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.