20 CFR 416.211 AND 416.414
The issue before the Appeals Council (AC) was whether the claimant's supplemental security income (SSI) benefit for April 1984 was subject to proration under section 1611(c)(2) of the Social Security Act (the Act).
Section 1611(c)(2) of the Act provides, in pertinent part, that the amount of an individual's SSI benefit for the first month following a period of ineligibility, if eligibility is restored after the first day of that month, shall "bear the same ratio to the amount of the benefit which would have been payable to such individual if . . . eligibility had been restored, on the first day of such month as the number of days in such month including and following the effective date of such . . . restoration of eligibility bears to the total number of days in such month."
Section 1611(e)(1)(A) provides, in pertinent part, that --
"Except as provided in subparagraphs (B), (C), and (D), no person shall be an eligible individual . . . for purposes of this title with respect to any month if throughout such month he is an inmate of a public institution."
Section 1611(e)(1)(B)(i) provides, in pertinent part, that --
"In any case where an eligible individual . . . is, throughout any month, in a hospital, extended care facility, nursing home, or intermediate care facility receiving payments (with respect to such individual . . .) under a State plan approved under title XIX, the benefit under this title for such individual for such month shall be payable --
(i) at a rate not in excess of $300 per year (reduced by the amount of any income not excluded pursuant to section 1612(b)). . . ."
Section 416.201 of Regulations No. 16 provides, in pertinent part, that --
"The term 'public institution' means an institution that is operated by or controlled by the Federal government, a State, or a political subdivision of a State such as a city or county. . . ."
Section 416.211 of Regulations No. 16 provides, in pertinent part, that --
"(a) General rule. You are not eligible for SSI benefits for any month throughout which you are a resident of a public institution (defined in § 416.201). By 'throughout' a month we mean that you reside in an institution as of the beginning of a month and stay the entire month. . . .
(b) Exception for medical care facilities. You may be eligible for SSI benefits at the reduced rate described in § 416.414 if --
(1) The public institution in which you reside throughout a month --
(i) Is a medical care facility; and
(ii) Medicaid (title XIX of the Act) pays a substantial part (more than 50 percent) of the cost of your care. . . ."
Section 416.414 of Regulations No. 16 provides, in pertinent part, that --
"(a) General rule. There is a reduced SSI benefit rate for persons who are in medical care facilities where more than 50 percent of the cost of their care is paid by a State plan approved under title XIX of the Social Security Act (Medicaid). Persons to whom this benefit rate applies are --
(1) Those who are otherwise eligible and who are in the medical care facility throughout a month. . . .
(b) The benefit rates are --
(1) Eligible individual. The benefit rate for an eligible individual with no eligible spouse is $300 per year. The benefit payment is figured by subtracting the eligible individual's countable income (see Subpart K) from the benefit rate. . . .
(c) Definition. For purposes of this section a 'medical care facility' means a hospital (see section 1861(e) of the Act), a skilled nursing facility (see section 1861(j) of the Act) or an intermediate care facility (see section 1905(c) of the Act)."
The claimant, who was born on January 4, 1963, was determined to be eligible for SSI benefits as a disabled individual based upon his application of July 24, 1981. According to the evidence of record, the claimant was continuously hospitalized at a public institution from February 7, 1984, until his discharge on April 13, 1984. Since individuals who are residents of a public institution throughout a month are ineligible for an SSI benefit for that month under section 1611(e)(1)(A) of the Act, the claimant's SSI benefits were suspended.
When his SSI benefit check for April 1984 did not arrive by April 3, 1984, the claimant contacted his local Social Security office. After confirming the claimant's discharge date from the hospital and his living arrangement, the Social Security Administration (SSA) issued the claimant an SSI benefit check of $169.15, representing payment for the period April 13, 1984, through April 30, 1984. (Had proration not applied, the claimant would have received an SSI benefit check for $281.91). Upon reconsideration, SSA determined that the claimant was ineligible for an SSI benefit for March 1984 (because he was a resident of a public institution throughout that month) and that, under section 1611(c)(2) of the Act, his SSI benefit for April 1984 was subject to proration based on the number of days from the date of discharge from the public institution to the end of the month.
The claimant appealed the amount of his SSI benefit check for April 1984 to an administrative law judge (ALJ) hearing. He claimed that the proration of benefits was unfair and that he required a "full" check to meet his monthly expenses.
At the hearing, the ALJ found that the claimant was eligible for an SSI benefit for the entire month of April 1984. In reaching this conclusion, the ALJ determined that the claimant was eligible for an SSI benefit for March 1984 (although at the $25 monthly rate, provided in section 1611(e)(1)(B)(i) of the Act). Consequently, the ALJ decided that the claimant's SSI benefit for April 1984 should not have been prorated.
The AC did not agree with the conclusion and findings of the ALJ. The AC decided that the claimant was ineligible for an SSI benefit for March 1984 because he was a resident of a public institution throughout that month. The record did not show that the exception for title XIX facilities, contained in section 1611(e)(1)(B) of the Act applied. Since the claimant was ineligible for an SSI benefit in March 1984 and was discharged from the public institution on April 13, 1984 (and not on the first day of April), the AC found that his SSI benefit for April 1984 must be prorated under section 1611(c)(2) of the Act. The AC further found that the claimant was eligible for (and had been paid) the correct amount of $169.15 in SSI benefits for April 1984.
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