4. Special Considerations for Adult Foster Care Supplementation

a. Close coordination between SSA field offices and the District’s SSI Central Referral Bureau is essential to ensure efficient administration of the Adult Foster Care supplementation program. Any liaison or processing difficulties should be brought to the attention of the Center for Programs Support in the regional office.

b. The District’s certification of eligibility for placement assumes that all eligibility factors are met. SSA must determine if they are actually met. The referring welfare office should be notified of all approvals and disallowances. An SSA-1610 (or other form of notification) should be furnished to the welfare office for all approvals; an SSA-1610 and the District’s certification form should be furnished to the welfare office for all denials.

c. Eligibility for the Adult Foster Care supplement begins with the month of placement for current recipients. The “effective date” shown on the certification form should be the same as the month of placement in the facility. If it is not, the District’s SSI Central Referral Bureau should be contacted to resolve the discrepancy. (See instructions in SI PHI01415.009C.2.a. (1.) for individuals not residing in D.C. on the first day of the month during which they are placed in a CRF.) Eligibility for the Adult Foster Care supplement for individuals who are just filing for SSI begins with the month of effective filing of an SSI application, or the month of placement, if later than the effective filing date. As in all initial claims, SSI payment, including any state supplement, is not made for the first month of eligibility.

d. Ineligibility for the Adult Foster Care supplement is effective with the month specified on the decertification form submitted by the District’s SSI Central Referral Bureau (see SI PHI01415.009C.1 (b.) and SI PHI01415.009C.2 (c.)). An individual may move from one certified facility to another without losing eligibility for the state supplement. The SSI Central Referral Bureau should submit a “new” certification form for each facility.

e. Applicants/recipients who own a home will, in most cases, be ineligible for the Adult Foster Care supplement (and any Federal SSI payments) on the basis of excess resources (PSY N04). Generally, a move to an Adult Foster Care Home is not intended to be a temporary placement. Therefore, the home that the individual owns would not be the person’s principal place of residence and would not be an excludable resource. (See SI 01130.100B.5.c. and SI 01130.100D. for development.)

f. Individuals who are candidates for Adult Residential Care placement may receive a pre-adjudicative claim decision prior to actual placement in a CRF. For institutionalized individuals whose release is contingent upon a finding that they would be eligible for an SSI payment if released from the facility, the pre-release procedures in SI 00520.900 will apply. For non-institutionalized individuals whose placement in a CRF is contingent upon a finding that they would be eligible for an SSI payment if placed in a CRF, procedures similar to the pre-release process will apply. Such individuals may file a claim and be afforded a claim evaluation—including a disability determination—on the basis of a projected living arrangement if an authorized representative from the Department of Health, the Department of Mental Health, or, Mental Health and Developmental Disabilities Administration attests that the person’s placement in a certified facility is imminent. Placement will be considered “imminent” if the one of the three agencies above indicates in writing that the person will be placed in a CRF within 30 days of the “pre-adjudicative” evaluation.

This procedure enables SSA to evaluate the claimant’s potential eligibility on the basis of the higher income limit afforded by the total payment level for an Adult Residential Care resident without the person actually being a resident. Eligibility and payment would not be established, however, until placement in the CRF is confirmed via the proscribed certification form from the SSI Central Referral Bureau.

This procedure enables SSA to evaluate the claimant’s potential eligibility on the basis of the higher income limit afforded by the total payment level for an Adult Residential Care resident without the person actually being a resident. Eligibility and payment would not be established, however, until placement in the CRF is confirmed via the proscribed certification form from the SSI Central Referral Bureau.

(DC), Appendix I — Chart 44 (RTN 66– 12/2014) SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2015 -12/2015 )

Living Arrangement L/A Code O/S Code O/S Amount Federal Payment Amount Total Payment Level INDIVIDUALS 1/ In Own Household No EP A Z $733.00 $733.00 1 EP A Z $1100.00 $1100.00 In Certified Adult A A $585.00 $733.00 $1,318.00 Foster Care Home 2/ A B $695.00 $733.00 $1,428.00 In Another's Household No EP B Z $488.67 $488.67 1 EP B Z $733.34 $733.34 In Parental Household C Z $733.00 $733.00 Medicaid Facility D G $40.00 $30.00 $70.00 COUPLES 1/ In Own Household No EP A Z $1100.00 $1100.00 1 EP A Z $1467.00 $1467.00 In Certified Adult A A $1536.00 $1100.00 $2636.00 Foster Care Home 2/ A B $1756.00 $1100.00 $2856.00 In Another's Household No EP B Z $733.34 $733.34 1 EP B Z $978.00 $978.00 Medicaid Facility D G $80.00 $60.00 $140.00

1/ For individuals/couples whose FCI precludes a Federal payment, the amounts in the "O/S Amount" column will vary depending on income. See SI 02005.001 , which discusses situations of this kind.

OS-A applies to recipients in Adult Foster Care Homes with 50 or fewer residents

OS-B applies to recipients in Adult Foster Care Homes with 51 or more residents.

