUTION RESIDENCE - TI BENEFITS SELECTED
[48-C]
*INSTITUTION TEMPORARY
(X) YES ( ) NO ( ) DECIDE LATER
1619/1611E SPECIAL BENEFITS
INDIVIDUALS WITH EARNINGS AT OR OVER THE SUBSTANTIAL GAINFUL
ACTIVITY (SGA) LIMIT WHO BECOME INSTITUTIONALIZED MAY BE ELIGIBLE
FOR BENEFIT CONTINUATION FOR UP TO THE FIRST TWO FULL MONTHS OF
INSTITUTIONALIZATION
[49-C]
*EARNINGS AT OR OVER THE SUBSTANTIAL GAINFUL ACTIVITY (SGA) LIMIT BUT
REMAINS ELIGIBLE FOR SSI PAYMENT OR MEDICAID UNDER SECTION 1619(A) OR
(B)
(X) YES ( ) NO ( ) DECIDE LATER
[50-C]
*ELIGIBLE FOR SSI UNDER SECTION 1619(A) OR (B) IN THE MONTH PRIOR TO THE
FIRST FULL MONTH OF INSTITUTIONALIZATION
(X) YES ( ) NO ( ) DECIDE LATER
[51-C]
*INSTITUTION PERMITS CLAIMANT TO RETAIN ANY SSI PAYMENT MADE UNDER
THIS PROVISION
(X) YES ( ) NO ( ) DECIDE LATER
[52-C]
*ELIGIBLE FOR AND CHOOSES UP TO 2 MONTHS OF BENEFIT CONTINUATION
( ) YES (X) NO ( ) DECIDE LATER
TEMPORARY INSTITUTIONALIZATION BENEFITS
INDIVIDUALS IN A PUBLIC INSTITUTION WHOSE PRIMARY PURPOSE IS MEDICAL
OR PSYCHIATRIC CARE OR IN A PUBLIC OR PRIVATE MEDICAID CERTIFIED
FACILITY AND WHOSE STAY IS CERTIFIED BY A PHYSICIAN AS NOT LIKELY TO
EXCEED 3 MONTHS, MAY BE ELIGIBLE FOR CONTINUING SSI BENEFITS WHEN
16

RECEIPT OF BENEFITS IS NECESSARY TO MAINTAIN A LIVING ARRANGEMENT TO
WHICH THE INDIVIDUAL MAY RETURN
[53-C]
*ELIGIBLE FOR AND CHOOSES UP TO 3 MONTHS OF TEMPORARY
INSTITUTIONALIZATION BENEFITS
(X) YES ( ) NO ( ) DECIDE LATER
[54-C]
*CARE TYPE
-[55-C]
*WHICH MEMBER OF COUPLE
-[56-C]
*HOME EXPENSE STATEMENT DATE FOR (FIRST NAME + LAST NAME) (SSN)
99/99/9999
[57-C]

MM/DD/YYYY

*PHYSICIAN CERTIFICATION DATE FOR (FIRST NAME + LAST NAME) (SSN)
99/99/9999
[58-C]

MM/DD/YYYY

[ ] *TEMPORARY INSTITUTIONALIZATION BENEFIT PERIOD ENDED
[32-O]
[˅/˄] SHOW/HIDE PERSON REMARKS
[33-O]
PERSON REMARKS (PRINTED)
XX[MAXIMUM OF 1000 CHARACTERS]XX
[34-O]
[˅/˄] SHOW/HIDE FILE DOCUMENTATION NOTES
17

[35-O]
FILE DOCUMENTATION NOTES
XX[MAXIMUM OF 1000 CHARACTERS]XX
[36-O]
[CLEAR PAGE/UNDO CHANGES]

