403.01 Introduction 2

403.02 Categorical Eligibility 2

403.03 Non-Financial Criteria 2

403.04 Criteria Specific to OSS 2

403.04.01 Pre-Approval for Admission 2

403.05 Income Criteria 4

403.05.01 Countable Income 5

403.05.02 Specific OSS Income Considerations 5

403.05.03 Two-Step Income Process 6

403.05.03A Eligibility 6

403.05.03B Payment Calculation 7

403.06 Resource Criteria 7

403.07 Accrual Rights 8

403.08 Bed Hold – Medical Absence 8

403.08.01 Bed Hold Requirements 8

403.08.02 Failure to Meet 30 Consecutive Calendar Days Requirement 9

403.09 Continued Eligibility 9

403.09.01 Review 9

403.09.02 Changes 10

403.10 Community Residential Care Facilities (CRCF) and Home and Community Based Services (HCBS) 10

403.11 Case Processing 10

403.12 Terminated SSI Benefits 12

403.01 Introduction

(Eff. 3/01/25)

The Optional State Supplementation (OSS) program (OSS) assists certain individuals who reside in a Community Residential Care Facility (CRCF) licensed by the Department of Public Health (DPH). The eligibility determination for this group is based on strict Supplemental Security Income (SSI) criteria.

The OSS program provides Medicaid coverage, and it can pay a supplement directly to the CRCF to assist with the cost of living in the facility.

403.02 Categorical Eligibility

(Eff. 10/01/05)

To qualify for assistance in this category, the individual must be:

Aged (65 or older)

Blind (as defined by SSI rules)

Disabled (as defined by SSI rules)

403.03 Non-Financial Criteria

(Eff. 05/01/25)

To qualify for assistance in this category, the individual must meet certain non-financial requirements.

Identity MPPM 102.02

State Residency MPPM 102.03

Citizenship/Alienage MPPM 102.04

Enumeration/Social Security Number MPPM 102.05

Assignment of Rights to Third Party Medical Payments MPPM 102.07

403.04 Criteria Specific to OSS

(Eff. 03/01/25)

In addition to meeting the categorical requirements and the non-financial criteria, the individual must:

Reside in a CRCF licensed by DPH; and

Be assigned an approved slot pre-authorized by OSS Centralized Intake Office..

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403.04.01 Pre-Approval for Admission

(Rev. 10/01/23)

The DHHS eligibility worker from the OSS Specialty Unit is responsible for determining that an applicant meets all financial eligibility criteria before notifying the applicant they are cleared for admission to a facility.

