Long-term care Overview

Revised April 25, 2013

What is an institutional Medicaid program and what is long term care services?

The term "institutional" Medicaid means institutional medicaid rules are used in eligibility. 

In ACES the institutional Medicaid programs  are under the L track for Aged, Blind and Disabled (ABD) or K track for children and families.

Long-term care (LTC) programs provide services for the elderly and disabled in need of institutional care. Some clients who receive LTC services are able to continue living in their home or in an alternate living facility   (ALF) on a Home and Community based (HCB) Waiver authorized by HCS or DDD. 

Home and community-based services, provided under a Medicaid waiver granted by the federal government, enable them to live in a residential setting outside of a nursing or other medical facility or in their own home. Such services are referred to as waiver services.  

Others require institutional services that can be provided only in a medical facility.  Institutional medicaid rules can be used for individuals residing in a medical facility 30 days or more. 

Some clients receive hospice services in addition to or instead of services in their home or a medical facility.

 All clients approved for DDD or HCS Waiver services, Hospice  services or in a medical institution 30 days or more have attained institutional status and are considered to be institutionalized as described in Medicaid law and the regulations used to implement these programs. 

The department must determine a client's eligibility for LTC services according to both functional and financial requirements. A department-designated social service specialist establishes functional eligibility; some of their responsibilities are described in this category. A financial services specialist (FSS) uses the rules and procedures described in this category to establish a client's financial eligibility and responsibility to pay toward their cost of care. The amount of income and resources a client must contribute to the cost of care for services received is established in what is called the post-eligibility determination (participation ).  

When determining eligibility and the cost of care for LTC services, program policy requires an allocation of income and resources from the institutionalized spouse to the community spouse. For purposes of these allocations, the distinction is made throughout this category between an institutionalized spouse, who is applying for or receiving LTC services, and a community spouse, who is not, when eligibility and participation in the cost of care for these services is determined. The Medicare Catastrophic Care Act in 1988 began the spousal allocation process used to discourage the impoverishment of a spouse due to the need for LTC services by their husband or wife. That law and those that have extended and/or amended it are referred to as spousal impoverishment  legislation. (section 1924 of the Social Security Act).

The rules used to determine eligibility and participation costs for waiver services are similar to those for institutional services, but there are important differences. These differences, in addition to those related to hospice services, are discussed when the rules that describe them are covered in this section.

A client may be eligible for both medical assistance and institutional services, or be eligible for one but not the other.

Medical Personal Care (MPC)

Home & Community Services (HCS) and Division of Developmental Disabilities (DDD) can authorize Medicaid Personal Care (MPC)  for clients eligible to receive a non institutional CN Medicaid program and assessed to be eligible for MPC. 

MPC clients are not considered institutionalized.  The financial eligibility for MPC is eligibility for a "non-institutional" CN Medicaid program. A chart in the MPC section gives more information. 

This category also describes the rules and procedures used to determine a client's eligibility for non-institutional medical assistance provided in an ALF. This is called the "G03 Medicaid program" and is a SSI related non-institutional program.

Some clients require the assistance provided in such ALF  , but do not require the additional services provided under an  program. The financial standards used to determine eligibility for non-institutional medical assistance in an ALF are based on the department-contracted rate and the private rate of the facility in which the client lives.

See long-term care medical standards and personal needs allowance  chart for current institutional standards.     

Responsibilities and program administration

1. Community Services Division  CSC  financial service specialist (FSS) staff determine financial eligibility for the following long-term care (LTC) clients:

2. Home and community services  (HCS) FSS staff determine financial eligibility for all other LTC clients who receive the following services from HCS:

Rule of thumb:  If there is active TANF/family/children related case attached, the case is retained by the CSO/CSC unless the active case is with the MEDS or Foster Care unit (076).

HCS retains all nursing facility cases that are "institutionalized" 30 days or more unless there is an active TANF/family/children related case attached.

The HCS SW must authorize all nursing facility admissions before a nursing home award letter can be issued. (See application for nursing facility care on the bottom of this clarifying page) .  For active Medicaid clients with short stay admissions (under 30 days) see short stay instructions.  The exception to this is an admission into a State Veteran's Nursing Facility. A Veteran's Affairs Registered Nurse (VARN) determines NFLOC for admissions into a State Veteran's Nursing Facility.   

3. HCS case and a shared case with the MEDS or Foster Care  (076) unit:

·       The only time cases are shared on an ongoing basis is when HCS shares a case unit with the MEDS or Foster Care unit  under 076.  (See case records). The MEDS unit maintains the assistance unit active with their office. The HCS unit maintains the assistance unit receiving HCS services.

• Client active on COPES through HCS and applies for Basic Health Plus (BH-P) medical assistance or Children's Health Insurance Program through MEDS for the children. HCS will maintain the COPES case and MEDS will maintain the children's medical.

• Client's child is active on children's medical program through MEDS. A parent applies for COPES or nursing home services. The application for the COPES and/or nursing facility services would be handled by HCS if there is no active program with the local CSO.

• Client active on COPES through HCS and applies for pregnancy medical for their spouse through the MEDS unit.

• Client's child active on a foster care or adoption support program through the 076 Foster Care Unit. (Active D02).

  • E-mail Lori Rolley HCS HQ to coordinate with MPA-Foster Care Unit.  Include client name and client ID.   

  • D02 Foster Care cases remain with 076 until they age out, usually at age 21. 

• Financial staff determines financial eligibility by comparing the client's income, resources, and circumstances to program requirements. 
• The HCS social service specialist, Area Agency on Aging (AAA) case manager,  DDD case manager (CM), or the Veterans Affairs registered nurse (VARN) determines functional eligibility according to the particular program and place of residence and authorizes the services that are appropriate for the plan of care. Both financial and functional eligibility must be established concurrently. Coordination between financial and social service staff is required to process applications and provide services. 
• Financial staff determine eligibility for non-institutional medical assistance at the same time they determine eligibility for institutional, waiver, or hospice services.