[Federal Register Volume 62, Number 152 (Thursday, August 7, 1997)]
[Rules and Regulations]
[Pages 42411-42412]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 97-20741]


-----------------------------------------------------------------------

SOCIAL SECURITY ADMINISTRATION

20 CFR Part 416

[Regulation No. 16]
RIN 0960-AE61


Reduction in Supplemental Security Income (SSI) Payable to 
Institutionalized Children Whose Medical Costs Are Covered by Private 
Insurance

AGENCY: Social Security Administration.

ACTION: Final rules.

-----------------------------------------------------------------------

SUMMARY: The interim final rules published at 62 FR 1053, on January 8, 
1997, are adopted as final without change. These rules implement an 
amendment to section 1611(e)(1)(B) of the Social Security Act (the Act) 
made by section 214 of Pub. L. 104-193, the Personal Responsibility and 
Work Opportunity Reconciliation Act of 1996.

DATES: These rules are effective beginning January 8, 1997.

FOR FURTHER INFORMATION CONTACT: Daniel T. Bridgewater, Legal 
Assistant, Division of Regulations and Rulings, Social Security 
Administration, 6401 Security Boulevard, Baltimore, MD 21235, (410) 
965-3298 for information about these rules. For information on 
eligibility or claiming benefits, call our national toll-free number, 
1-800-772-1213.

SUPPLEMENTARY INFORMATION:

Background

    Section 1611(e)(1)(A) of the Act generally precludes eligibility 
for SSI benefits when a claimant is a resident of a public institution 
throughout a month. However, section 1611(e)(1)(B) provided an 
exception to that bar. Under that section, payments could be made at 
the reduced Federal benefit rate to individuals in institutions 
``receiving payments (with respect to such individual or spouse) under 
a State plan approved under title XIX * * *'' This language was 
implemented through regulations to mean that individuals in 
institutions would receive only the reduced benefit amount when 
``Medicaid (title XIX of the Social Security Act) pays a substantial 
part (more than 50 percent) of the cost of'' the claimant's care 
(Sec. 416.211(b)).
    Section 214 of Pub. L. 104-193, effective for benefits beginning 
with the month of December 1996, amends section 1611(e)(1)(B) of the 
Act by extending applicability of the reduced SSI benefit rate to 
children under age 18 in medical care facilities receiving payments on 
their behalf under a health insurance policy issued by a private 
provider (hereinafter referred to as private health insurance). Prior 
to the enactment of section 214, children under the age of 18 in 
private institutions with private health insurance generally could be 
eligible for a full SSI payment. Section 214 now restricts the SSI 
payment for such children to the Federal reduced benefit rate. Also, 
prior to this legislation, individuals in public institutions not 
receiving substantial Medicaid payments on their behalf generally were 
ineligible for SSI. However, as a result of this legislation, children 
under age 18 in public institutions receiving private health insurance 
on their behalf now are eligible for SSI payments at the reduced 
Federal benefit amount.
    The final rules apply the reduced Federal benefit amount to 
children under age 18 with private health insurance when it, either 
alone or in combination with Medicaid, pays a substantial part (more 
than 50 percent) of the cost of their care in the institution.

Regulatory Changes

    During the public comment period, we received two comments within 
the scope of this rulemaking. One commenter, representing a major 
advocacy group for retarded citizens, expressed agreement with the 
Social Security Administration's interpretation of the provision 
regarding the amount of private insurance payments required in order 
for the reduced Federal SSI benefit rate to apply. Another commenter 
asked that we add a clarification specifying that Health Maintenance 
Organizations (HMOs) are

[[Page 42412]]

considered to be private health insurance providers within the meaning 
of this provision. However, the constantly evolving variety of 
innovative funding sources for institutional care precludes any attempt 
to specifically address each possible situation in these regulations. 
Our administrative issuances provide guidance to adjudicators in 
determining whether particular HMOs, or other kinds of insurers, may or 
may not be considered private health insurance providers. We also 
received several other comments, but they were not within the scope of 
this rulemaking.
    Therefore, the interim final rules are adopted as final without 
change.

    Dated: July 28, 1997.
John J. Callahan,
Acting Commissioner for Social Security.

PART 416--SUPPLEMENTAL SECURITY INCOME FOR THE AGED, BLIND, AND 
DISABLED

    Accordingly, the interim final rules amending 20 CFR part 416 which 
were published at 62 FR 1053 on January 8, 1997, are adopted as final 
without change.

[FR Doc. 97-20741 Filed 8-6-97; 8:45 am]
BILLING CODE 4190-29-P