Procedure for OSS Application/Referral Is the applicant known to the System of Record ? If yes: Is the person an SSI recipient (CAT 80)? If yes, Only the DHHS Form 1728 , SSI Recipient Request for Optional State Supplement – OSS is required Is DHHS Form 1728 completed/returned? If yes: Create a new tracking form for OSS Scan DHHS Form 1728 into OnBase (Refer to the Document Type Guide.pdf for additional scanning instructions) Proceed with Step 2 to determine OSS eligibility. If no, process is terminated. If not SSI, is the person eligible in another full or limited category? E ligible in a limited category, A DHHS Form 3400-A or DHHS Form 3400-B is required; If an addendum is required, has the addendum been returned? If not, terminate the process If yes, determine eligibility Eligible in a full category No updated application is required if eligible in a full coverage category . C reate an Application Tracking Form with the OSS claim type. Add comment indicating the request for OSS services. Determine OSS eligibility- See Step 2 Applicant is not known to System of Record or is not currently eligible in another PCAT The DHHS Form 3401 , Application for Nursing Home, Residential or In-Home Care or the DHHS Form 3400 and 3400-A or 3400-B are required Is an application returned with OSS requested on the application? If yes, Refer to the Document Type Guide.pdf for additional scanning instructions. If no, process is terminated. Determine Financial Eligibility If the applicant is eligible and already in an OSS approved facility: Call the CRCF listed as the applicant’s current residence to verify the admission date. Once the admission date is received, the worker can generate the CRCF-01 unless already provided by the facility If not already in the case file, complete the entire form If already provided by the facility, complete Sections II, IV and V Complete the DHHS Form CRCF-01 including the authorization date, countable income and personal needs amount. Sign Section III, scan into On-Base. Select “NO” as a trailing document. Submit the original DHHS Form CRCF-01 to the facility. If the applicant is financially eligible, and not already in the facility: Generate the CRCF Entry Ticket Notice in CGIS and send the form to the applicant. Cúram will automatically set a timer and take action if the applicant does not enter within 30 + 5 days. The applicant is given 30 days from the time they are notified to enter an OSS facility. C reate a Tracking Form, enter a comment, and set a follow-up for 35 days. The OSS facility will return the DHHS Form CRCF-01 to with the facility name and date of admission. CDM will scan the form back in to OnBase as a MEDS-Categorical Verification trailing document. If the DHHS Form CRCF-01 is returned from OSS for a financially eligible individual who entered an OSS facility, the Eligibility Specialist will finalize the eligibility determination: Complete the DHHS Form CRCF-01 including the authorization date, countable income, and personal needs amount. Sign Section III and scan into On-Base. Select “NO” as a trailing document. Submit the original DHHS Form CRCF-01 to the facility. If an applicant fails to enter a facility, OSS eligibility should be denied. The applicant should remain open in the previous category, or an ex parte determination should be made. Curam will automatically deny the request if the applicant does not enter. If the applicant enters a facility before the request is denied in the SOR, a new application is not required . If the applicant enters a facility after the request is denied in the SOR, a new application or request will be required. If the applicant is ineligible, deny the OSS application; and the process is terminated. NOTE For OSS participants currently living in a CRCF that have changes such as discharges, income changes, or individuals who have transferred to another facility, etc., the facility should send the DHHS Form CRCF-01 to SCDHHS-Central Mail. Centralized Document Management (CDM) should scan the DHHS Form CRCF-01 into On-Base. Once the changes have been made, the DHHS Form CRCF-01 should be updated as needed, signed, scanned into On-Base and returned to the facility. See MPPM 403.09

403.05 Income Criteria

(Rev. 07/01/07)

An individual’s countable income must be less than or equal to the Net Income Limit (NIL) in effect at the time of eligibility determination.

If married, only the applicant’s income is considered. If both members of a married couple are applying, each is treated as an individual.

(Refer to MPPM Chapter 401 for detailed information concerning Income.)

403.05.01 Countable Income

(Rev. 09/01/23)

Countable net income is the total of earned and unearned income remaining after all exclusions and disregards are given. Refer to MPPM 401.04.08 for procedures for earned income verification of reported income. When a beneficiary has not entered an OSS facility at the time of application, income must be verified and budgeted for the month of entry into the facility. At approval, any Cost-of-Living increases or income reductions must be budgeted (as appropriate) from one year to the next.

Example 1

An applicant meets eligibility based on the income reported at the time of application in the month of 4/2023. The applicant enters the facility in the month of 5/2023, but an increase is received in social security benefits in May. The income increase must be counted and budgeted in the month of entry.

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403.05.02 Specific OSS Income Considerations

(Rev. 01/01/11)

OSS does not consider the value of In-kind Support and Maintenance (ISM) in the income determination.

Recouped and garnished amounts are not counted as income. (Refer to MPPM 401.08.03 and 401.08.04)

Any money given to the CRCF on behalf of an individual or to cover his or her basic needs is considered income to the individual. It is counted in the eligibility and payment determinations.

If an individual’s income is less than the SSI need standard, he or she is REQUIRED to apply for SSI within 30 days of applying for OSS.

If the individual has not applied for SSI within 30 days, beginning the month following the month the 30th day occurs, budget the amount of SSI he would be receiving if he had applied for and received SSI.

If the applicant is denied SSI benefits, determine if the reason for denial affects his eligibility for OSS. If the applicant is denied for failure to cooperate or failing to provide information, budget the amount of SSI he would have received if approved for SSI.

If an individual is currently residing in a medical facility and SSI is suspended because of the living arrangement, a slot can be requested for the individual. For the month of entry into a CRCF, the individual will have zero SSI. Beginning the month following the month of entry, assume the individual will begin to receive SSI and budget accordingly.

