IMA POLICY MANUAL
PART VII: SPECIAL MA PROCESSING
CHAPTER 2: LONG-TERM CARE/IMPOVERISHED SPOUSE
In addition to meeting the needs of families and individuals who reside in the community, the MA program provides coverage of some or all of the costs of care for persons who reside in certain LTC facilities.
In order to receive coverage, LTC residents must establish both MA eligibility and LTC eligibility (also referred to as payability). Individuals eligible for MA but over-income are eligible for LTC coverage. The LTC Eligibility Unit handles all LTC cases. The LTC unit determines MA eligibility for LTC residents (if they have not already established MA eligibility) and payability. Exhibit VII-2: Diagram of LTC Processing depicts how LTC processing differs depending on how the LTC resident enters LTC status.
LTC residents are eligible for additional income allowances when determining LTC eligibility or payability; these additional income allowances are used in the calculation of the Patient Pay Amount (PPA). The PPA is another way in which LTC differs from standard MA. Unlike standard MA coverage, eligible LTC residents often contribute to their cost of care by paying the PPA.
LTC residents also spend-down their income in a different manner than in standard MA. Unlike standard MA where total countable income must meet a certain standard, LTC spend-down is governed by the comparison of the PPA to the cost of care rate.
LTC facilities are licensed by the District and have provider agreements with the Department. Types of LTC facilities authorized to accept District residents who are eligible for LTC coverage include:
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nursing facilities,
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intermediate care facilities for the mentally retarded (ICF/MR),
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institutions for mental diseases (person under age 21 or age 65 or older only), and
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certain youth residential treatment facilities.
For the purposes of this chapter, the following terms are used:
- LTC recipient: an individual who and residing in a LTC facility;
- institutionalized spouse: an individual who is married and is:
- residing in a LTC facility,
- likely to be hospitalized for at least 30 days, or
- likely to reside either in a hospital or a LTC facility for at least 30 consecutive days;
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community spouse: an individual who is married to an institutionalized spouse and who is living in the community, and
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family member: any minor or dependent child, dependent sibling, or dependent parent of the institutionalized spouse or community spouse who is claimed as a dependent for tax purposes.
| Mr. Newman is married and enters the hospital on June 25th. His doctors expect that he will be discharged on July 10th to a LTC facility and that he will stay at the LTC facility for three weeks. Even though he is expected to stay in the hospital for only 15 days, he is considered an institutionalized spouse because he is likely to spend a total of 36 days in either a hospital or a LTC facility. |
The policies in this chapter apply to LTC recipients and institutionalized spouses. However, the income and assets of institutionalized spouses who have a community spouse are treated differently if the institutionalized spouse was institutionalized after September 30, 1989. The income and asset allowances and deductions are designed to prevent the impoverishment of the community spouse. The policies regarding institutionalized spouses who have a community spouse and who entered a LTC facility after September 30, 1989 are referred to as the "Impoverished Spouse" provisions. For the purposes of this chapter, Impoverished Spouse provisions, which apply only to institutionalized spouses who entered a LTC facility after September 30, 1989 and who have a community spouse, will be set off by the italicized heading Impoverished Spouse. Unless otherwise noted, the policies in this chapter also apply to those individuals eligible for the Impoverished Spouse provisions.
Because there are very few individuals currently in LTC who were institutionalized before October 1, 1989 and have a community spouse, Exhibit VII-3: Provisions for Pre-October 1989 Institutionalization lists how policies are to be adjusted for these individuals by section. However, unless otherwise noted, the policies in this chapter also apply to these individuals.
The policies in this chapter supercede any MA policy which is inconsistent with these policies. The policies apply the first month the individual resides in a LTC facility and is MA-eligible and cease the first full calendar month following changes in circumstances (i.e., if changes occur in November, these policies would not apply in December).
| Long-Term Care |
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MA: 42 USC 1396a(a)(10);
42 USC 1396a(q)-(r); 42 USC 1396r; 42 USC 1396r-5; 45 CFR 435.700; 45 CFR 435.725; 45 CFR 435.726 |
MEDICAL CERTIFICATION FOR LTC 2.3
The Medical Assistance Administration (MAA), a part of DOH, certifies the individual's medical need for LTC prior to approval of coverage of the costs of care.
