Housing, Medicaid and Social Security

Maintaining your benefits when transitioning to independent living is possible with the right planning. It is important to consider all of your assets and benefits when developing your housing plan. By understanding the interaction between housing, Medicaid, and Social Security income, we can ensure your living arrangement and expenses are financed in ways that do not disqualify you from or interrupt your benefits. MIH will assist you to navigate these areas and help you make informed decisions.


Supplemental Security Income (SSI)

The Supplemental Security Income (SSI) program pays benefits to disabled adults and children who have limited income and resources.

Social Security Rules Related to Housing

If you receive SSI, it’s important to know that Social Security has rules about money you receive from other people to help you pay for “shelter expenses,” also called “room and board”. The Social Security Administration requires people to contribute their “fair share” toward their shelter expenses.  These expenses include rent or mortgage, utilities, and food. If people do not pay their fair share for these expenses, SSA will deduct the “presumed maximum value” of the portion of shelter expenses you do not pay. This can happen if someone else pays all or part of your shelter expenses, or if you do not contribute your fair share to the shelter expenses where you live.

Why is your living arrangement important?

Your living arrangement is where you live, if you live alone or with someone else, or if you live in an institution, such as a nursing home. Your living arrangement also depends on who pays for your food and shelter. Whether you live alone or with someone else, we need to know who pays for your food, shelter, and utilities. 

Presumed Maximum Value

According to SSA, suppose you live alone and your only income is SSI. Your brother pays your rent of $800. We count this payment as in-kind support and maintenance. Although the rent is $800, we limit how much of the $800 we count by using a presumed maximum value (PMV) rule. The PMV is equal to 1/3 of the Federal benefit rate plus $20.  Here are the steps we use to figure the SSI benefit amount.


The Maryland Developmental Disabilities Council also has information on living arrangements and SSI in their publication called Planning Now (PDF)

The SSI Federal Benefit Rate is $794.00.

One-third of the SSI Federal Benefit Rate of $794 is $264.66.

  1. $264.66 (1/3 of the Federal Benefit Rate)
    +$20.00 (from the PMV rule)
    =$284.66 (the PMV of in-kind support and maintenance)
  2. $284.66 (the PMV of in-kind support and maintenance)
    -20.00 (general income exclusion)
    = $264.66 (the amount of the reduction due to in-kind support and maintenance)
  3. $794 (Federal Benefit Rate)
    -$264.66 (reduction due to in-kind support and maintenance)
    = $529.34 (your SSI benefit amount)


Social Security Disability Insurance (SSDI)

The Social Security Disability Insurance (SSDI) program pays benefits to you and certain family members if you are “insured,” meaning that you worked long enough – and recently enough – and paid Social Security taxes on your earnings. While the Social Security and Supplemental Security Income disability programs are different, the medical requirements are the same. If you meet the non-medical requirement criteria, monthly benefits are paid if you have a medical condition that’s expected to last at least one year or result in death.

The SSDI program does not consider your living arrangements when calculating your benefits. Your living arrangements will have no impact on your benefits.

The Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) program


Retirement Income

Social Security Retirement Benefits (www.ssa.gov)

How Retirement Benefits Work

Social Security replaces a percentage of your pre-retirement income based on their lifetime earnings. The portion of your pre-retirement wages that Social Security replaces is based on your highest 35 years of earnings and varies depending on how much you earn and when you choose to start benefits.

When you work, you pay taxes into Social Security. We use the tax money to pay benefits to:

  1. People who have already retired.
  2. People who are disabled.
  3. Survivors of workers who have died.
  4. Dependents of beneficiaries.

The money you pay in taxes isn’t held in a personal account for you to use when you get benefits. We use your taxes to pay people who are getting benefits right now. Any unused money goes to the Social Security trust fund that pays monthly benefits to you and your family when you start receiving retirement benefits.

Social Security should be just one part of your retirement plan. On average, retirement beneficiaries receive 40% of their pre-retirement income from Social Security. As you make your retirement plan, knowing the approximate amount you will receive in Social Security benefits can help you determine how much other retirement income you’ll need to reach your goals.

Your living arrangements have no impact on your Social Security Retirement benefits.


Is a Home an Asset?

