Institutional Status
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Institutional Status

Revised April 25, 2013

Long-term care
Purpose:
WAC 182-513-1320Determining institutional status for long-term care (LTC) services

WAC 182-513-1320

WAC 182-513-1320

Effective January 1, 2013

WAC 182-513-1320 Determining institutional status for long-term care (LTC) services

  1. Institutional status is an eligibility requirement for long-term care services (LTC) and institutional medical programs.  To attain institutional status, you must:
    1. Be approved for and receiving home and community based waiver services or hospice services; or
    2. Reside or based on a department assessment is likely to reside in a medical institution, institution for mental diseased (IMD) or inpatient psychiatric facility for a continuous period of:
      1. Thirty days for if you are an adult eighteen and older;
      2. Thirty days if you are a child seventeen years of age or younger admitted to a medical institution; or
      3. Ninety days if you are a child seventeen years of age or younger receiving inpatient chemical dependency or inpatient psychiatric treatment.
  2. Once the department has determined that you meet institutional status, your status is not affected by:
    1. Transfers between medical facilities; or
    2. Changes from one kind of long-term care services (waiver, hospice or medical institutional services) to another.
  3. 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 a client requires LTC services.  A client attains institutional status when the need for inpatient services in a medical institution is 30 days or more. 

A client attains institutional status when he/she:

  • Resides continuously in a medical institution for 30 consecutive days or longer; or
  • Is likely to remain in a medical institution for 30 consecutive days or longer; or
  • Receives a home and community based (HCB) Waiver service through DDD or HCS.

A client loses institutional status when he/she:

  • Is absent from a medical institution for at least 30 days, or
  • Does not receive HCB Waiver services for at least 30 days from DDD or HCS

"Likely to remain" means there is a reasonable expectation the client will be in a medical institution for 30 consecutive days or longer.  Once made, the determination holds even if the client does not actually remain institutionalized for 30 consecutive days.  If an admission into a medical institution is expected to last under 30 days for an evaluation, brief rehabilitation based on current information, then institutional medicaid rules cannot be used. 

For nursing facilities, the HCS social service worker gives the best projection possible as to whether the client is projected to be in the facility 30 days or more along with a determination of nursing facility level of care (NFLOC). 

For State Veteran's nursing facility, the Veteran's Affairs Registered Nurse (VARN) gives the best projection possible as to whether the client is projected to be in the facility 30 days or more along with a determination of nursing facility level of care (NFLOC). 

For State IMD Hospitals, IMD social service or nursing staff give the best projection possible as to whether the client is projected to be in the facility 30 days or more. 

The combination of Waiver services, admission into a medical institution, hospitalization, etc. counts toward the 30 day institutionalization if there is no break in service.

What is a Medical Institution?

Not every facility is considered a medical institution.  Assisted living, Enhanced Adult Residential Centers (EARC), Adult Residential Centers (ARC), DDD group homes and Adult Family Homes are not considered a medical institution.  Clients can be receiving institutional HCB Waiver services in these facilities.

WAC 182-500-0050 defines a medical institution. 


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.  

NOTE:

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

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

Worker Responsibilities

Obtain the determination of whether the client is likely to remain institutionalized for 30 consecutive days from the department-designated social service specialist.

For nursing facility cases, the HCS social service specialist 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.  

For active medicaid clients who lose institutional medicaid status due to discharge from a medical institution or no longer receiving a HCB Waiver service, redetermine eligibility under a non institutional medicaid program.

Children discharged from a medical institutional under the K01 program are given continuous eligibility under the F06 program to the next review.

ACES PROCEDURES

K track is used for institutional children and families.

L track is used for Aged/Blind/Disabled institutional and waiver programs.

See Long Term Care and Waiver Services

Modification Date: April 25, 2013