18

O. FACSIMILE 6: INSTITUTION RESIDENCE - INELIGIBLE FOR TI BENEFITS
[48-C]
*INSTITUTION TEMPORARY
(X) YES ( ) NO ( ) DECIDE LATER
1619/1611E SPECIAL BENEFITS
INDIVIDUALS WITH EARNINGS AT OR OVER THE SUBSTANTIAL GAINFUL
ACTIVITY (SGA) LIMIT WHO BECOME INSTITUTIONALIZED MAY BE ELIGIBLE
FOR BENEFIT CONTINUATION FOR UP TO THE FIRST TWO FULL MONTHS OF
INSTITUTIONALIZATION
[49-C]
*EARNINGS AT OR OVER THE SUBSTANTIAL GAINFUL ACTIVITY (SGA) LIMIT BUT
REMAINS ELIGIBLE FOR SSI PAYMENT OR MEDICAID UNDER SECTION 1619(A) OR
(B)
(X) YES ( ) NO ( ) DECIDE LATER
[50-C]
*ELIGIBLE FOR SSI UNDER SECTION 1619(A) OR (B) IN THE MONTH PRIOR TO THE
FIRST FULL MONTH OF INSTITUTIONALIZATION
(X) YES ( ) NO ( ) DECIDE LATER
[51-C]
*INSTITUTION PERMITS CLAIMANT TO RETAIN ANY SSI PAYMENT MADE UNDER
THIS PROVISION
(X) YES ( ) NO ( ) DECIDE LATER
[52-C]
*ELIGIBLE FOR AND CHOOSES UP TO 2 MONTHS OF BENEFIT CONTINUATION
( ) YES (X) NO ( ) DECIDE LATER
TEMPORARY INSTITUTIONALIZATION BENEFITS
INDIVIDUALS IN A PUBLIC INSTITUTION WHOSE PRIMARY PURPOSE IS MEDICAL
OR PSYCHIATRIC CARE OR IN A PUBLIC OR PRIVATE MEDICAID CERTIFIED
FACILITY AND WHOSE STAY IS CERTIFIED BY A PHYSICIAN AS NOT LIKELY TO
EXCEED 3 MONTHS, MAY BE ELIGIBLE FOR CONTINUING SSI BENEFITS WHEN
19

RECEIPT OF BENEFITS IS NECESSARY TO MAINTAIN A LIVING ARRANGEMENT TO
WHICH THE INDIVIDUAL MAY RETURN
[53-C]
*ELIGIBLE FOR AND CHOOSES UP TO 3 MONTHS OF TEMPORARY
INSTITUTIONALIZATION BENEFITS
( ) YES (X) NO ( ) DECIDE LATER
[59-C]

[60-O]

TEMPORARY INSTITUTIONALIZATION INELIGIBILITY REASON
LIST OF
TEMPORARY INSTITUTIONALIZATION INELIGIBILITY DECISION CODES
( ) INDIVIDUAL NOT IN A MEDICAL FACILITY
( ) INDIVIDUAL DOES NOT HAVE HOME EXPENSES THAT MUST CONTINUE TO BE
PAID
( ) PROOF OF HOME EXPENSES NOT RECEIVED(OBSOLETE)
( ) PROOF OF HOME EXPENSES NOT SUBMITTED BY REQUIRED DATE
( ) PHYSICIAN EXPECTS INSTITUTIONALIZATION TO LAST OVER 90 DAYS
( ) PHYSICIAN CERTIFICATION NOT SUBMITTED BY REQUIRED DATE
( ) PHYSICIAN'S CERTIFICATION NOT PREPARED AND DATED BY REQUIRED DATE
(OBSOLETE)
( ) PHYSICIAN'S CERTIFICATION NOT RECEIVED (OBSOLETE)
( ) INDIVIDUAL NOT ELIGIBLE FOR SSI PAYMENT IN MONTH PRIOR TO FIRST
MONTH OF INSTITUTIONALIZATION
( ) INDIVIDUAL DOES NOT HAVE HOME EXPENSES THAT MUST CONTINUE TO BE
PAID AND PHYSICIAN CERTIFICATION NOT SUBMITTED BY REQUIRED DATE
( ) PROOF OF HOME EXPENSES NOT RECEIVED AND PHYSICIAN'S CERTIFICATION
NOT RECEIVED BY REQUIRED DATE (OBSOLETE)
( ) PROOF OF HOME EXPENSES NOT SUBMITTED BY REQUIRED DATE AND
PHYSICIAN CERTIFICATION NOT SUBMITTED BY REQUIRED DATE
( ) PHYSICIAN EXPECTS INSTITUTIONALIZATION TO LAST OVER 90 DAYS AND
PHYSICIAN CERTIFICATION NOT SUBMITTED BY REQUIRED DATE

