Short Stays-Temporary admissions into Medical Facilities
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Short Stays-Temporary admissions into Medical Facilities


Revised September 12, 2014



Purpose: For clients who do not meet institutional status described in WAC 182-513-1320 but meet the functional eligibility requirement and are eligible for a aged, blind, disabled (ABD) SSI related classic Medicaid program, Medicaid under the Foster Care Program or state-funded Medical Care Services (MCS) program. Individuals eligible for Medicaid through the Health Benefit Exchange (HBE) under the Modified Adjusted Gross Income (MAGI) methodology are eligible for nursing facility services, but those services are paid by either the Washington Apple Health managed care plan or fee for service as a claim. No nursing facility award letter is done for individuals eligible for MAGI through the HBE. Nursing facilities bill through the managed care plan for rehabilitation or Provider One for fee for service.

NOTE:

This section is specific to short stay admissions in a nursing facility when an individual is receiving Medicaid under a SSI related/Aged, Blind, Disabled program, Foster care or Medical Care Services (MCS)  program under the A01, A05, S01, S02, S08, S95, S99, G03, G95, G99 or D track program.

For individuals eligible for Medicaid under a MAGI program (N track program) through the Health Benefit Exchange (HBE) no NF award letter is needed.   NF is covered under the N track program with the exception of N21 and N25 (AEM). MAGI clients must meet NFLOC. 


NOTE: 

Individuals residing in a medical institution 30 days or more are considered institutionalized per WAC 182-513-1320.

The short stay screen in ACES has been designed to allow an award letter to be issued through ACES without having to do a program change for individuals eligible under ABD/SSI related medicaid.    Use the short stay time frame chart below to determine time frames allowed to issue a letter using the ACES short stay screen.

Special instructions for NF admissions under Washington Apple Health Managed Care. (formally Healthy Options).

For clients enrolled in Washington Apple Health managed care, do not issue a short stay letter when the client has been admitted to the NF.  Washington Apple Health Managed Care and Long term care  has specific instructions regarding managed care rehabilitation admissions into a NF. 


Short Stays

Some clients temporarily need care in a medical facility such as a nursing facility but it is not needed for a long period of time. 

 

An example is someone on S02, S95 or active S99 medical needing to be in a nursing home for a few days after a fall.  Generally, the financial worker learns of the nursing home admit after the client has already discharged and must issue a historical award letter so the nursing facility can bill DSHS.  Nursing facilities cannot bill the department using a medical id for ABD/SSI related Classic Medicaid or Foster care medicaid. 

 

Clients must meet nursing facility level of care (NFLOC) in order for the department to pay for nursing facility care.  This approval is done by a DSHS designated social worker/case manager.  This is generally done by an HCS social worker but can come from a DDA case manager when placed in a nursing facility or on the Area Agency on Aging (AAA) case manager for MPC cases admitted for a short stay.  A Veteran Registered Nurse or VARN completes the assessment for individuals in VA nursing homes.  Individuals who are on a HCS Waiver going into a nursing home already meet NFLOC. 

 

Short Stay time frames

(For the purposes of using the short stay screen in ACES)

 

Institutional medical programs

 (L01, L02, L04,  L21, L22, L24, L95, L99, , K01, K03,  K95, K99)

29 consecutive days or less.  See below for detailed instructions on the circumstances the short stay screen is used when an individual is active on an institutional program.

Remaining non-institutional Classic medical programs and Medical Care Services (MCS)

(In ACES, S track, G track, D track cases)

29 consecutive days or less

 

Institutional Services Prior Approval Requirements

  • Receiving Medicaid does not automatically entitle recipients to coverage for Long Term Care Services. 

 

  • All  Classic Medicaid recipients needing nursing home and waiver services paid for by Medicaid, even if the need for services is temporary, must be assessed and approved as needing nursing facility level of care before services are authorized in ACES. .