(DC), Appendix I — Chart 43 (RTN 65 – 11/2014)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2014 – 12/2014)

Living Arrangement L/A Code O/S Code O/S Amount Federal Payment Amount Total Payment Level INDIVIDUALS 1/ In Own Household No EP A Z $721.00 $721.00 1 EP A Z $1082.00 $1082.00 In Certified Adult A A $615.00 $721.00 $1,336.00 Foster Care Home 2/ A B $725.00 $721.00 $1,446.00 In Another's Household No EP B Z $480.67 $480.67 1 EP B Z $721.34 $721.34 In Parental Household C Z $721.00 $721.00 Medicaid Facility D G $40.00 $30.00 $70.00 COUPLES 1/ In Own Household No EP A Z $1082.00 $1082.00 1 EP A Z $1443.00 $1443.00 In Certified Adult A A $1590.00 $1082.00 $2672.00 Foster Care Home 2/ A B $1810.00 $1082.00 $2892.00 In Another's Household No EP B Z $721.34 $721.34 1 EP B Z $962.01 $962.01 Medicaid Facility D G $80.00 $60.00 $140.00

State Supplement amounts for calendar year 2014 were temporarily increased in November 2014, retroactive to January 2014.

1/ For individuals/couples whose FCI precludes a Federal payment, the amounts in the "O/S Amount" column will vary depending on income. See SI 02005.001 , which discusses situations of this kind.

2/ OS-A applies to recipients in Adult Foster Care Homes with 50 or fewer residents.

OS-B applies to recipients in Adult Foster Care Homes with 51 or more residents.

(DC), Appendix I — Chart 42 (RTN 64 – 01/2014)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2014 – 12/2014)

Living Arrangement L/A Code O/S Code O/S Amount Federal Payment Amount Total Payment Level INDIVIDUALS 1/ In Own Household No EP A Z $721.00 $721.00 1 EP A Z $1082.00 $1082.00 In Certified Adult A A $585.00 $721.00 $1,306.00 Foster Care Home 2/ A B $695.00 $721.00 $1,416.00 In Another's Household No EP B Z $480.67 $480.67 1 EP B Z $721.34 $721.34 In Parental Household C Z $721.00 $721.00 Medicaid Facility D G $40.00 $30.00 $70.00 COUPLES 1/ In Own Household No EP A Z $1082.00 $1082.00 1 EP A Z $1443.00 $1443.00 In Certified Adult A A $1530.00 $1082.00 $2612.00 Foster Care Home 2/ A B $1750.00 $1082.00 $2832.00 In Another's Household No EP B Z $721.34 $721.34 1 EP B Z $1082.34 $1082.34 Medicaid Facility D G $80.00 $60.00 $140.00

1/ For individuals/couples whose FCI precludes a Federal payment, the amounts in the "O/S Amount" column will vary depending on income. See SI 02005.001 , which discusses situations of this kind.

2/ OS-A applies to recipients in Adult Foster Care Homes with 50 or fewer residents.

OS-B applies to recipients in Adult Foster Care Homes with 51 or more residents.

(DC), Appendix I — Chart 41 (RTN 63 – 04/2013)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2013 – 12/2013)

Living Arrangement L/A Code O/S Code O/S Amount Federal Payment Amount Total Payment Level INDIVIDUALS 1/ In Own Household No EP A Z $710.00 $710.00 1 EP A Z $1066.00 $1066.00 In Certified Adult A A $585.00 $710.00 $1,195.00 Foster Care Home 2/ A B $695.00 $710.00 $1,305.00 In Another's Household No EP B Z $473.34 $473.34 1 EP B Z $710.67 $710.67 In Parental Household C Z $710.00 $710.00 Medicaid Facility D G $40.00 $30.00 $70.00 COUPLES 1/ In Own Household No EP A Z $1066.00 $1066.00 1 EP A Z $1422.00 $1442.00 In Certified Adult A A $1524.00 $1066.00 $2390.00 Foster Care Home 2/ A B $1744.00 $1066.00 $2610.00 In Another's Household No EP B Z $710.67 $710.67 1 EP B Z $948.00 $948.00 Medicaid Facility D G $80.00 $60.00 $140.00

State Supplement amounts for calendar year 2013 were temporarily increased in April 2013, retroactive to January 2013.

1/ For individuals/couples whose FCI precludes a Federal payment, the amounts in the "O/S Amount" column will vary depending on income. See SI 02005.001 , which discusses situations of this kind.

2/ OS-A applies to recipients in Adult Foster Care Homes with 50 or fewer residents.

OS-B applies to recipients in Adult Foster Care Homes with 51 or more residents.

(DC), Appendix I — Chart 40 (RTN 62 – 01/2013)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2013 – 12/2013)

Living Arrangement L/A Code O/S Code O/S Amount Federal Payment Amount Total Payment Level INDIVIDUALS 1/ In Own Household No EP A Z $710.00 $710.00 1 EP A Z $1066.00 $1066.00 In Certified Adult A A $485.00 $710.00 $1,195.00 Foster Care Home 2/ A B $595.00 $710.00 $1,305.00 In Another's Household No EP B Z $473.34 $473.34 1 EP B Z $710.67 $710.67 In Parental Household C Z $710.00 $710.00 Medicaid Facility D G $40.00 $30.00 $70.00 COUPLES 1/ In Own Household No EP A Z $1066.00 $1066.00 1 EP A Z $1422.00 $1442.00 In Certified Adult A A $1324.00 $1066.00 $2390.00 Foster Care Home 2/ A B $1544.00 $1066.00 $2610.00 In Another's Household No EP B Z $710.67 $710.67 1 EP B Z $948.00 $948.00 Medicaid Facility D G $80.00 $60.00 $140.00

1/ For individuals/couples whose FCI precludes a Federal payment, the amounts in the "O/S Amount" column will vary depending on income. See SI 02005.001 , which discusses situations of this kind.

2/ OS-A applies to recipients in Adult Foster Care Homes with 50 or fewer residents.

OS-B applies to recipients in Adult Foster Care Homes with 51 or more residents.