A slot can be requested if an individual has an approval letter from SSI indicating eligibility will begin once the individual has been discharged from a medical facility. For the month of entry into a CRCF, the individual will have zero SSI. Beginning the month following the month of entry, assume the individual will begin to receive SSI and budget accordingly.

Example #1 Sallie Barnes applies for OSS. Her only income is SAA. The gross SSA benefit is $750; however, Sallie only receives $600 per month due to a previous overpayment. Her countable gross income is $600. Example #2 Clyde Wilton receives gross SSA of $500 per month. He also receives VA. His total gross monthly VA pension is $500 ; $ 300 is pension and the remaining $200 is Aid and Attendance of $200. $50 of his VA is being recouped due to an overpayment. His countable gross income is $750. $300 – $50 (recouped amount) = $250 $200 A&A is excluded $500 (SSA) + $250 = $750 Example #3 Audrey Green resides at Safe Haven RCF. She gets $600 per month SSA. Her daughter gives the CRCF $100 per month to help pay for a private room. Her countable income is $700. Example #4 Bryson Hall applied for OSS on April 1. His only income is $400 per month in SSA. He must apply for SSI and provide verification of this by May 1. Example #5 Stuart Little applies for OSS April 15. His only income is $500 SSA. He does not apply for SSI within 30 days. Beginning June, budget Mr. Little’s case as if he were receiving a SSI payment.

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Note: All alleged income must be VERIFIED and DOCUMENTED in the Case Record. All available data matches must be performed: BENDEX, SDX, State Retirement, Wage Match, and CHIP (if available).

403.05.03 Two-Step Income Process

(Eff. 10/01/05)

A two-step process is utilized to evaluate income in the OSS program: eligibility determination and payment calculation.

403.05.03A Eligibility

(Eff. 05/01/07)

In this step, the applicant’s net income is calculated and compared to the Net Income Limit (NIL). (Refer to MPPM 103.10) The Automated Budgeting Workbook must be used to budget OSS cases. The instructions below are for manual budgeting to demonstrate the process.

Net Income is calculated as follows:

Use the DHHS Form 1296-B ME, Optional State Supplementation Worksheet.

Begin with gross countable income (after exclusions).

Subtract allowable deductions (disregards):

$20 General disregard from any income other than SSI

Earned income disregards:

– $65

– ½ of the remaining earned income

Compare result to the NIL:

If net income exceeds the NIL, the individual is not eligible.

If net income is equal to or less than the NIL, proceed to Payment Calculation step.

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403.05.03B Payment Calculation

(Eff. 10/01/05)

In this step, the applicant’s OSS payment amount is calculated.

Begin with NIL.

Subtract countable income.

The remainder is the payment amount.

Note The OSS payment calculation automatically includes a personal needs allowance for the beneficiary. The difference between the NIL and the CRCF fee is the beneficiary’s personal needs allowance. No deduction is given for health insurance premiums.

The OSS payment cannot exceed the difference between the maximum SSI payment for an individual and the Net Income Limit (NIL), even if the applicant/beneficiary is not actually receiving a SSI check except in the following situations:

The individual’s SSI, SSA, or VA benefits are being recouped; or

The month of application for SSI benefits

403.06 Resource Criteria

(Rev. 10/01/13)

To be eligible for OSS, an individual’s countable resources must be $2,000 or below.

The “First of the Month” rule applies. Changes in resources within the month do not affect eligibility for that month.

Strict SSI-related resource policy applies.

ALL alleged resources must be verified and documented in the Case Record for all applicants who do not receive SSI. (Refer to MPPM Chapter 402 for information on treatment of resources). SSI recipients should make the request for OSS using the DHHS Form 1728 ME, SSI Recipient Request for Optional State Supplementation, but may use the DHHS Form 3400 Healthy Connections Application AND DHHS Form 3400-A, Additional Information for Select Medicaid Programs, OR the DHHS Form 3401, Application for Nursing Home, Residential or In-Home Care. Even if the DHHS Form 3400 OR 3401 are used, resources must not be verified for SSI recipients.

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403.07 Accrual Rights

(Rev. 10/01/23)

An applicant accrues the right to an OSS payment beginning with the LATEST of the following dates:

Date of application; or

Date of entry into a CRCF.