The SSA does not consider everything you own as an asset. For example, a house you own and live in is not considered an asset when determining your financial eligibility for benefits. In addition, a vehicle you use for personal transportation is not considered an asset. This link provides more information from SSA on the assets that are and are not counted when calculating your financial eligibility for benefits

Understanding Supplemental Security Income SSI Resources


ABLE Accounts and Paying for Housing

ABLE account funds can be used to pay for your housing costs, including rent, mortgage, property taxes, utilities (gas, electric, water sewer), condo fees, home maintenance, etc. The Social Security Administration will not consider ABLE account funds used for housing costs as income IF the funds are withdrawn from your ABLE account and spent on housing costs in the same month. Here’s an example: You rent an apartment and the rent is due on the 1st of the month. You want to pay your rent for April. It takes a few days for the funds to transfer from your ABLE account to your checking account. How can you use your ABLE account funds and not be late in paying your rent? If you withdraw the funds during the last week of March and pay your rent on March 31, the money you withdraw from your ABLE account is not considered income. You withdrew the money and paid your rent in the same month. And, you paid your rent early! That will make your landlord happy!

One more good thing to know – ABLE account funds are not considered an asset when you apply for a “means tested” program. A “means tested” program is one that looks at your assets and income to see if you qualify financially. Typically, these programs have an upper limit on the amount of income and/or assests you can have to qualify. Means tested programs include SSI, most federal, state and locally funded rent subsidy programs such as the Housing Choice Voucher (Section 8) program, HUD 811 Project Rental Assistance program and the Weinberg Apartments program, Moderate Income and Disability Income Housing Unit programs in Howard County and the Moderately Priced Dwelling Unit program in Montgomery County.

More information on the rules for using ABLE account funds to pay for housing costs:
Maryland ABLE
Can I use funds to pay for housing or rent? — Maryland ABLE
 Housing and Urban Development (HUD) Releases Guidance on ABLE Accounts


Home and Community Based Services (HCBS) Settings Rule

In 2014, the Centers for Medicare and Medicaid Services (CMS) at the Department of Health and Human Services issued the Home and Community Based Services (HCBS) Settings Rule. This rule requires that every state ensure that services delivered to seniors and people with disabilities living in the community – outside of institutions – meet minimum standards for integration, access to community life, choice, autonomy, and other important consumer protections. The HCBS Settings Rule was created to expand the availability of community-based services that maximize autonomy and choice for individuals with disabilities, and to address the problem of institutional-like settings receiving scarce HCBS dollars.

The Home and Community Based Services Settings Rule

What does the HCBS Settings Rule require?

The rule applies to all settings (i.e. place where seniors and people with disabilities live, work, or spend time) that receive HCBS funding, and requires that the setting:

  1. is integrated in the greater community;
  2. supports the individual’s full access to the greater community, including opportunities to seek employment, work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community;
  3. is selected by the individual from among different setting options, including non-disability specific options and an option for a private unit in a residential setting;
  4. ensures an individual’s rights to privacy, dignity, respect, and freedom from coercion and restraint;
  5. optimizes individual initiative, autonomy, and independence in making life choices, including in daily activities, physical environment, and personal associations; and
  6. facilitates individual choice regarding services and supports and who provides them.


The requirements are designed to ensure that people with disabilities living in the community have access to the same kind of choice and control over their own lives as those not receiving Medicaid HCBS funding.

Why is this important? Maryland, like other states, relies on funding from Medicaid to pay for part of the cost of providing services to people with intellectual and developmental disabilities in community-based settings. The Maryland Developmental Disabilities Administration (DDA) has three Medicaid waivers which are approved by CMS, and which help pay for Home and Community Based Services. For Medicaid funding to be used, community-based settings must meet the requirements of the HCBS New Settings Rule. Settings that isolate people with disabilities from the broader community cannot receive HCBS funding.

What is an institution/setting that isolates? CMS has issued guidance on what kinds of settings fall into the category of those that “have the effect of isolating individuals receiving Medicaid-funded HCBS from the broader community.” The guidance explains that these settings are typically designed specifically for people with disabilities (or even people with a certain type of disability). In such settings, the individuals residing within them are primarily or exclusively people with disabilities. They may be designed to provide people with disabilities with many services and activities on-site, and to offer limited, if any, interaction with the broader community. They may authorize the use of unacceptable interventions such as seclusion.