20

( ) PHYSICIAN'S CERTIFICATION NOT PREPARED AND DATED BY REQUIRED DATE
AND PHYSICIAN'S CERTIFICATION NOT RECEIVED BY REQUIRED DATE
(OBSOLETE)
( ) INDIVIDUAL NOT ELIGIBLE FOR SSI PAYMENT IN MONTH PRIOR TO FIRST
MONTH OF INSTITUTIONALIZATION, AND PHYSICIAN CERTIFICATION NOT
SUBMITTED BY REQUIRED
( ) DECIDE LATER
[32-O]
[˅/˄] SHOW/HIDE PERSON REMARKS
[33-O]
PERSON REMARKS (PRINTED)
XX[MAXIMUM OF 1000 CHARACTERS]XX
[34-O]
[˅/˄] SHOW/HIDE FILE DOCUMENTATION NOTES
[35-O]
FILE DOCUMENTATION NOTES
XX[MAXIMUM OF 1000 CHARACTERS]XX
[36-O]

21

Q. HOW YOU GOT THERE
You:
•

Selected Residence type = “Institution” on the Residence Address and Jurisdiction page.
– Entered LINS into the TRANSFER TO field in MSSICS.
• Selected Institution Residence from the Person Status page.
– Selected Institution Residence from the left navigation menu.

•
•

Selected [Previous] on the subsequent page in the path.
Selected [Next] on the prior page in the path.

22

R. COMMON FIELDS
[1-D]PERIOD EFFECTIVE DATES: SS/SS/SSSS – SS/SS/SSSS
[2-O][˅/˄] SHOW/HIDE FAVORITES
[3-O]REFRESH
[4-O]MANAGE OFFICE LEVEL FAVORITES
[5-D]INSTITUTION NAME: SS[MAXIMUM OF 40 CHARACTERS]SS
[6-D]ADDRESS: SS[MAX 134 CHARACTERS]SS
[7-D]PHONE: SS[MAXIMUM OF 15 CHARACTERS]SS
[8-O][SELECT]
[21-O]UNKNOWN: [ ]
[22-O]PHONE: ( )
[23-O]PHONE: (999)999-9999 (DOMESTIC)
[24-O]PHONE: 99[MAX 15 CHARACTERS]99 (INTERNATIONAL)
[31-O]MORE INFO
[32-O][˅/˄] SHOW/HIDE PERSON REMARKS
[33-O]PERSON REMARKS (PRINTED): XX[1000 CHARACTERS MAXIMUM]XX
[34-O][˅/˄] SHOW/HIDE FILE DOCUMENTATION NOTES
[35-O]FILE DOCUMENTATION NOTES: XX[1000 CHARACTERS MAXIMUM]XX
[36-O][CLEAR PAGE/UNDO CHANGES]

23

S. FIELD DESCRIPTIONS
[9-M] *INSTITUTION NAME: XX[MAXIMUM OF 40 CHARACTERS]XX [ ]
UNKNOWN
Enter the name of the institution where the claimant resides. Select “Unknown” if you are unable
to obtain this information when you are completing the page. Selecting “Unknown” will result in
an incomplete page status and will prevent you from closing the event until you complete the
field.
[10-M] *COUNTRY: - Select the Country for the institution address. The default is “United States or U.S. Territory”.
When Country is “United States or U.S. Territory”, the following Address fields display:
•

Street 1.

•

Street 2.

•

Street 3.

•

Street 4.

•

City/Town.

•

State/Territory.

•

ZIP Code.

When you select a Country other than “United States or U.S. Territory”, the following Address
fields display:
•

Street 1.

•

Street 2.

•

Street 3.

•

Street 4.

•

City/Town.

•

State/Province/Region.

•

Postal Code.