(DC), Appendix I — Chart 39 (RTN 61 – 12/2011)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2012)

Living Arrangement L/A Code O/S Code O/S Amount Federal Payment Amount Total Payment Level INDIVIDUALS 1/ In Own Household No EP A Z $698.00 $698.00 1 EP A Z $1048.00 $1048.00 In Certified Adult A A $485.00 $698.00 $1,183.00 Foster Care Home 2/ A B $595.00 $698.00 $1,293.00 In Another's Household No EP B Z $465.34 $465.34 1 EP B Z $698.67 $698.67 In Parental Household C Z $698.00 $698.00 Medicaid Facility D G 40.00 $30.00 $70.00 COUPLES 1/ In Own Household No EP A Z $1048.00 $1048.00 1 EP A Z $1398.00 $1398.00 In Certified Adult A A $1318.00 $1048.00 $2366.00 Foster Care Home 2/ A B $1538.00 $1048.00 $2586.00 In Another's Household No EP B Z $698.67 $698.67 1 EP B Z $932.00 $932.00 Medicaid Facility D G $80.00 $60.00 $140.00

1/ For individuals/couples whose FCI precludes a Federal payment, the amounts in the "O/S Amount" column will vary depending on income. See SI 02005.001 , which discusses situations of this kind.

2/ OS-A applies to recipients in Adult Foster Care Homes with 50 or fewer residents.

OS-B applies to recipients in Adult Foster Care Homes with 51 or more residents.

(DC), Appendix I — Chart 38 (RTN 60 – 12/2010)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2011 - 12/2011)

Living Arrangement L/A Code O/S Code O/S Amount Federal Payment Amount Total Payment Level INDIVIDUALS 1/ In Own Household No EP A Z — $674.00 $674.00 1 EP A Z — $1012.00 $1012.00 In Certified Adult A A $485.00 $674.00 $1,159.00 Foster Care Home 2/ A B $595.00 $674.00 $1,269.00 In Another's Household No EP B Z — $449.34 $449.34 1 EP B Z — $674.67 $674.67 In Parental Household C Z — $674.00 $674.00 Medicaid Facility D G 40.00 $30.00 $70.00 COUPLES 1/ In Own Household No EP A Z — $1011.00 $1011.00 1 EP A Z — $1349.00 $1349.00 In Certified Adult A A $1307.00 $1011.00 $2318.00 Foster Care Home 2/ A B $1527.00 $1011.00 $2538.00 In Another's Household No EP B Z — $674.00 $674.00 1 EP B Z — $899.34 $899.34 Medicaid Facility D G $80.00 $60.00 $140.00

1/ For individuals/couples whose FCI precludes a Federal payment, the amounts in the "O/S Amount" column will vary depending on income. See SI 02005.001 , which discusses situations of this kind.

2/ OS-A applies to recipients in Adult Foster Care Homes with 50 or fewer residents.

OS-B applies to recipients in Adult Foster Care Homes with 51 or more residents.

(DC), Appendix I — Chart 37 (RTN 59 – 11/2010)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2010 - 12/2010)

Living Arrangement L/A Code O/S Code O/S Amount Federal Payment Amount Total Payment Level INDIVIDUALS 1/ In Own Household No EP A Z — $674.00 $674.00 1 EP A Z — $1012.00 $1012.00 In Certified Adult A A $510.00 $674.00 $1,184.00 Foster Care Home 2/ A B $620.00 $674.00 $1,294.00 In Another's Household No EP B Z — $449.34 $449.34 1 EP B Z — $674.67 $674.67 In Parental Household C Z — $674.00 $674.00 Medicaid Facility D G 40.00 $30.00 $70.00 COUPLES 1/ In Own Household No EP A Z — $1011.00 $1011.00 1 EP A Z — $1349.00 $1349.00 In Certified Adult A A $1357.00 $1011.00 $2368.00 Foster Care Home 2/ A B $1577.00 $1011.00 $2588.00 In Another's Household No EP B Z — $674.00 $674.00 1 EP B Z — $899.34 $899.34 Medicaid Facility D G $80.00 $60.00 $140.00

State Supplement amounts for calendar year 2010 were temporarily increased in December 2010, retroactive to January 2010.

1/ For individuals/couples whose FCI precludes a Federal payment, the amounts in the "O/S Amount" column will vary depending on income. See SI 02005.001 , which discusses situations of this kind.

OS-A applies to recipients in Adult Foster Care Homes with 50 or fewer residents. OS-B applies to recipients in Adult Foster Care Homes with 51 or more residents.

(DC), Appendix I — Chart 36 (RTN 58 – 12/2008)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2009 - 12/2009)

Living Arrangement L/A Code O/S Code O/S Amount Federal Payment Amount Total Payment Level INDIVIDUALS 1/ In Own Household No EP A Z — $674.00 $674.00 1 EP A Z — $1012.00 $1012.00 In Certified Adult A A $485.00 $674.00 $1,159.00 Foster Care Home 2/ A B $595.00 $674.00 $1,269.00 In Another's Household No EP B Z — $449.34 $449.34 1 EP B Z — $674.67 $674.67 In Parental Household C Z — $674.00 $674.00 Medicaid Facility D G 40.00 $30.00 $70.00 COUPLES 1/ In Own Household No EP A Z — $1011.00 $1011.00 1 EP A Z — $1349.00 $1349.00 In Certified Adult A A $1307.00 $1011.00 $2318.00 Foster Care Home 2/ A B $1527.00 $1011.00 $2538.00 In Another's Household No EP B Z — $674.00 $674.00 1 EP B Z — $899.34 $899.34 Medicaid Facility D G $80.00 $60.00 $140.00

1/ For individuals/couples whose FCI precludes a Federal payment, the amounts in the "O/S Amount" column will vary depending on income. See SI 02005.001 , which discusses situations of this kind.

