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Institutional status

Revised Date:

February 14, 2018

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

Effective February 17, 2017

To attain institutional status outside a medical institution, a person must be approved for and receive:
1. Home and community based (HCB) waiver services under chapter 182-515 WAC;
2. Roads to community living (RCL) services under WAC 182-513-1235;
3. Program of all-inclusive care for the elderly (PACE) under WAC 182-513-1230;
4. Hospice services under WAC 182-513-1240(3); or
5. State-funded long-term care service under WAC 182-507-0125.
To attain institutional status in a medical institution, a person must reside in a medical institution thirty consecutive days or more, or based on a department assessment, be likely to reside in a medical institution thirty consecutive days or more.
Once a person meets institutional status, the person's status is not affected if the person:
1. Transfers between medical facilities; or
2. Changes between any of the following programs: HCB waiver, RCL, PACE, hospice or services in a medical institution.
A person loses institutional status if the person is absent from a medical institution, or does not receive HCB waiver, RCL, PACE, or hospice services, for more than twenty-nine consecutive days.

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 person requires LTC services. An individual attains institutional status when the need for inpatient services in a medical institution is 30 days or more.

A person attains institutional status when they:

Reside continuously in a medical institution for 30 consecutive days or longer;
Are likely to remain in a medical institution for 30 consecutive days or longer; or
Receives a home and community based (HCB) waiver service through DDA or HCS.
Receives program of all-inclusive care for the elderly (PACE); or
Elects hospice services; or
Receives state-funded long-term care for noncitizens.

A person loses institutional status when they:

Are absent from a medical institution for at least 30 consecutive days, or
Doesn't receive DDA or HCS HCB waiver services, PACE, hospice, or state-funded long term care for noncitizens for at least 30 days.

"Likely to remain" means there is a reasonable expectation the person will be in a medical institution for 30 consecutive days or longer. Once made, the determination holds even if the person doesn't 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 can't be used.

For nursing facilities, the HCS social service worker gives the financial worker by the 14-443 as to whether the person 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 person is going to remain in the facility 30 days or more along with a determination of NFLOC.

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

For DDA institutions, the DDA case manager gives the best projection possible as to whether the person is going to remain in the facility 30 days or more along with a ICF-ID level of care.

The combination of HCB Waiver services, Hospice, state funded LTC for noncitizens or 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), DDA 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 an individual 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) and Community First Choice (CFC) are not considered "institutional" programs.
MPC and CFC-only eligibility is tied to noninstitutional categorically needy (CN) medicaid.

Worker Responsibilities

Obtain the determination of whether the person is likely to remain institutionalized for 30 consecutive days from the department-designated social service worker or case manager.

For nursing facility cases, the HCS social service worker notifies financial of the date of request for assessment, whether the person is projected to be in a nursing facility 30 days or more and if the person meets NFLOC.

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

For individual persons who don't meet the 30 day or more institutionalization, institutional Medicaid can't be considered. Eligibility for Medicaid is determined as if the person were in their own home. If the person is eligible for another Medical program, the admission into the medical institution is considered a short stay (29 days or less). See Short Stays.

For active Apple Health 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 noninstitutional medical program.

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