The MAA is responsible for:
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reviewing the medical documentation from the individual's physician, the acute hospital arranging the placement, or other competent medical authority to determine the level of care appropriate to the individual's needs; and
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notifying the appropriate LTC facilities of the individual's level of care.
The facility which accepts the individual submits a Patient Start of Care Notice and a Level of Care Notice to the LTC Eligibility Unit in IMA indicating the assigned level of care and the date of admission or date of transfer to MA status.
The PSRO (at DoH) reviews the level of care determinations periodically. If the patient's medical needs change significantly and a different level of care is determined, the individual may be transferred to a different facility or discharged to a community placement. The PSRO submits a new level of care and the effective date of the change to the facility which in turn submits the information to the LTC Eligibility Unit.
LTC APPLICATION PROCESS 2.4
Transfer of Case Record 2.4.1
Determining eligibility for LTC coverage (payability) is the responsibility of the LTC Eligibility Unit. An individual who is already a recipient of MA as a community-assistance unit (AR, AX, SR, or QM (must be Medicaid eligible)) must have his/her eligibility for LTC coverage redetermined by the LTC Eligibility Unit at the time of admission to a LTC facility (see Section 2.4.3: Assistance Unit Requirements in this Chapter). The SSR should transfer the recipient's MA case record to the appropriate LTC SSR (see Chapter 2: Case Transfers Between Service Centers in Part VIII).
See Section 2.3: Time Standards in Part III. In addition, if the Patient Start of Care Notice has not been received from the facility by the 45th day of pending disposition, the application for MA must be processed as if it was for a community-assistance unit (i.e., no eligibility for LTC coverage).
If the start of care date falls within the 45 days of pending disposition but not within the month of application, eligibility for the first month, or first and second months, must be established as a community-assistance unit. If the start of care date falls within the three months prior to the month of application, then the LTC SSR should determine if the LTC resident is eligible for retroactive LTC coverage.
Assistance Unit Requirements 2.4.3
The individual or couple entering a LTC facility must establish eligibility as either an AR, AX, SR, or QM (must also be Medicaid-eligible)) unit (see Section 2.5: MA Income Eligibility Determination and Section 2.9: MA Asset Eligibility Determination in this Chapter and Part IV: Non-Financial Eligibility). Once the individual or couple has been certified by the MAA (see Section 2.3: Medical Certification for LTC), then s/he is considered an SR unit, regardless if s/he was initially considered as an AR, AX, or QM unit.
If the individual or couple is residing in a LTC facility and has not yet established MA eligibility, then s/he must establish eligibility as an SR unit. Because s/he is establishing eligibility while residing in a LTC facility, his/her income and assets are treated differently (see Section 2.5: MA Income Eligibility Determination in this Chapter and Section 2.9: MA Asset Eligibility Determination in this Chapter).
If an individual who is residing in or entering a LTC facility has an eligible spouse who is residing in or entering the same LTC facility, include both spouses in the same assistance unit whether or not they share a room.
If the individual in LTC has an eligible spouse who is residing in a different LTC facility, each spouse is considered to be financially responsible for the other for the month of their physical separation. During this one-month period, both spouses are included in the same assistance unit.
See Exhibit VII-3: Provisions for Pre-October 1989 Institutionalization for additional policy for LTC residents institutionalized before October 1, 1989 who have a community spouse.
Impoverished Spouse: See above. However, if the individual in LTC is eligible for the Impoverished Spouse provisions (i.e., has a community spouse and was institutionalized after September 30, 1989), then no income from the community spouse should be deemed to the institutionalized spouse for any month in which s/he is institutionalized (see Section 2.5: MA Income Eligibility Determination and Section 2.15: Determining Total Countable Income for P/A Calculation in this Chapter).