2/ Effective March 1, 2003, "Residential Care Homes" include Adult Foster Care Homes, Adult Residential Care Facilities and Assisted Living Facilities. Eligibility for the state supplement is contingent upon receipt of the ADULT RESIDENTIAL CARE CERTIFICATION FORM, completed and signed by the proper authority.

OS-A applies to recipients in Adult Foster Care Homes with 50 or fewer residents. OS-B applies to recipients in Adult Foster Care Homes with 51 or more residents.

(DC), Appendix I — Chart 3 5 (RTN 5 7 – 12/200 7 )

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2008 - 12/2008)

Living Arrangement L/A Code O/S Code O/S Amount Federal Payment Amount Total Payment Level INDIVIDUALS 1/ In Own Household No EP A Z — $637.00 $637.00 1 EP A Z — $956.00 $956.00 In Certified Adult A A $485.00 $637.00 $1,122.00 Foster Care Home 2/ A B $595.00 $637.00 $1,232.00 In Another's Household No EP B Z — $424.67 $424.67 1 EP B Z — $637.34 $637.34 In Parental Household C Z — $637.00 $637.00 Medicaid Facility D G 40.00 $30.00 $70.00 COUPLES 1/ In Own Household No EP A Z — $956.00 $956.00 1 EP A Z — $1,275.00 $1,275.00 In Certified Adult A A $1,288.00 $956.00 $2,244.00 Foster Care Home 2/ A B $1,508.00 $956.00 $2,464.00 In Another's Household No EP B Z — $637.34 $637.34 1 EP B Z — $850.00 $850.00 Medicaid Facility D G $80.00 $60.00 $140.00

(DC), Appendix I — Chart 3 4 (RTN 5 3 – 12/2006 )

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2007 - 12/2007)

Living Arrangement L/A Code O/S Code O/S Amount Federal Payment Amount Total Payment Level INDIVIDUALS 1/ In Own Household No EP A Z — $623.00 $623.00 1 EP A Z — $935.00 $935.00 In Certified Adult A A $485.00 $623.00 $1,108.00 Foster Care Home 2/ A B $595.00 $623.00 $1,218.00 In Another's Household No EP B Z — $415.34 $415.34 1 EP B Z — $623.34 $623.34 In Parental Household C Z — $623.00 $623.00 Medicaid Facility D G 40.00 $30.00 $70.00 COUPLES 1/ In Own Household No EP A Z — $934.00 $934.00 1 EP A Z — $1,246.00 $1,246.00 In Certified Adult A A $1,282.00 $934.00 $2,216.00 Foster Care Home 2/ A B $1,502.00 $934.00 $2,436.00 In Another's Household No EP B Z — $622.67 $622.67 1 EP B Z — $830.67 $830.67 Medicaid Facility D G $80.00 $60.00 $140.00

(DC), Appendix I — Chart 33 (RTN 52 - 06/2006)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2006 - 12/2006)

Living Arrangement L/A Code O/S Code O/S Amount Federal Payment Amount Total Payment Level INDIVIDUALS 1/ In Own Household No EP A Z — $603.00 $603.00 1 EP A Z — $904.00 $904.00 In Certified Adult A A $455.00 $603.00 $1,058.00 Foster Care Home 2/ A B $565.00 $603.00 $1,168.00 In Another's Household No EP B Z — $402.00 $402.00 1 EP B Z — $603.34 $603.34 In Parental Household C Z — $603.00 $603.00 Medicaid Facility D G 40.00 $30.00 $70.00 COUPLES 1/ In Own Household No EP A Z — $904.00 $904.00 1 EP A Z — $1,206.00 $1,206.00 In Certified Adult A A $1,212.00 $904.00 $2,116.00 Foster Care Home 2/ A B $1,432.00 $904.00 $2,336.00 In Another's Household No EP B Z — $602.67 $602.67 1 EP B Z — $804.00 $804.00 Medicaid Facility D G $80.00 $60.00 $140.00

(DC), Appendix I — Chart 32 (RTN 51 - 1/2006)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2006 - 12/2006)

Living Arrangement L/A Code O/S Code O/S Amount Federal Payment Amount Total Payment Level INDIVIDUALS 1/ In Own Household No EP A Z — $603.00 $603.00 1 EP A Z — $905.00 $905.00 In Certified Adult A A $347.00 $603.00 $950.00 Foster Care Home 2/ A B $457.00 $603.00 $1,060.00 In Another's Household No EP B Z — $402.00 $402.00 1 EP B Z — $603.34 $603.34 In Parental Household C Z — $603.00 $603.00 Medicaid Facility D G 40.00 $30.00 $70.00 COUPLES 1/ In Own Household No EP A Z — $904.00 $904.00 1 EP A Z — $1,206.00 $1,206.00 In Certified Adult A A $996.00 $904.00 $1,900.00 Foster Care Home 2/ A B $1,216.00 $904.00 $2,120.00 In Another's Household No EP B Z — $602.67 $602.67 1 EP B Z — $804.00 $804.00 Medicaid Facility D G $80.00 $60.00 $140.00

(DC), Appendix I — Chart 31 (RTN 50- 10/2005)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2005-12/2005)