Note:
When you select “Canada” as the Country, Postal Code cannot be blank.
24

[11-M] *STREET 1: PP[MAXIMUM OF 22 CHARACTERS]PP
Enter the first line of the street address. This field allows letters, numbers, spaces, hyphens,
apostrophes and/or forward slashes. Select “Unknown” if you are unable to obtain the Street 1
address information at the time you are completing the page. Selecting “Unknown” will result in
an incomplete page status and will prevent you from closing the event until you update the field.
The system prefills this field with Street 1 from the Residence Address and Jurisdiction page,
Residence address section.
[12-O] STREET 2: PP[MAXIMUM OF 22 CHARACTERS]PP
Enter the second line of the street address. This field allows letters, numbers, spaces, hyphens,
apostrophes and/or forward slashes.
When data is available, the system prefills this field with Street 2 from the Residence Address
and Jurisdiction page, Residence address section.
[14-O] STREET 3: PP[MAXIMUM OF 22 CHARACTERS]PP
Enter the third line of the street address. This field allows letters, numbers, spaces, hyphens,
apostrophes and/or forward slashes.
When data is available, the system prefills this field with Street 3 from the Residence Address
and Jurisdiction page, Residence address section.
[15-O] STREET 4: PP[MAXIMUM OF 22 CHARACTERS]PP
Enter the fourth line of the street address. This field allows letters, numbers, spaces, hyphens,
apostrophes and/or forward slashes.
When data is available, the system prefills this field with Street 4 from the Residence Address
and Jurisdiction page, Residence address section.
[16-M] *CITY/TOWN: PP[MAXIMUM OF 22 CHARACTERS]PP
Enter the City/Town of the address. This field allows letters, spaces and/or hyphens. Select the
“Unknown” checkbox if you are unable to obtain the City/Town information at the time you are
completing the page. Selecting “Unknown” will result in an incomplete page status and will
prevent you from closing the event until you update the field.
When data is available, the system prefills this field with City/Town from the Residence Address
and Jurisdiction page, Residence address section.

25

[17-C] *STATE/TERRITORY: - Select the State/Territory from the dropdown list. Select the “Unknown” checkbox if you are
unable to obtain the State/Territory information at the time you are completing the page.
Selecting “Unknown” will result in an incomplete page status and will prevent you from closing
the event until you update the field.
When data is available, the system prefills this field with State/Territory from the Residence
Address and Jurisdiction page, Residence address section.
[18-C] *STATE/PROVINCE/REGION: PP[MAXIMUM OF 22 CHARACTERS]PP
Enter the State/Province/Region for the address. This field displays when Country [X-M] does
not equal “United States or U.S. Territory”. This field allows letters, spaces and hyphens.
When data is available, the system prefills this field with State/Province/Region from the
Residence Address and Jurisdiction page, Residence address section.
[19-C] *ZIP CODE: PPPPP
Enter the ZIP Code for the address. Select the “Unknown” checkbox if you are unable to obtain
the ZIP Code at the time you are completing the page. Selecting “Unknown” will result in an
incomplete page status and will prevent you from closing the event until you update the field.
When data is available, the system prefills this field with ZIP Code from the Residence Address
and Jurisdiction page, Residence address section.
[20-C] *POSTAL CODE: PPPPPPPPPPPPPPP
Enter the Postal Code for the address. This field allows letters, numbers, spaces and hyphens.
You must complete this field when Country [X-M] is “Canada”. When Country is “Canada”, this
field must contain the following sequence of characters: alpha, numeric, alpha, space, numeric,
alpha, numeric, e.g., X9X 9X9.
Select the “Unknown” checkbox if you are unable to obtain Postal Code information for
“Canada” at the time you are completing the page. Selecting “Unknown” will result in an
incomplete page status and will prevent you from closing the event until you update the field.
When data is available, the system prefills this field with Postal Code from the Residence
Address and Jurisdiction page, Residence address section.

