Technical Updates to Applicability of the Supplemental Security Income (SSI) Reduced Benefit Rate for Individuals Residing in Medical Treatment Facilities -- 416.708(k) What you Must Report

MSSICS Screen Used to Record Information for this Collection

This is a facsimile of the MSSICS “LINS” screen used to collect information about an SSI recipient’s residence in an institution. Item 10-D and 11-D are used to record admission and discharge dates from an institution which are items that the SSI recipient is required to report to SSA.

FACSIMILE 1:  LINS - INSTITUTION RESIDENCE DATA

MSSICS                    INSTITUTION RESIDENCE DATA           PAGE 1 OF LINS

                               [1-D]                      [2-O]

SSS-SS-SSSS  SSSSS SSSSSSSSSS  PERIOD BEGAN: SS/SS/SSSS   TRANSFER TO:  XXXX

[3-M]

INSTITUTION NAME: BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB

          [4-M]

          ADDRESS: PPPPPPPPPPPPPPPPPPPPPP PPPPPPPPPPPPPPPPPPPPPP

                   PPPPPPPPPPPPPPPPPPPPPP PPPPPPPPPPPPPPPPPPPPPP

           [5-M]                          [6-C]        [7-M]

           CITY: PPPPPPPPPPPPPPPPPPPPPP   STATE: PP    ZIP: PPPPP

           [8-C]

           COUNTRY: XXXXXXXXXXXXXXXXXXXXXX

           [9-O]

           TELEPHONE: PPP PPP PPPP

[10-D]                              [11-O]

ADMISSION DATE (MMDDYY): SS/SS/SS   DISCHARGE DATE (MMDDYY): 999999

         [12-M]

         VERIFIED (Y/N): X

[13-D]

DATE INSTITUTIONALIZATION BEGAN (MMDDYY):  SS/SS/SS

[14-M]                        [15-M]

INSTITUTION: 9   1=PUBLIC     CONFINEMENT REASON:  9  1=MEDICAL/PSYCH

                 2=PRIVATE                            2=EDUCATION/VOC

                                                      3=EMERG SHELTER

                                                      4=PUB COMM RES

[16-C]                                                5=PRISONER

OVER 50% MEDICAID PAYMENTS (Y/N): B                   6=OTHER

[17-C]

PRIVATE HEALTH INSURANCE   (Y/N): B

[18-C]

INSTITUTION FOR FOOD STAMP PURPOSES (Y/N): P

                                                             [19-O]

                                                             REMARKS (Y): X

FACSIMILE 2:  LINS - INSTITUTION RESIDENCE DATA

MSSICS               INSTITUTION RESIDENCE DATA               PAGE 2 OF LINS

                               [1-D]                      [2-O]

SSS-SS-SSSS  SSSSS SSSSSSSSSS  PERIOD BEGAN: SS/SS/SSSS   TRANSFER TO:  XXXX

[20-M]

INSTITUTION TEMPORARY (Y/N): X

[21-M]

ELIGIBLE FOR AND CHOOSES SPECIAL INSTITUTIONAL PAYMENTS - 1619/1611E (Y/N): X

    [22-C]

    IF NO,

       ELIGIBLE FOR AND CHOOSES CONTINUING PAYMENT - 9115 (Y/N): X

    [23-C]

    IF YES,  TYPE OF CARE: 9

       CARE OPTIONS   1=ACUTE CARE    2=INTERMEDIATE CARE (MENTAL)

                      3=INTERMEDIATE CARE (NON-MENTAL) 4=SKILLED NURSING CARE

             [24-C]

             HOME EXPENSE STATEMENT DATE FOR   SSSSS SSSSSSSSSS:  999999

             HOME EXPENSE STATEMENT DATE FOR   SSSSS SSSSSSSSSS:  999999

             [25-C]

             PHYSICIAN'S CERTIFICATION DATE FOR SSSSS SSSSSSSSSS:  999999

             PHYSICIAN'S CERTIFICATION DATE FOR SSSSS SSSSSSSSSS:  999999

             [26-C]

             IF NOT DISCHARGED, CONTINUED PAYMENT PERIOD ENDED (Y):  X

                 [27-C]

                 WHICH MEMBER OF COUPLE: X  1=SSSSS SSSSSSSSS

                                            2=SSSSS SSSSSSSSS

                                            3=BOTH

          [28-C]

          IF NO, 9115 INELIGIBILITY DECISION CODE: X

                                                               [19-O]

                                                               REMARKS (Y): X

FACSIMILE 3:  LINS - INSTITUTION RESIDENCE DATA

MSSICS              INSTITUTION RESIDENCE DATA                 PAGE 2 OF LINS

                               [1-D]                     [2-O]

SSSSSSSSS  SSSSS SSSS-SS-SSSS  PERIOD BEGAN: SS/SS/SSSS  TRANSFER TO:  XXXX

[20-M]

INSTITUTION TEMPORARY (Y/N): X

[21-M]

ELIGIBLE FOR AND CHOOSES SPECIAL INSTITUTIONAL PAYMENTS - 1619/1611E (Y/N): X

     [22-C]

     IF NO,

        ELIGIBLE FOR AND CHOOSES CONTINUING PAYMENT - 9115 (Y/N): X

     [23-C]

     IF YES,  TYPE OF CARE: 9

        CARE OPTIONS  1=ACUTE CARE    2=INTERMEDIATE CARE (MENTAL)

                      3=INTERMEDIATE CARE (NON-MENTAL) 4=SKILLED NURSING CARE

             [24-C]

             HOME EXPENSE STATEMENT DATE FOR   SSSSS SSSSSSSSSS:  999999

             [25-C]

             PHYSICIAN'S CERTIFICATION DATE FOR SSSSS SSSSSSSSSS:  999999

             [26-C]

             IF NOT DISCHARGED, CONTINUED PAYMENT PERIOD ENDED (Y):  X

            [28-C]

            IF NO, 9115 INELIGIBILITY DECISION CODE: X        [19-O]

                                                              REMARKS (Y): X