Living Arrangement L/A Code O/S Code O/S Amount Federal Payment Amount Total Payment Level INDIVIDUALS 1/ In Own Household No EP A Z — $579.00 $579.00 1 EP A Z — $869.00 $869.00 In Certified Adult A A $367.00 $579.00 $946.00 Foster Care Home 2/ A B $477.00 $579.00 $1,056.00 In Another's Household No EP B Z — $386.00 $386.00 1 EP B Z — $579.34 $579.34 In Parental Household C Z — $579.00 $579.00 Medicaid Facility D G 40.00 $30.00 $70.00 COUPLES 1/ In Own Household No EP A Z — $869.00 $869.00 1 EP A Z — $1,159.00 $1,159.00 In Certified Adult A A $1,023.00 $869.00 $1,892.00 Foster Care Home 2/ A B $1,243.00 $869.00 $2,112.00 In Another's Household No EP B Z — $579.34 $579.34 1 EP B Z — $772.67 $772.67 Medicaid Facility D G $80.00 $60.00 $140.00

(DC), Appendix I — Chart 30 (RTN 49 - 1/2005)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2005-12/2005)

Living Arrangement L/A Code O/S Code O/S Amount Federal Payment Amount Total Payment Level INDIVIDUALS 1/ In Own Household No EP A Z — $579.00 $579.00 1 EP A Z — $869.00 $869.00 In Certified Adult A A $347.00 $579.00 $926.00 Foster Care Home A B $457.00 $579.00 $1,036.00 In Another's Household No EP B Z — $386.00 $386.00 1 EP B Z — $579.34 $579.34 In Parental Household C Z — $579.00 $579.00 Medicaid Facility D G 40.00 $30.00 $70.00 COUPLES 1/ In Own Household No EP A Z — $869.00 $869.00 1 EP A Z — $1,159.00 $1,159.00 In Certified Adult A A $983.00 $869.00 $1,852.00 Foster Care Home A B $1,203.00 $869.00 $2,072.00 In Another's Household No EP B Z — $579.34 $579.34 1 EP B Z — $772.67 $772.67 Medicaid Facility D G $80.00 $60.00 $140.00

(DC), Appendix I — Chart 29 (RTN 48 - 10/2004)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2004-12/2004)

Living Arrangement L/A Code O/S Code O/S Amount Federal Payment Amount Total Payment Level INDIVIDUALS 1/ In Own Household No EP A Z — $564.00 $564.00 1 EP A Z — $846.00 $846.00 In Certified Adult A A $367.00 $564.00 $931.00 Foster Care Home A B $477.00 $564.00 $1,041.00 In Another's Household No EP B Z — $376.00 $376.00 1 EP B Z — $564.00 $564.00 In Parental Household C Z — $564.00 $564.00 Medicaid Facility D G 40.00 $30.00 $70.00 COUPLES 1/ In Own Household No EP A Z — $846.00 $846.00 1 EP A Z — $1,128.00 $1,128.00 In Certified Adult A A $1,016.00 $846.00 $1,862.00 Foster Care Home A B $1,236.00 $846.00 $2,082.00 In Another's Household No EP B Z — $564.00 $564.00 1 EP B Z — $752.00 $752.00 Medicaid Facility D G $80.00 $60.00 $140.00

(DC), Appendix I — Chart 28 (RTN 47 - 1/2004)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2004 - 12/2004)

Living Arrangement L/A Code O/S Code O/S Amount Federal Payment Amount Total Payment Amount INDIVIDUALS 1/ In Own Household No EP A Z — $564.00 $564.00 1 EP A Z — $846.00 $846.00 In Certified Adult A A $307.00 $564.00 $871.00 Foster Care Home A B $417.00 $564.00 $981.00 In Another's Household No EP B Z — $376.00 $376.00 1 EP B Z — $564.00 $564.00 In Parental Household C Z — $564.00 $564.00 Medicaid Facility D G $40.00 $30.00 $70.00 COUPLES 1/ In Own Household No EP A Z — $846.00 $846.00 1 EP A Z — $1,128.00 $1,128.00 In Certified Adult A A $896.00 $846.00 $1,742.00 Foster Care Home A B $1,116.00 $846.00 $1,962.00 In Another's Household No EP B Z — $564.00 $564.00 1 EP B Z — $752.00 $752.00 Medicaid Facility D G $80.00 $60.00 $140.00

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2003 - 12/2003)

Living Arrangement L/A Code O/S Code O/S Amount Federal Payment Amount Total Payment Amount INDIVIDUALS 1/ In Own Household No EP A Z — $552.00 $552.00 1 EP A Z — $829.00 $829.00 In Certified Adult A A $307.00 $552.00 $859.00 Foster Care Home A B $417.00 $552.00 $969.00 In Another's Household No EP B Z — $368.00 $368.00 1 EP B Z — $552.67 $552.67 In Parental Household C Z — $552.00 $552.00 Medicaid Facility D G $40.00 $30.00 $70.00 COUPLES 1/ In Own Household No EP A Z — $829.00 $829.00 1 EP A Z — $1,106.00 $1,106.00 In Certified Adult A A $889.00 $829.00 $1,718.00 Foster Care Home A B $1,109.00 $829.00 $1,938.00 In Another's Household No EP B Z — $552.67 $552.67 1 EP B Z — $737.34 $737.34 Medicaid Facility D G $80.00 $60.00 $140.00

(DC), Appendix I — Chart 26 (RTN 45 - 1/2002)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2002 - 12/2002)