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[25-D] DATE INSTITUTIONALIZATION BEGAN: SS/SS/SSSS
This is the date the claimant first began residing in an institution during a period of
institutionalization.
A period of institutionalization may consist of a single living arrangement period or consecutive
living arrangement periods where the Residence type is “Institution” on the Residence address
and Jurisdiction page.
The system derives the Date institutionalization began from the Residence start date on first the
Residence Address and Jurisdiction page where Residence type is “Institution.”
[26-C] *MEDICAID, OR MEDICARE PART A WITH STATE BUY-IN, PAYS MORE
THAN 50%: ( ) YES ( ) NO ( ) UNKNOWN
Select “Yes” if Medicaid, or Medicare Part A with state buy-in, is paying or is expected to pay
over 50 percent of the cost of care.
Select “No” if Medicaid, or Medicare Part A with state buy-in, is not paying or is not expected to
pay over 50 percent of the cost of care.
Select “Unknown” if you are unable to obtain this information when you are completing the
page. Selecting “Unknown” will result in an incomplete page status and will prevent you from
closing the event until you update the field with either “Yes” or “No.”
When the state shown for the institution’s address is a Levings state, this field displays after Date
institutionalization began [X-D].
When the state shown for the institution’s address is not a Levings state and Confinement reason
[X-C] is “Medical or psychiatric care”, this field displays after Confinement reason.
[27-C] *MONTHLY CHARGE: 9999.99 [ ] UNKNOWN
Enter the amount the institution charges for the claimant's food, shelter and services each month.
Select “Unknown” if you are unable to obtain this information when you are completing the
page. Selecting “Unknown” will result in an incomplete page status and will prevent you from
closing the event until you update the field with an amount.
This fields displays when the state shown for the institution’s address is a Levings state.
You must complete this field if Medicaid, or Medicare Part A with state buy-in, pays more than
50% [X-C] is "No" and the state shown for the institution’s address is a Levings state.

27

Note: This is the usual charge if there is a usual charge. If there is no usual charge, then input
the amount the institution estimates for the claimant's cost of food, shelter and services each
month.
[28-C] *AMOUNT CLAIMANT PAYS: 9999.99 [ ] UNKNOWN
Enter the amount the claimant pays towards the monthly cost of the claimant's food, shelter and
services each month.
Select “Unknown” if you are unable to obtain this information when you are completing the
page. Selecting “Unknown” will result in an incomplete page status and will prevent you from
closing the event until you update the field with an amount.
This fields displays when the state shown for the institution’s address is a Levings state.
You must complete this field if Medicaid, or Medicare Part A with state buy-in, pays more than
50% [X-C] is "No" and the state shown for the institution’s address is a Levings state.
[29-C] INSTITUTION FOR SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM
(SNAP) PURPOSES: ( ) YES ( ) NO
Select “Yes” if the institution meets the State requirements for food stamp purposes. Otherwise,
select “No”.
You must complete this field if the state on the Residence Address and Jurisdiction page,
Residence Address, is not California.
[30-C] *MEETS LEVINGS REQUIREMENTS: ( ) YES ( ) NO ( ) DECIDE LATER
Select "Yes" if claimant meets the requirement of the Levings Court Decision.
Select "No" if claimant does not meet the requirement of the Levings Court Decision.
Select “Decide later” if you are unable to obtain this information when you are completing the
page. Selecting “Decide later” will result in an incomplete page status and will prevent you from
closing the event until you update the field with “Yes” or “No”.
This fields displays when the state shown for the institution’s address is a Levings state.
If Meets Levings requirements is "No", the system requires additional Institution Residence data,
beginning with Admission date [X-C].
[40-D] ADMISSION DATE: SS/SS/SSSS
This is the date the claimant entered this particular institution. The system prefills this with the
Residence Start Date from the Residence Address and Jurisdiction page.
[41-C] *ADMISSION DATE VERIFIED: ( ) YES ( ) NO
28

Select “Yes” if you verified the admission date. Otherwise, select “No”.
Note:
You must verify admission date before adjudication. If you select “No”, the system
generates an issue on Development Worksheet (DW01).
[42-O] DISCHARGED FROM THE INSTITUTION: [ ]
Select this checkbox when the claimant no longer resides in the institution. When you select the
checkbox, the Discharge date [X-C] and Discharge date verified fields [X-C] display.
[43-C] *DISCHARGE DATE: 99/99/9999
Enter the claimant’s discharge date from the institution. “mm/dd/yyyy” displays under the field
to indicate the format required.
You must complete this field before you enter a new Admission date or Residence type for a new
living arrangement period.
[44-C] *DISCHARGE DATE VERIFIED: ( ) YES ( ) NO
Select “Yes” if you verified the discharge date. Otherwise, select “No”.
Note: You must verify discharge date. If you select “No”, the system generates an issue on
Development Worksheet (DW01).
[45-C] *INSTITUTION TYPE: ( ) PUBLIC ( ) PRIVATE ( ) UNKNOWN
Select “Public” if it is considered a public institution.
Select “Private” if it is considered a private institution.
Select “Unknown” if you are unable to obtain this information when you are completing the
page. Selecting “Unknown” will result in an incomplete page status and will prevent you from
closing the event until you update the field with “Public” or “Private.”
[46-C] *CONFINEMENT REASON: -Select the reason the claimant is in the institution from the following dropdown list.
•

Education or vocational training.