According to guidance from CMS issued on March 22, 2019 in the form of FAQs: “2 Question: What are the characteristics of a setting that isolates HCBS beneficiaries from their broader community? Answer: CMS intends to take the following factors into account in determining whether a setting may have the effect of isolating individuals receiving Medicaid HCBS from the broader community of individuals not receiving HCBS:

  1. Due to the design or model of service provision in the setting, individuals have limited, if any, opportunities* for interaction in and with the broader community, including with individuals not receiving Medicaid-funded HCBS;
  2. The setting restricts beneficiary choice to receive services or to engage in activities outside of the setting; or
  3. The setting is physically located separate and apart from the broader community and does not facilitate beneficiary opportunity to access the broader community and participate in community services, consistent with a beneficiary’s person-centered service plan.”

States may identify additional factors beyond those included above. However, the state needs to clarify any additional characteristics of isolation so that stakeholders have a clear understanding of what the state considers isolating.”

Home and Community-Based Settings Regulation – Heightened Scrutiny (PDF)

Additional Residential Service Provider Requirements

The new HCBS Community Settings Rule includes additional safeguards and requirements that must be met in settings that are owned or controlled by the service provider.  

Definition of provider-owned or controlled setting:  According to CMS, a “provider-owned or controlled residential setting” is one in which the service provider also owns or controls the real estate where the individual lives, as distinct from a setting owned or controlled by the person receiving services or their family where the provider merely arrives to deliver support services.

In a provider-owned or controlled residential setting, additional conditions must be met:

  1. The unit or dwelling is a specific physical place that can be owned, rented, or occupied under a legally enforceable agreement by the individual receiving services, and the individual has, at a minimum, the same responsibilities and protections from eviction that tenants have under the landlord/tenant law of the State, county, city, or other designated entity. For settings in which landlord tenant laws do not apply, the State must ensure that a lease, residency agreement or other form of written agreement will be in place for each HCBS participant, and that the document provides protections that address eviction processes and appeals comparable to those provided under the jurisdiction’s landlord tenant law.
  2. Each individual has privacy in their sleeping or living unit.
  3. Units have entrance doors lockable by the individual, with only appropriate staff having keys to doors.
  4. Individuals sharing units have a choice of roommates in that setting.
  5. Individuals have the freedom to furnish and decorate their sleeping or living units within the lease or other agreement.
  6. Individuals have the freedom and support to control their own schedules and activities and have access to food at any time.
  7. Individuals are able to have visitors of their choosing at any time.
  8. The setting is physically accessible to the individual.

Any modification of the additional conditions specified above must be supported by a specific assessed need and justified in the person-centered service plan. The following requirements must be documented in the person-centered service plan:

  1. Identify a specific and individualized assessed need.
  2. Document the positive interventions and supports used prior to any modifications to the person-centered service plan.
  3. Document less intrusive methods of meeting the need that have been tried but did not work.
  4. Include a clear description of the condition that is directly proportionate to the specific assessed need.
  5. Include regular collection and review of data to measure the ongoing effectiveness of the modification.
  6. Include established time limits for periodic reviews to determine if the modification is still necessary or can be terminated.
  7. Include the informed consent of the individual.
  8. Include an assurance that interventions and supports will cause no harm to the individual.

What are Home and Community Based Services (HCBS)?

Home and Community Based Services (HCBS) provide opportunities for Medicaid beneficiaries to receive services in their own home or community rather than institutions or other isolated settings. These programs serve a variety of targeted population groups, such as people with intellectual or developmental disabilities, physical disabilities, and/or mental illnesses.  Home and community-based services are provided through a Medicaid waiver or Medicaid state plan service.

Home & Community Based Services


Maryland Medicaid Waivers

Maryland has a number of waivers that serve different populations.  Each waiver has separate eligibility criteria as well. Information from the Maryland Department of Health on Maryland’s Medicaid waivers and other home and community-based services can be found at:
Home and Community-Based Services (HCBS)

A good description of Maryland waivers can also be found on the Pathfinders for Autism website at:
PFA TIPS: MARYLAND WAIVER PROGRAMS

Below is a brief description of each of Maryland’s Medicaid waivers.