Example #1 Candice Dean entered Safe Harbor CRCF on May 30. She applies for OSS on June 5. If otherwise eligible, her benefits may be effective June 5. Example #2 Angela Nelson applied for OSS on June 10. She met all the eligibility criteria on June 20. On July 8, she enters a CRCF. Benefits are effective July 8.

The right to a payment accrues on the first day of each month, IF the individual is alive and eligible on that date.

403.08 Bed Hold – Medical Absence

(Eff. 10/01/05)

The OSS benefit payment may continue under certain circumstances if a resident is temporarily absent from the CRCF due to a medical confinement such as:

Hospitalization

Temporary admission to a nursing facility

Admission to a mental health facility

403.08.01 Bed Hold Requirements

(Rev. 05/01/17)

If the absence is expected to last less than thirty (30) consecutive calendar days, payments may continue under the following circumstances:

The CRCF:

Obtains a physician’s statement that certifies the need for medical confinement AND gives the expected length of absence;

Obtains a statement from the beneficiary verifying he or she needs the OSS payment to continue; AND

Completes Sections I and III of the DHHS Form CRCF-01, and submits the DHHS Form CRCF-01 to the OSS Program Manager at the State Department of Health and Human Services at one of the addresses below.

Courier Address | US Postal Service Address OSS Program Manager SC Dept. of Health and Human Services Dept. of Community Based Services 1801 Main Street Columbia , SC 29202 | OSS Program Manager SC Dept. of Health and Human Services Dept. of Community Based Services PO Box 8206 Columbia , SC 29202-8206

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403.08.02 Failure to Meet 30 Consecutive Calendar Days Requirement

(Eff. 10/01/05)

If a resident is admitted to a medical facility and does not return within 30 days, the CRCF must send the eligibility worker the DHHS Form CRCF-01 as notification to initiate closure procedures for OSS.

If a resident is admitted to a medical facility and is not expected to return within 30 consecutive calendar days, the CRCF must send the CRCF-01 Form to notify the eligibility worker within 72 hours. The eligibility worker initiates closure procedures for OSS.

Note The eligibility worker must determine if the individual is eligible for Medicaid under another payment category.

403.09 Continued Eligibility

(Eff. 10/01/05)

Eligibility must be reviewed according to the standards indicated in MPPM 403.09.01. Eligibility must be redetermined when a change in circumstances is reported or identified. The redetermination must be completed within 10 days from the date the eligibility worker becomes aware of the change. If a COLA change causes a beneficiary to lose eligibility, the beneficiary must be evaluated for OSS Pass-Along. If eligible, the beneficiary remains in category 85 with a one dollar payment. (Refer to MPPM 404.04)

403.09.01 Review

(Eff. 10/01/05)

For SSI-eligible beneficiaries (Payment Category 86), a review is not required.

Procedure: The eligibility worker must: Verify CRCF residency annually. Pull SDX to verify continued SSI eligibility. File SDX in Case Record.

For Non-SSI eligible beneficiaries (Payment Category 85), a complete review must be conducted annually. (Refer to MPPM 101.11)

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403.09.02 Changes

(Eff. 01/01/11)

When a change occurs between reviews, the change must be evaluated to determine the individual’s continuing eligibility for OSS benefits. An award amount is subject to change due to several reasons including the annual review or Cost-of-Living Adjustment (COLA).

Procedure When an Award Amount Changes: The eligibility worker must: Complete Sections I and I I I of DHHS Form CRCF-01 . Forward the DHHS Form CRCF-01 to the CRCF.

403.10 Community Residential Care Facilities (CRCF) and Home and Community Based Services (HCBS)

(Rev. 05/01/23)

Home and Community Based Services are available to residents of Community Residential Care Facilities if they qualify for the AIDS/HIV waiver or any waiver served by the Department of Behavioral Health and Developmental Disabilities (BHDD).

HCBS under the Community Choices waiver or the VENT waiver are not available to CRCF residents.

Note

A DHHS Form 1277, Statement of Intent to Return, may be needed when moving from HCBS to OSS coverage. See MPPM 402.15.01 to determine if the home can remain excluded without an Intent to Return.

403.11 Case Processing

(Rev. 10/01/23)

The Standard of Promptness is 45 days; however, if a disability case needs to be determined, 90 days may be allowed.