•

Medical or psychiatric care.

•

Public Emergency Shelter for the Homeless (PESH).

•

Publicly Operated Community Residence (POCR).
29

•

Prisoner.

•

Other.

•

Unknown.

Select “Unknown” if you are unable to obtain this information when you are completing the
page. Selecting “Unknown” will result in an incomplete page status and will prevent you from
closing the event until you update the field with another value from the dropdown list.
[47-C] *PRIVATE HEALTH INSURANCE, OR A COMBINATION OF PRIVATE
HEALTH INSURANCE AND MEDICAID, IS PAYING OR IS EXPECTED TO PAY
MORE THAN 50 PERCENT: ( ) YES ( ) NO ( ) UNKNOWN
Select “Yes” if private health insurance, or a combination of private health insurance and
Medicaid, is paying or is expected to pay more than 50 percent of the cost.
Select “No” if private health insurance, or a combination of private health insurance and
Medicaid, is not paying or is not expected to pay more than 50 percent of the cost.
Select “Unknown” if you are unable to obtain this information when you are completing the
page. Selecting “Unknown” will result in an incomplete page status and will prevent you from
closing the event until you update the field with “Yes” or “No.”
This field displays when:
•

the Confinement reason [X-C] is “Medical or psychiatric” care, and

•

Medicaid, or Medicare Part A with state buy-in, pays more than 50% [X-C] is “No,” and

•

the claimant is under age 18 as of the Living Arrangement Start Date, and

•

the Residence Start Date is 11/01/1996 or later.

[49-C] *EARNINGS AT OR OVER THE SUBSTANTIAL GAINFUL ACTIVITY (SGA)
LIMIT BUT REMAINS ELIGIBLE FOR SSI PAYMENT OR MEDICAID UNDER SECTION
1619(A) OR (B): ( ) YES ( ) NO ( ) DECIDE LATER
Select “Yes” if the claimant has earnings above the substantial gainful activity limit and remains
eligible for SSI or Medicaid under 1619(a) or (b).
Select “No” if the claimant does not have earnings above the substantial gainful activity limit, or
is not eligible for SSI or Medicaid under 1619(a) or (b).
Select “Decide later” if you are unable to obtain this information when you are completing the
page. Selecting “Decide later” will result in an incomplete page status and will prevent you from
closing the event until you update the field with “Yes” or “No.”

30

When you select “No” or “Decide later,” the claimant is not eligible for 2 months of 1619/1611E
Special Benefits.
[50-C] *ELIGIBLE FOR SSI UNDER SECTION 1619(A) OR (B) IN THE MONTH
PRIOR TO THE FIRST FULL MONTH OF INSTITUTIONALIZATION: ( ) YES ( ) NO
( ) DECIDE LATER
Select “Yes” if the claimant was eligible for SSI under section 1619(a) or (b) in the month prior
to the first full month of institutionalization.
Select “No” if the claimant was not eligible for SSI under section 1619(a) or (b) in the month
prior to the first full month of institutionalization.
Select “Decide later” if you are unable to obtain this information when you are completing the
page. Selecting “Decide later” will result in an incomplete page status and will prevent you from
closing the event until you update the field with “Yes” or “No.”
This field displays when Earnings at or over the substantial gainful activity (SGA) limit but
remains eligible for SSI payment or Medicaid under section 1619(a) or (b) [X-C] is “Yes.”
When you select “No” or “Decide later,” the claimant is not eligible for 2 months of 1619/1611E
Special Benefits.