 

  • For nursing home coverage, HCS social services workers complete the brief assessment unless: 
    • The client has elected Hospice via the DSHS Medicaid Hospice Notification. The client has admitted into a VA nursing home.  The VA Registered Nurse (VARN) completes the assessment.
    • The client admits into Providence Children's Hospital in Portland Oregon.  A letter is issued upon admission.  No NFLOC is needed.
    • The client is active on HCS Waiver and already meets NFLOC.

 

Nursing Home Approval and Institutional Start Date

 

Applicants Not Currently Receiving Medicaid

 

  • HCS Social Services must determine if the client is nursing home level of care (NFLOC)
  • If yes, client is NFLOC, the start date can be the date the client is financially eligible AND in the facility receiving services. .
  • If No, client is NOT NFLOC, the client is not eligible for institutional medical services. 

 

Current Medicaid Recipients

 

  • HCS Social Services must determine if the client is nursing home level of care (NFLOC)
  • If yes, the client is NFLOC.
  • The institutional start date is the date the department was first notified of the Medicaid recipient’s admission into a nursing facility.  This notification can be via a DSHS 15-031 from the nursing facility, a request by the client or representative that a client has admitted into a nursing home, or a contact from the nursing facility to an HCS social worker.  The HCS social worker will complete a 14-443 indicating the level of care and the date notified of the admission into the nursing facility.
  • If No, client is NOT NFLOC, the client is not eligible for institutional medical services.  No NF award letter is issued. 

 

Clients who are financially eligible but not functionally eligible (NFLOC) for nursing facility payment do not qualify under Medicaid payment.   Do not issue a nursing facility award letter.   Chapter 10 Nursing Facility relocation and case management describes the process when a medicaid NF resident does not meet NFLOC. 

 

Short Stay-Less than 30 days in a Nursing Facility

 

Clients who do not meet institutional status described in WAC 182-513-1320 but meet the functional eligibility requirement (NFLOC) can have the nursing facility covered if eligible for another Medicaid program.

 

For an active Medicaid recipient or medical care services client,  a medical redetermination is not required for nursing facility admissions under 30 days.

 

See managed care and LTC if the client is enrolled in Washington Apple Health managed care. 

 

Short Stay-Less than 30 days in a Nursing Facility-has not met spenddown

 

For a Medicaid client who has a spenddown base period and has not met their spenddown, the nursing home bill the individual is responsible to pay would be used to meet their spenddown.  The spenddown bill is entered for each day based on the nursing home private daily rate.  The institutional and medicaid eligibility date would be the same date as the spenddown is met.  Once a spenddown is open, the authorized date indicated on the short stay screen is the date the individual met their spenddown.  (see below). A NFLOC is needed for an NF award letter to be issued.


Agency Responsibilities

Institutional eligibility means using institutional rules for eligibility, a client must be institutionalized or projected to be institutionalized 30 days or more to use institutional Medicaid rules).  Institutional Medicaid programs are L and K track. 

 

When HCS is notified of a Classic Medicaid client needing a short stay letter, the financial worker sends a 65-10 to the local HCS social worker requesting a NFLOC when notified by the nursing facility that a client has admitted to their facility.  Set a tickler for the 29th day to check the status.  The short stay screen is not used until the client has discharged from the NF.  

 

The HCS office located in the area of the nursing facility is notified by the facility of the admission.   The HCS social worker is responsible to notify the  financial worker via the 14-443 financial/service communication form of the CA request date and if the client meets NFLOC.  The 14-443 has a section for admission date and discharge date. 

 

The HCS financial worker will notify the HCS social worker for a NFLOC  when a case is active on Classic Medicaid  with the  076 MEDS or foster care unit.  The HCS financial worker will assist the 076 MEDS or Foster Care unit in issuing a short stay letter. 

