Institutional Status

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Institutional Status

Revised September 2, 2009

Long-term care

Purpose:

WAC 388-513-1320 Determining institutional status for long-term care (LTC) services

WAC 388-513-1320
WAC 388-513-1320
Effective April 10, 2009

WAC 388-513-1320 Determining institutional status for long-term care (LTC) services

Institutional status is an eligibility requirement for long-term care services (LTC) and institutional medical programs. To attain institutional status, you must:

Be approved for and receiving home and community based waiver services or hospice services; or

Reside or be likely to reside in a medical institution, institution for medical diseased (IMD) or inpatient psychiatric facility for a continuous period of:

Thirty days for if you are an adult eighteen and older;

Thirty days if you are a child seventeen years of age or younger admitted to a medical institution; or

Ninety days if you are a child seventeen years of age or younger receiving inpatient chemical dependency or inpatient psychiatric treatment.

Once the department has determined that you meet institutional status, your status is not affected by:

Transfers between medical facilities; or

Changes from one kind of long-term care services (waiver, hospice or medical institutional services) to another.

If you are absent from the medical institution or you do not receive waiver or hospice services for at least thirty consecutive days, you lose institutional status.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying Information
The term, "institutional status," refers to a minimum period of time for which a client requires LTC services. A client attains this status when the need for inpatient services is equal to or greater than the number of days defined in WAC 388-513-1320. A client who is approved for waivered or hospice services and is receiving such services has also achieved institutional status.

Institutional programs in ACES are under the K, C and L track.

A client attains institutional status when he/she:

Resides continuously in a nursing facility/hospital/state institution for 30 days or longer; or

Is likely to remain in a nursing facility/hospital/state institution for 30 consecutive days or longer.

Receives waiver program services through DDD or HCS.

Medical Institutions

Not every facility is considered a medical institution. Assisted living, adult family home, boarding home, DDD Group homes are not considered medical institutions, but clients can be receiving an institutional (Waiver) program in these facilities.

This is a list of medical institutions:

Hospital

Institution for the Mentally Diseased (IMD) (Western and Eastern State Hospitals)

Intermediate Care Facilities for the Mentally Retarded (ICF-MR) (DDD facilities)

Nursing Facility (NF)

Veteran's Home-nursing facility section

Hospice Care Center

Rehabilitation Habilitation Centers (RHC) (DDD facilities)

Medicaid Personal Care (MPC) is not considered an "institutional" program.

MPC eligibility is tied to non institutional categorically needy (CN) Medicaid eligibility.

NOTE:
"Likely to remain" means there is a reasonable expectation the client will be in a nursing facility/hospital/state institution/hospice care center for 30 consecutive days or longer. Once made, the determination holds, even if the client does not actually remain institutionalized for 30 consecutive days. For nursing facilities, the HCS social worker gives the best projection possible as to whether the client is projected to be in the facility 30 days or more.

A client loses institutional status when he/she is absent from a medical institution for at least 30 days , or

Does not receive waiver program services for at least 30 days from DDD or HCS.

NOTE: Hospice services can be received in a medical facility or in conjunction with waiver services. They are a group of services provided to a client who is terminally ill. Hospice services do not constitute a waiver program but waiver rules can be used for hospice medicaid eligibility. If residing in a medical institution 30 days or more (nursing facility, hospital, hospice care center) institutional rules must be used See hospice.

Worker Responsibilities
Obtain the determination of whether the client is likely to remain institutionalized for 30 consecutive days from the department-designated social worker (SW).

For nursing facility cases, the HCS SW notifies financial of the date of request for assessment, whether the client is projected to be in a nursing facility 30 days or more and if the client meets nursing facility level of care (NFLOC).

For clients who meet both 30 day or more institutionalization and NFLOC, institutional Medicaid is considered.

For clients who do not meet the 30 day or more institutionalization, institutional Medicaid cannot be considered. Eligibility for Medicaid is determined as if the client were in their own home. If the client is eligible for another Medical program, the admission into the medical institution is considered a short stay (30 days or less). SEE SHORT STAYS.

ACES PROCEDURES
See Long Term Care and Waivered Services

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