[51-C] *INSTITUTION PERMITS CLAIMANT TO RETAIN ANY SSI PAYMENT
MADE UNDER THIS PROVISION: ( ) YES ( ) NO ( ) DECIDE LATER
Select “Yes” if the institution has agreed to permit the claimant to retain any SSI benefit payment
made under this provision.
Select “No” if the institution has not agreed to permit the claimant to retain any SSI benefit
payment made under this provision.
Select “Decide later” if you are unable to obtain this information when you are completing the
page. Selecting “Decide later” will result in an incomplete page status and will prevent you from
closing the event until you update the field with “Yes” or “No.”
This field displays when Eligible for SSI under section 1619(a) or (b) in the month prior to the
first full month of institutionalization [X-C] is “Yes.”
When you select “No” or “Decide later,” the claimant is not eligible for 2 months of 1619/1611E
Special Benefits.

[52-C] *ELIGIBLE FOR AND CHOOSES UP TO 2 MONTHS OF BENEFIT
CONTINUATION: ( ) YES ( ) NO ( ) DECIDE LATER
31

Select “Yes” if the claimant elects to receive special institution payments under 1619/1611E.
Select “No” if the claimant elects not to receive special institution payments under 1619/1611E.
Select “Decide later” if you are unable to obtain this information when you are completing the
page. Selecting “Decide later” will result in an incomplete page status and will prevent you from
closing the event until you update the field with “Yes” or “No.”
This field displays when Institution permits claimant to retain any SSI payment made under this
provision [X-C] is “Yes.”
When you select “No” or “Decide later,” the claimant is not eligible for 2 months of 1619/1611E
Special Benefits.

[53-C] *ELIGIBLE FOR AND CHOOSES UP TO 3 MONTHS OF TEMPORARY
INSTITUTIONALIZATION BENEFITS: ( ) YES ( ) NO ( ) DECIDE LATER
Select “Yes” if you determine that the claimant meets the eligibility requirements and the
claimant elects to receive temporary institutionalization benefits.
Select “No” if you determine that the claimant does not meet the eligibility requirements or the
claimant elects not to receive temporary institutionalization benefits.
Select “Decide later” if you are unable to obtain this information when you are completing the
page. Selecting “Decide later” will result in an incomplete page status and will prevent you from
closing the event until you update the field with “Yes” or “No.”
This field displays when the claimant is not eligible for or does not choose 2 months of benefit
continuation under the 1619/1611E provision, and:
•

Medicaid, or Medicare Part A with state buy-in, pays more than 50% [X-C] is “Yes”, or
Private health insurance, or a combination of Private health insurance and Medicaid, is
paying or is expected to pay more than 50 percent [X-C] is “Yes”, and

•

Confinement reason [X-C] is “Medical or psychiatric care,”

•

Institution type [X-C] is “Public”, and

•

Confinement reason is “Medical or psychiatric care.”

or

Note: If you select “Yes” and the current month is not within the TI period, and the claimant
still resides in the institution, you must select “Yes” for Temporary institutionalization benefit
period ended [X-C]. This directs the system to default to FLA D or payment status N02 (as
appropriate) at the end of the TI period.
32

Reminder 1: The claimant may choose up to 2 months of benefit continuation or up to 3
months of temporary institutionalization benefits. If the claimant elects 2 months of benefit
continuation, he or she may also be eligible for the third month of TI benefits under the
temporary institutionalization provision.
Reminder 2: Temporary institutionalization benefits only apply when the claimant would
otherwise be in a FLA D or Payment Status N02.
[54-C] *CARE TYPE: -Select the type of care received from the institution from the following dropdown list:
•

Acute care.

•

Intermediate care (mental).

•

Intermediate care (non-mental).

•

Skilled nursing care.

•

Unknown.

Select “Unknown” if you are unable to obtain this information when you are completing the
page. Selecting “Unknown” will result in an incomplete page status and will prevent you from
closing the event until you update the field with another value.
This field displays when Eligible for and chooses up to 3 months of temporary
institutionalization benefits [X-C] is “Yes.”
[55-C] *WHICH MEMBER OF COUPLE: -Select which member of the couple resides in the institution from the following dropdown list:
•

(Claimant First Name + Last Name) (Claimant SSN).

•

(Claimant Spouse’s First Name + Last Name) (Claimant Spouse’s SSN).

•

Both.

This field displays for eligible couples when Eligible for and chooses up to three months of
temporary institutionalization benefits [X-C] is “Yes.”