Living Arrangement L/A Code O/S Code O/S Amount Federal Payment Amount Total Payment Amount INDIVIDUALS 1/ In Own Household No EP A Z — $545.00 $545.00 1 EP A Z — 818.00 818.00 In Certified Adult A A $307.00 545.00 852.00 Foster Care Home A B 417.00 545.00 962.00 In Another's Household No EP B Z — 363.34 363.34 1 EP B Z — 545.34 545.34 In Parental Household C Z — 545.00 545.00 Medicaid Facility D G 40.00 30.00 70.00 COUPLES 1/ In Own Household No EP A Z — $817.00 $817.00 1 EP A Z — 1,090.00 1,090.00 In Certified Adult A A $887.00 817.00 1,704.00 Foster Care Home A B 1,107.00 817.00 1,924.00 In Another's Household No EP B Z — 544.67 544.67 1 EP B Z — 726.67 726.67 Medicaid Facility D G 80.00 60.00 140.00

(DC), Appendix I — Chart 25 (RTN 44 - 1/2001)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2001 - 12/2001)

Living Arrangement L/A Code O/S Code O/S Amount Federal Payment Amount Total Payment Amount INDIVIDUALS 1/ In Own Household No EP A Z — $530.00 $530.00 1 EP A Z — 796.00 796.00 In Certified Adult A A $307.00 530.00 837.00 Foster Care Home A B 417.00 530.00 947.00 In Another's Household No EP B Z — 353.34 353.34 1 EP B Z — 530.67 530.67 In Parental Household C Z — 530.00 530.00 Medicaid Facility D G 40.00 30.00 70.00 COUPLES 1/ In Own Household No EP A Z — $796.00 $796.00 1 EP A Z — 1,062.00 1,062.00 In Certified Adult A A $878.00 796.00 1,674.00 Foster Care Home A B 1,098.00 796.00 1,894.00 In Another's Household No EP B Z — 530.67 530.67 1 EP B Z — 708.00 708.00 Medicaid Facility D G 80.00 60.00 140.00

(DC), Appendix I — Chart 24 (RTN 43 - 1/2000)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/2000 - 12/2000)

Living Arrangement L/A Code O/S Code O/S Amount Federal Payment Amount Total Payment Amount INDIVIDUALS 1/ In Own Household No EP A Z — $512.00 $512.00 1 EP A Z — 769.00 769.00 In Certified Adult A A $307.00 512.00 819.00 Foster Care Home A B 417.00 512.00 929.00 In Another's Household No EP B Z — 341.34 341.34 1 EP B Z — 512.67 512.67 In Parental Household C Z — 512.00 512.00 Medicaid Facility D G 40.00 30.00 70.00 COUPLES 1/ In Own Household No EP A Z — $769.00 $769.00 1 EP A Z — 1,026.00 1,026.00 In Certified Adult A A $869.00 769.00 1,638.00 Foster Care Home A B 1,089.00 769.00 1,858.00 In Another's Household No EP B Z — 512.67 512.67 1 EP B Z — 684.00 684.00 Medicaid Facility D G 80.00 60.00 140.00

(DC), Appendix I — Chart 23 (RTN 42 - 1/1999)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/1999-12/1999)

Living Arrangement L/A Code O/S Code O/S Amount Federal Payment Amount Total Payment Level INDIVIDUALS 1/ In Own Household No EP A Z — $500.00 $500.00 1 EP A Z — 751.00 751.00 In Certified Adult 2/ A A 307.00 500.00 807.00 Foster Care Home 2/ A B 417.00 500.00 917.00 In Another's Household No EP B Z — 333.34 333.34 1 EP B Z — 500.00 500.00 In Parental Household C Z — 500.00 500.00 Medicaid Facility D G 40.00 30.00 70.00 COUPLES 1/ In Own Household No EP A Z — $751.00 $751.00 1 EP A Z — 1001.00 1011.00 In Certified Adult 2/ A A 863.00 751.00 1,614.00 Foster Care Home 2/ A B 1083.00 751.00 1,834.00 In Another's Household No EP B Z — 500.67 500.67 1 EP B Z — 667.33 667.33 Medicaid Facility D G 80.00 60.00 140.00

1/ For individuals/couples whose FCI precludes a Federal payment, the amounts in the "O/S Amount" column will vary depending on income. See SI 02005.001 , which discusses situations of this kind.

2/ In July 1998, the District of Columbia increased OS codes A and B rates by $30.00 per individual and $65.00 per couple retroactive to 01.98. A retroactive check was issued for amounts due from 01/98 to 08/98.

In January 1999, the District of Columbia increased OS codes A and B rates by $10.00 per individual and $22.00 per couple.

(DC, Appendix I — Chart 22 (RTN 41 - 09/1998)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/1998 – 12/1998)

Living Arrangement L/A Code O/S Code O/S Amount Federal Payment Amount Total Payment Level INDIVIDUALS 1/ In Own Household No EP A Z ———— $494.00 $494.00 1 EP A Z ———— 741.00 741.00 In Certified Adult 2/ A A $ 297.00 494.00 791.00 Foster Care Home 2/ A B 407.00 494.00 901.00 In Another's Household No EP B Z ———— $329.34 $329.34 1 EP B Z ———— 494.00 494.00 In Parental Household C Z ———— 494.00 494.00 Medicaid Facility D G 40.00 30.00 70.00 COUPLES 1/ In Own Household No EP A Z ———— $741.00 $ 741.00 1 EP A Z ———— 988.00 988.00 In Certified Adult 2/ A A $ 841.00 741.00 1582.00 Foster Care Home 2/ A B 1061.00 741.00 1802.00 In Another's Household No EP B Z ———— 494.00 494.00 1 EP B Z ———— 658.67 658.67 Medicaid Facility D G 80.00 60.00 140.00

