Institutional Coverage Groups Residing in a Medical Institution

Institutional Coverage Groups Residing in a Medical Institution A. Long Term Hospitalization 1. An individual can qualify for Medicaid using institutional rules after meeting the thirty (30) consecutive day requirement, as outlined in Miss. Admin. Code, Title 23, Part 105, Chapter 7, Rule 7.5. Individuals eligible in an at-home category of eligibility that grants full Medicaid coverage have acute care coverage paid as a Medicaid covered service and do not need to apply separately for long term hospitalization coverage. 2. Institutional provisions that do not apply to an application to cover only long term hospitalization are the transfer of assets provision, the substantial home equity provision, the Income Trust provision, and payment of cost of care to the hospital, referred to as Medicaid Income. All other institutional requirements apply. 3. Eligibility is determined using the individual’s own income or his proportionate share of jointly owned income which must be less than three hundred percent (300%) of the Supplemental Security Income (SSI) individual federal benefit rate. Spousal impoverishment rules apply if the individual is legally married, as outlined in Miss. Admin. Code, Title 23, Part 105, Chapter 7, Rule 7.2. B. Long Term Care in a Nursing Facility or Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IDD) 1. An individual can qualify for Medicaid using institutional rules after meeting the thirty (30) consecutive day requirement, as outline in Miss. Admin. Code, Title 23, Part 105, Chapter 7, Rule 7.5. Exceptions for meeting the thirty (30) consecutive day requirement are outlined in Miss. Admin. Code, Title 23, Part 105, Chapter 7, Rule 7.5. 2. Policy provisions that apply to individuals qualifying for long term care in a nursing facility and/or ICF/IDD are: a) Deeming of spousal or parental income does not apply in evaluating income eligibility for the individual entering or residing in the facility, b) Spousal impoverishment rules apply to legally married spouses, as outlined in Miss. Admin. Code, Title 23, Part 105, Chapter 7, Rule 7.2. c) The transfer of assets provision along with the five (5) year lookback period prior to the first application for Medicaid that was not withdrawn applies, as outlined in Miss. Admin. Code, Title 23, Part 103, Chapter 7. d) The substantial home equity provision applies, as outlined in Miss. Admin. Code, Title 23, Part 103, Rule 4.22. e) The Income Trust provision applies for individuals whose income exceeds the three hundred percent (300%) need standard but whose income is less than the private pay rate for the facility in which the individual resides, as outlined in Miss. Admin. Code, Title 23, Part 103, Chapter 5, Rule 5.17. f) Physician certification is required, as outlined in Miss. Admin. Code, Title 23, Part 105, Chapter 7, Rule 7.1. g) Medicaid Income is payable, as outlined in Miss. Admin. Code, Title 23, Part 105, Chapter 8. h) All other factors of eligibility as outlined in Miss. Admin. Code, Title 23, Part 105, Chapter 1, Rule 1.4 also apply. C. Recipients Eligible Upon Entry to Long Term Care (LTC) 1. Adults and children eligible upon entry to a nursing facility or Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IDD), hospital or a child under age twenty-one (21) admitted to a Psychiatric Residential Treatment Facility (PRTF) can have eligibility from one of the following sources: a) Supplemental Security Income (SSI), b) The Department of Child Protection Services for a foster child or a former foster child who is eligible to age twenty-six (26), c) MAGI-related eligibility for an adult or child under age nineteen (19), including children eligible for CHIP, d) Aged, Blind and Disabled (ABD) at-home eligibility. 2. The source of eligibility for an adult or child determines when or if a separate application for ABD Medicaid is required. Regardless of the source of eligibility, upon entry to long term care, institutional provisions are applicable as follows: a) The transfer of assets, substantial home equity, spousal impoverishment and Estate Recovery provisions apply to nursing facility and ICF/IDD admissions, as outlined in Miss. Admin. Code, Title 23, Part 105, Rule 1.4. b) Medicaid Income is payable, if income allows, for nursing facility, ICF/IDD and PRTF admissions, see Miss. Admin. Code Part 105, Chapter 8. The exception is for months in which a recipient is eligible under a MAGI or foster care source of eligibility. 3. SSI recipients with income less than fifty dollars ($50) per month who enter a nursing facility or ICF/IDD may continue to be eligible for SSI for the duration of their admission. In addition to low income, the SSI recipient must also meet all institutional requirements to qualify for Medicaid payment of room/board in the facility. If SSI eligibility is terminated by the Social Security Administration due to excess income or resources, the individual must complete a SSI Review Form that serves as a renewal for Medicaid. If SSI terminates for any other reason, a Medicaid ABD application is required. 4. Foster children certified as Medicaid eligible by the Department of Child Protection Services and former foster children eligible to age twenty-six (26) who enter a nursing facility or ICF/IDD for a short term admission, defined as ninety (90) days or less, are not required to file a separate ABD Medicaid application in order for their admission to be covered, provided all institutional requirements are met. Admissions that will exceed ninety (90) days require a separate ABD Medicaid application. Foster children under age nineteen (19) who file an ABD Medicaid application and do not qualify are provided institutional coverage until the end of their twelve (12) month period of protected coverage. Hospital and PRTF admissions do not have a limitation imposed on the length of stay. 5. Modified Adjusted Gross Income (MAGI) eligible children and/or adults who enter a nursing facility or ICF/IDD for a short term admission, defined as ninety (90) days or less, are not required to file a separate ABD Medicaid application in order for their admission to be covered, provided all institutional requirements are met. MAGI-eligible children who file an ABD Medicaid application and do not qualify are provided continued institutional coverage until the end of their protected twelve (12) month period of protected coverage. MAGI-eligible pregnant women who file an ABD Medicaid application and do not qualify are covered until the end of their post-partum period. A non-pregnant MAGI eligible adult has ninety (90) days of MAGI long term care coverage. Hospital admissions and PRTF admissions for a child do not have a limitation imposed on the length of stay. 6. ABD at-home eligible children or adults who enter a nursing facility or ICF/IDD must qualify for an ABD institutional category of eligibility, meeting all institutional requirements. The only allowable exception is a child eligible under the Katie Beckett category of eligibility or a child eligible for the Healthier MS waiver may remain in their respective category of eligibility if admitted to a PRTF. ABD at-home recipients eligible in any full service category of eligibility or as Qualified Medicare Beneficiary (QMB) only receive covered inpatient admissions without changing to an institutional category.