[56-C] *HOME EXPENSE STATEMENT DATE FOR (CLAIMANT FIRST NAME +
LAST NAME) (SSN): 99/99/9999
Enter the date you received the home expense statement for the specified individual(s) in the
field office. "mm/dd/yyyy” displays under the input field to indicate the required format.
33

This field displays for the claimant and claimant spouse when Which member of couple [X-C] is
“Both.”
You must complete this field when Eligible for and chooses up to 3 months of temporary
institutionalization benefits is “Yes,” and
•

A Discharge date is present, or

•

The TI period ended.

If Eligible for and chooses up to three months of temporary institutionalization benefits [X-C] is
“Yes” and this field is blank, an issue is added to the DW01.

[57-C] *PHYSICIAN CERTIFICATION DATE FOR (CLAIMANT FIRST NAME +
LAST NAME) (SSN): 99/99/9999
Enter the date you received the physician’s certification for the specified individual(s) in the field
office. "mm/dd/yyyy” displays under the input field to indicate the required format.
This field displays for the claimant and claimant spouse when Which member of couple [X-C] is
“Both.”
You must complete this field when Eligible for and chooses up to 3 months of temporary
institutionalization benefits is “Yes,” and
•

A Discharge date is present, or

•

The TI period ended.

If Eligible for and chooses up to three months of temporary institutionalization benefits [X-C] is
“Yes” and this field is blank, an issue is added to the DW01.

[58-C] *TEMPORARY INSTITUTIONALIZATION BENEFIT PERIOD ENDED: [ ]
Select the checkbox if, as of the current date, the temporary institutionalization period ended.
This field notifies the system to build a default of FLA D or payment status N02 (as appropriate)
after the TI period.
You must complete this field when Eligible for and chooses up to 3 months of temporary
institutionalization benefits is “Yes”, the TI period has ended, and the claimant still resides in the
institution.

[59-C] *TEMPORARY INSTITUTIONALIZATION INELIGIBILITY REASON:
34

•

( ) Individual not in a medical facility.

•

( ) Individual does not have home expenses that must continue to be paid.

•

( ) Proof of home expenses not received (Obsolete).

•

( ) Proof of home expenses not submitted by required date.

•

( ) Physician expects institutionalization to last over 90 days.

•

( ) Physician certification not submitted by required date.

•

( ) Physician's certification not prepared and dated by required date (Obsolete).

•

( ) Physician's certification not received (Obsolete).

•

( ) Individual not eligible for SSI payment in month prior to first month of
institutionalization.

•

( ) Individual does not have home expenses that must continue to be paid and physician
certification not submitted by required date.

•

( ) Proof of home expenses not received AND physician's certification not received by
required date (Obsolete).

•

( ) Proof of home expenses not submitted by required date and physician certification not
submitted by required date.

•

( ) Physician expects institutionalization to last over 90 days and physician certification
not submitted by required date.

•

( ) Physician's certification not prepared and dated by required date AND physician's
certification not received by required date (Obsolete).

•

( ) Individual not eligible for SSI payment in month prior to first month of
institutionalization, and physician certification not submitted by required date.

•

( ) Decide later.

Select the appropriate reason the claimant is ineligible for TI benefits.
Select “Decide later” if you are unable to obtain this information when you are completing the
page. Selecting “Decide later” will result in an incomplete page status and will prevent you from
closing the event until you update the field with another value.
You must complete this field when Eligible for and chooses up to 3 months of temporary
institutionalization benefits [X-C] is “No,” or the Institution type [X-C] is “Public” and the
Confinement reason [X-O] is “Prisoner” or “Other.”
35

Reminder: Currently the system cannot send the correct notice to the claimant for an initial
claim when a temporary institutionalization ineligibility reason applies. You must enter "Y" in
the SUPPRESS SYSTEMS GENERATED NOTICE on Miscellaneous Data (CMSC) and send a
manual notice.

[60-O] LIST OF TEMPORARY INSTITUTIONALIZATION INELIGIBILITY
DECISION CODES
Select this button to display the list of codes and definition in separate columns that are sortable.
The default sort is alphabetical by code.

T. RESULTS
Once all required fields are completed and you select to navigate away from the page, the
information entered is saved and you are taken to the page selected.

36