(DC), Appendix I — Chart 21 (RTN 41 - 1/1998)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/1998-12/1998)

Living Arrangement L/A Code O/S Code O/S Amount Federal Payment Amount Total Payment Level INDIVIDUALS 1/ In Own Household No EP A Z — $494.00 $494.00 1 EP A Z — 741.00 741.00 In Certified Adult 2/ A A 297.00 494.00 791.00 Foster Care Home 2/ A B 407.00 494.00 901.00 In Another's Household No EP B Z — 329.34 329.34 1 EP B Z — 494.00 494.00 In Parental Household C Z — 494.00 494.00 Medicaid Facility D G 40.00 30.00 70.00 COUPLES 1/ In Own Household No EP A Z — $741.00 $741.00 1 EP A Z — 988.00 988.00 In Certified Adult 2/ A A 841.00 741.00 1,582.00 Foster Care Home 2/ A B 1061.00 741.00 1,802.00 In Another's Household No EP B Z — 494.00 494.00 1 EP B Z — 658.67 658.67 Medicaid Facility D G 80.00 60.00 140.00

2/ In July 1998, the District of Columbia increased OS codes A and B rates by $30.00 per individual and $65.00 per couple retroactive to 01.98. A retroactive check was issued for amounts due from 01/98 to 08/98.

(DC), Appendix I — Chart 20

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/1997-12/1997)

Living Arrangement L/A Code O/S Code O/S Amount Federal Payment Amount Total Payment Level INDIVIDUALS 1/ In Own Household No EP A Z — $484.00 $484.00 1 EP A Z — 726.00 726.00 In Certified Adult A A 267.00 484.00 751.00 Foster Care Home A B 377.00 484.00 861.00 In Another's Household No EP B Z — 322.67 322.67 1 EP B Z — 484.00 484.00 In Parental Household C Z — 484.00 484.00 Medicaid Facility D G 40.00 30.00 70.00 COUPLES 1/ In Own Household No EP A Z — $726.00 $726.00 1 EP A Z — 968.00 968.00 In Certified Adult A A 776.00 726.00 1,502.00 Foster Care Home A B 996.00 726.00 1,722.00 In Another's Household No EP B Z — 484.00 484.00 1 EP B Z — 645.34 645.34 Medicaid Facility D G 80.00 60.00 140.00

(DC), Appendix I — Chart 19

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/1996-12/1996)

Living Arrangement L/A Code O/S Code O/S Amount Federal Payment Amount Total Payment Level INDIVIDUALS 1/ In Own Household No EP A C $ 4.70 $470.00 $474.00 1 EP A E 0.00 705.00 705.00 In Certified Adult A A 147.20 470.00 617.00 Foster Care Home A B 257.20 470.00 727.00 In Another's Household No EP B D 8.13 313.34 321.47 1 EP B F 4.46 470.00 474.46 In Parental Household C CZ 4.70 470.00 474.70 Medicaid Facility D G 40.00 30.00 70.00 COUPLES 1/ In Own Household No EP A C $ 14.60 $705.00 $719.60 1 EP A E 9.10 940.00 949.00 In Certified Adult A A 523.40 705.00 1,228.00 Foster Care Home A B 743.40 705.00 1,448.00 In Another's Household No EP B D 19.73 470.00 489.73 1 EP B F 16.06 623.67 642.73 Medicaid Facility D G 80.00 60.00 140.00

(DC), Appendix I — Chart 18

SUPPLEMENTATION CODING AND PAYMENT LEVELS (05/1995-12/1995)

Living Arrangement L/A Code O/S Code O/S Amount Federal Payment Amount Total Payment Level INDIVIDUALS 1/ In Own Household No EP A C $4.70 $458.00 $462.70 1 EP A E 0.00 687.00 687.00 In Certified Adult A A 147.20 458.00 605.20 Foster Care Home A B 257.20 458.00 715.20 In Another's Household No EP B D 8.13 305.34 313.47 1 EP B F 4.46 458.00 462.46 In Parental Household C C 4.70 458.00 462.70 Medicaid Facility D G 40.00 30.00 70.00 COUPLES 1/ In Own Household No EP A C $ 14.60 $687.00 $701.60 1 EP A E 9.10 916.00 925.10 In Certified Adult A A 523.40 687.00 1,210.00 Foster Care Home A B 743.40 687.00 1,430.00 In Another's Household No EP B D 19.73 458.00 477.73 1 EP B F 16.06 610.67 626.73 Medicaid Facility D G 80.00 60.00 140.00

(DC), Appendix I — Chart 17

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/1995-04/1995)

Living Arrangement L/A Code O/S Code O/S Amount Federal Payment Amount Total Payment Level INDIVIDUALS 1/ In Own Household No EP A C $ 15.00 $458.00 $473.00 1 EP A E 15.00 687.00 702.00 In Certified Adult A A 147.20 458.00 605.20 Foster Care Home A B 257.20 458.00 715.20 In Another's Household No EP B D 15.00 305.34 320.34 1 EP B F 15.00 458.00 473.00 In Parental Household C C 15.00 458.00 473.00 Medicaid Facility D G 40.00 30.00 70.00 COUPLES 1/ In Own Household No EP A C $ 30.00 $687.00 $717.00 1 EP A E 30.00 916.00 946.00 In Certified Adult A A 523.40 687.00 1,210.00 Foster Care Home A B 743.40 687.00 1,430.00 In Another's Household No EP B D 30.00 458.00 488.00 1 EP B F 30.00 610.67 640.67 Medicaid Facility D G 80.00 60.00 140.00