Procedures Regarding Application Process: Application Form For SSI-eligible applicants, the DHHS Form 1728 ME , SSI Recipient Request for Optional State Supplementation, is primarily used. However, the DHHS Form 3400 Healthy Connections Application AND DHHS Form 3400-A , Additional Information for Select Medicaid Programs, OR the DHHS Form 3401 , Application for Nursing Home, Residential or In-Home Care may be used. For Non-SSI eligible applicants, the DHHS Form 3401, Healthy Connections Application for Institutional/Waiver/OSS, is primarily used. However, the DHHS Form 3400 Healthy Connections Application, used in conjunction with Additional Information for Select Medicaid Programs, DHHS Form 3400A, is also acceptable For Medicaid eligible individuals under a different category, a new application is not required, but the worker must evaluate the case to determine if the individual meets the eligibility criteria for OSS. Intake – Applications may be submitted online, by mail, by telephone via the call center, or in person taken at the following locations: County Eligibility Office where the applicant resides County Eligibility Office where CRCF is located Processing Responsibilities for the County Eligibility Office Scan applications received by LEP staff into OnBase. (Refer to the Document Type Guide.pdf for specific instructions) Gather all required documents available for processing at initial contact and scan the documents into OnBase as appropriate. Forward any questions regarding an OSS application or OSS beneficiary to OSS Provider Eligibility at OSSProElig@scdhhs.gov OSS Specialty Unit Eligibility Worker Responsibilities When the application is not taken in person, ensure Primary Individual/Authorized Representative is advised of the following: – Eligibility Requirements – Standard of Promptness – Rights and Responsibilities, to include: Fair Hearing and Process of Appeal Civil Rights Requirement to Give Complete/Accurate Information Requirement to Report Changes Within 10 Days Requirement to Repay Benefits Received Ineligibly – Verification and Documentation Requirements – Computer Matches – Coverage Information and Retroactive Benefits Disseminate all appropriate pamphlets and handbooks. Set up Case Record and pend case in Cúram-CGIS Verify and/or document all eligibility criteria. Analyze verifications and apply appropriate policy. Calculate countable income and resources: If ineligible, deny and determine if eligible in another category. If eligible, request slot. When slot is approved and applicant enters a facility, complete DHHS Form CRCF-01. Enter information in Cúram-CGIS to authorize benefits. Using the DHHS Form 3229-A , Notice of Approval/Denial for Medical Assistance/ Optional Supplementation, inform the applicant of the amount of income that can be kept each month for personal needs.

403.12 Terminated SSI Benefits

(Eff. 03/01/25)

Beneficiaries that lost SSI benefits but have continued to receive coverage in PCAT 86 must be evaluated through the SDX Ex Parte Process.

NOTE Eligibility Specialist will receive a task in Workload Pro indicating an ex parte determination is needed for PCAT 86. Eligibility Specialist will leave the beneficiary in the PCAT 86 until an ex parte decision is made. If a beneficiary is found ineligible for another PCAT with income information only and the Eligibility Specialist cannot complete the SDX Ex Parte, then the manual DHHS Form 1233-EXP-SDX— SDX RFI Form—will need to be completed by the Eligibility Specialist and sent to the member. Follow MPPM 702.03.03 for further instructions or guidance on the SDX Ex Parte process for 86. A DHHS Form 3401, or 3400-B is not required to be sent out with the manual DHHS Form 1233-EXP-SDX . Note: The 90-day period will start on the date the manual DHHS Form 1233-EXP-SDX is sent to the member. For PCAT 86 (SSIOSS), the Eligibility Specialist must explore the OSS Pass-Along Program (PCAT 85) (MPPM 404.04). If a beneficiary is denied for failure to return requested information, the Eligibility Specialist will end-date coverage 90 days from the date the manual DHHS Form 1233-EXP-SDX was sent to the beneficiary (Adverse Action Rules Apply) and terminate the vendor payment (FM CRCF-01 for PCAT 86). 90-day Notice Period Note: The 90-day period will start on the date the Manual SDX RFI is sent to the member. First 30 days: Due Date of the Manual SDX RFI from the date the form was sent. 60 days from the date the Manual SDX RFI was sent: Manual Reminder Notice that the SDX RFI is due.