 

The DDA LTC specialty unit retains cases for non nursing facility medical institutions such as Hospice Care Centers, Hospice admissions into a nursing facility, DDA Rehabilitation Habilitation Centers (RHC), DDA  Institution for Intellectual Disabilities (ICF-ID),

 

Institutions for the Mentally Diseased (IMD) (Eastern and Western State hospital) are handled by specialty financial workers located at the state hospital. 

 

HCS retain cases for clients on an HCS HCB Waiver or MPC services who enter a hospital and they are expected to be discharged back into the community on HCS services within 60 days.

 

If an SSI related client is admitted into a nursing facility and is projected to be in the nursing facility or has been in the nursing facility over 30 days, the HCS office is responsible to do a redetermination of Medicaid using institutional rules.  This includes DDA clients who are admitted into a nursing facility and their stay is over 30 days or expected to beyond 30 days.  On active classic Medicaid cases  the HCS financial worker will request the record from the CSO unless the head of household is receiving TANF cash. 

 

There may be a delay of issuing a nursing facility award letter as a determination is made as to whether the client will be in the nursing facility over or under 30 days.  If a notice of action is received by the HCS office and it is unknown whether Medicaid client will be in the nursing facility over 30 days, an alert will be set to check the status by the 30th day.  A nursing facility would need to wait for the award letter to bill in this instance as a determination is needed as to the correct medical program to consider for eligibility.


Worker Responsibilities



 For applicants:

 

  1. Determine eligibility for Medicaid as if he/she lives in his/her own home based for individuals who have a under 30 day admission into a nursing facility. 
  2. Consider the income and resources of family members who would be in the client's assistance unit if he/she lived at home.
  3. Use the standard based on the number who would be in the assistance unit if he/she lived at home.
  4. Once eligibility for medical, request a NFLOC determination from the HCS social worker using the 65-10.  This is needed in order to issue a NF award letter using the STAY screen. 

 

     For applicants and recipients:

  1. Request a NFLOC determination from the HCS social worker assigned to the nursing facility using the 65-10. 
  2. See Washington Apple Health Managed Care ( formally Healthy Options_ and LTC  for additional instructions on managed care admissions.  Do not issue a short stay letter for clients enrolled in managed care upon admission to the NF. 
  3. When verification from a HCS social worker is received that a Medicaid eligible client meets NFLOC generate an ACES LTC approval letter showing zero participation to the nursing facility. The institutional date on the letter is based on the 1st date the department was notified by the nursing facility of the admission. The medical date is day of the month eligible for the Medicaid. This date is usually on the 1st day of the month unless it is a general assistance unemployable client where the medical starts the date of eligibility or if a client meets a spenddown on a day other than the 1st. The nursing facility name and address must show in the address of the generated letter. The nursing home, client and client's representative all need a copy of the nursing home award letter. Nursing homes must have an award letter in order to bill the department for Classic Medicaid programs. 
  4. Clients eligible for a non SSI related Medicaid program do not need to meet aged/blind/disabled criteria for a short stay nursing home letter to be issued.  Clients must meet NFLOC in order for the department to issue an award letter to the nursing home.  This includes state funded medical programs.  The exception is the pre-approval process for the state funded nursing facility program for non-citizens (45 slot program).
  5. Once a client meets institutional status described in WAC 182-513-1320, institutional rules must be used for eligibility. 

See additional instructions for Washington Apple Health Managed Care  NF admissions


Nursing Facility admissions for clients active on a HCB Waiver under 30 days

1. Clients on a HCB Waiver already meet NFLOC. 

2. The STAY screen is used for L21 and L22 in the following circumstances:

  • The client is on COPES in an ALF, goes into a NF for a short stay and returns to the same ALF. 
  • The client is on COPES at home, goes into a NF for a short stay and returns home

ACES Processing of Short Stays

ACES-Short Stay

Screens in ACES - Short Stay-STAY screen

Screens in ACES - Short Stay Cost of Care - SSCC screen

Modification Date: September 12, 2014