(DC), Appendix I — Chart 16

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/1994-12/1994)

Living Arrangement L/A Code O/S Code O/S Amount Federal Payment Amount Total Payment Level INDIVIDUALS 1/ In Own Household No EP A C $ 15.00 $446.00 $461.00 1 EP A E 15.00 669.00 684.00 In Certified Adult A A 147.20 446.00 593.20 Foster Care Home A B 257.20 446.00 703.20 In Another's Household No EP B D 15.00 297.34 312.34 1 EP B F 15.00 446.00 461.00 In Parental Household C C 15.00 446.00 461.00 Medicaid Facility D G 40.00 30.00 70.00 COUPLES 1/ In Own Household No EP A C $ 30.00 $669.00 $699.00 1 EP A E 30.00 892.00 922.00 In Certified Adult A A 517.40 669.00 1,186.40 Foster Care Home A B 737.40 669.00 1,406.40 In Another's Household No EP B D 30.00 446.00 476.00 1 EP B F 30.00 594.67 624.67 Medicaid Facility D G 80.00 60.00 140.00

(DC), Appendix I — Chart 15

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/1993-12/1993)

Living Arrangement L/A Code O/S Code O/S Amount Federal Payment Amount Total Payment Level INDIVIDUALS 1/ In Own Household No EP A C $ 15.00 $434.00 $449.00 1 EP A E 15.00 651.00 666.00 In Certified Adult A A2/ 147.20 434.00 581.20 Foster Care Home A B3/ 257.20 434.00 691.20 In Another's Household No EP B D 15.00 289.34 304.34 1 EP B F 15.00 434.00 449.00 In Parental Household C C 15.00 434.00 449.00 Medicaid Facility D G 40.00 30.00 70.00 COUPLES 1/ In Own Household No EP A C $ 30.00 $652.00 $682.00 1 EP A E 30.00 869.00 899.00 In Certified Adult A A2/ 510.40 652.00 1,162.40 Foster Care Home A B3/ 730.40 652.00 1,382.40 In Another's Household No EP B D 30.00 434.67 464.67 1 EP B F 30.00 579.34 609.34 Medicaid Facility4/ D G 80.00 60.00 140.00

2/ A special supplement is payable to an adult foster home resident in a small (50 or fewer residents) facility.

3/ A special supplement is payable to an adult foster home resident in a large (51 or more residents) facility.

4/ Effective October 1, 1990, the benefit rate to each member of a couple which separates must be adjusted to that of an individual the month after the month of separation. Prior to October 1, 1990, eligible couples who separated continued to be treated as a couple for 6 months.

(DC), Appendix I — Chart 14 (RTN 32 - 1/1992)

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/1992-12/1992)

Living Arrangement L/A Code O/S Code O/S Amount Federal Payment Amount Total Payment Level INDIVIDUALS 1/ In Own Household No EP A C $ 15.00 $422.00 $437.00 1 EP A E 15.00 633.00 648.00 In Certified Adult A A2/ 147.20 422.00 569.20 Foster Care Home A B3/ 257.20 422.00 679.20 In Another's Household No EP B D 15.00 281.34 296.34 1 EP B F 15.00 422.00 437.00 In Parental Household C C 15.00 422.00 437.00 Medicaid Facility D G 40.00 30.00 70.00 COUPLES 1/ In Own Household No EP A C $ 30.00 $633.00 $663.00 1 EP A E 30.00 844.00 874.00 In Certified Adult A A2/ 505.40 633.00 1,138.40 Foster Care Home A B3/ 725.40 633.00 1,358.40 In Another's Household No EP B D 30.00 422.00 452.00 1 EP B F 30.00 562.67 592.67 Medicaid Facility4/ D G 80.00 60.00 140.00

(DC), Appendix I — Chart 13

SUPPLEMENTATION CODING AND PAYMENT LEVELS (01/1991-12/1991)

Living Arrangement L/A Code O/S Code O/S Amount Federal Payment Amount Total Payment Level INDIVIDUALS 1/ In Own Household No EP A C $ 15.00 $407.00 $422.00 1 EP A E 15.00 611.00 626.00 In Certified Adult A A2/ 147.20 407.00 554.20 Foster Care Home A B3/ 257.20 407.00 664.20 In Another's Household No EP B D 15.00 271.34 286.34 1 EP B F 15.00 407.34 422.34 In Parental Household C C 15.00 407.00 422.00 Medicaid Facility D G 40.00 30.00 70.00 COUPLES 1/ In Own Household No EP A C $ 30.00 $610.00 $640.00 1 EP A E 30.00 814.00 844.00 In Certified Adult A A2/ 498.40 610.00 1,108.40 Foster Care Home A B3/ 718.40 610.00 1,328.40 In Another's Household No EP B D 30.00 406.67 436.67 1 EP B F 30.00 524.67 572.67 Medicaid Facility4/ D G 80.00 60.00 140.00

2/ A special supplement is payable to an adult foster home resident in a small (50 or fewer residents) facility.

3/ A special supplement is payable to an adult foster home resident in a large (51 or more residents) facility.

4/ Effective October 1, 1990, the benefit rate to each member of a couple which separates must be adjusted to that of an individual the month after the month of separation. Prior to October 1, 1990, eligible couples who separated continued to be treated as a couple for 6 months.

Exhibit — Appendix II — Certification Form For DC State Supplement

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