Home and Community Options Waiver: The Community Options Waiver provides services such as assisted living facilities, medical day care, personal assistance, home-delivered meals, and supports planning for Maryland residents aged 18 and over who need assistance with activities of daily living, like bathing, grooming, dressing, and getting around. Individuals must meet a nursing facility level of care and financial eligibility requirements.
Community Options Waiver

Medical Day Care Waiver:  The Medical Day Care Services Waiver offers qualified Medicaid participant services in a community-based day care center. Medical Day Care is a structured group program that seeks to maximize health functioning and independence of eligible Medicaid participants by providing community-based health, social and related support services, as an alternative to institutional care. Individuals must be at least 16 years old and not enrolled in another home and community-based waiver. They must qualify for Medicaid in the community and meet the level of care required for nursing facility services.
MEDICAL DAY CARE SERVICES WAIVER PROGRAM

Model Waiver for Disabled Children: The Model Waiver, a program started in Maryland in 1985, allows medically fragile individuals who would otherwise be hospitalized and are certified as needing either hospital or nursing facility level of care to receive medically necessary and appropriate services in the community. As a result, the Model Waiver clients can continue to live at home with their families. The maximum number of individuals who may be enrolled in the Model Waiver is 200.
Model Waiver Fact Sheet

Waiver for Individuals with Brain Injury: Maryland’s Home and Community-Based Services Waiver for Individuals with Brain injury provides specialized community-based services to adults with brain injuries who meet program eligibility.

Covered services include: residential habilitation, day habilitation, supported employment, individual support services, case management, and medical day care.Eligible individuals must be between the ages of 22 and 64, have sustained a brain injury after the age of 17, require a nursing facility or chronic hospital level of care and reside in a state owned and operated nursing facility, a CARF accredited chronic hospital, or a state psychiatric hospital. An individual’s income and assets are reviewed to determine financial eligibility for Medical Assistance.    Waiver for Individuals with Brain Injury

Waiver for Children with Autism Spectrum Disorder:  Maryland’s Home and Community Based Services Waiver for Children with Autism Spectrum Disorder allows eligible children with Autism Spectrum Disorder to receive specific waiver services and certain Medicaid services to support them in their homes and communities. Individuals must be certified as needing services from an Intermediate Care Facility for people with Intellectual Disabilities (ICF-ID) and be between the ages of 2 through 21.
AUTISM WAIVER

Community Pathways Waiver: The Community Pathways Waiver helps individuals with intellectual and developmental disabilities to live more independently in their homes and communities.  The program provides a variety of Meaningful Day, Support, and Residential Services that promote community living, including a self-directed service model and traditional, agency-based service model.  

The Community Pathways Waiver supports both children and adults and includes various services to support assessed needs. Based on the person-centered planning process and information that comes out of focus area exploration, a coordinator will work with the person to determine the most appropriate service(s) to support their needs. Authorized services are based on an assessed need and waiver service requirements as noted in the approved Waiver applications.  The waiver provides a variety of services including meaningful day, support, and residential services. Support services include assistive technology services; behavioral support services; environmental assessments; environmental modifications; family caregiver training and empowerment services; family and peer monitoring supports; housing supports; individual and family-directed good and services; participant education, training and advocacy supports; personal supports; respite care services; nurse case management and delegation services; transportation; and vehicle modifications.  Meaningful day services include supported employment; employment discovery and customization; community development services; day habilitation; and medical day care.  Residential services include supported living; shared living; and community living – group home. Maryland has set criteria to determine eligibility for Medicaid waiver enrollment. Financial eligibility is based only on the income of the individual, not the income of the parents. 
Community Pathways Waiver

Community Supports Waiver:  The Community Supports Waiver helps adults who are eligible for services through the Developmental Disabilities Administration to live more independently in their homes and communities.  The program provides a variety of Meaningful Day and Support Services that promote community living, including a self-directed service model and traditional, agency-based service model.  The services available through this waiver are less comprehensive than those provided in the DDA Community Pathways waiver. More information can be found at: 
Community Supports Waiver

Family Supports Waiver:  The Family Supports Waiver helps participants to live more independently in their homes and communities.  The program provides a variety of Support Services that promote community living, including a self-directed service model and traditional, agency-based service model. The Family Supports Waiver supports children up to age 21 and includes various Support Services to support children and their families. Based on the person-centered planning process and information that comes out of focus area exploration, a coordinator will work with the family to determine the most appropriate service(s) to support their needs.
Family Supports Waiver

Medicaid State Plan Services

The Blue Book Guide to Long Term Supports and Services provides an overview of long term supports and services available to Maryland Medicaid recipients. The Blue Book can be assessed at:
Maryland Medicaid Home and Community-Based Long Term Care Services (pdf)

Community First Choice and Community Personal Assistance Services: Maryland’s Community First Choice and Community Personal Services options provide community services and supports to enable older adults and people with disabilities to live in their own homes.
Community First Choice