Adult Medicaid Manual MA-2270 LONG TERM CARE NEED AND BUDGETING

II. WHEN TO USE LTC BUDGETING

Use LTC budgeting when a person meets all of the criteria below.

A. The a/r must have begun a continuous period of institutionalization (CPI). The definition of CPI is 30 consecutive days in a medical facility or combination of two or more medical facilities. If the individual in one of these facilities is discharged home or to an adult care home during the first 30 days, there is no CPI. The CPI continues if the a/r is discharged from a Medicaid facility but returns within 30 days.

Once a CPI has been established, it can end when the a/r has been discharged from the medical facility for 30 consecutive days. If the a/r returns to a medical facility for 30 consecutive days then a new CPI begins from that date.

A continuous period of institutionalization begins the first day:

1. The a/r enters a medical facility from a private living arrangement or an adult care home. A medical facility is an institution that primarily provides inpatient medical care (not residential care). A medical facility could be:

a. A Medicare-Medicaid certified nursing facility, ICF-MR, Skilled nursing facility (SNF), or SNF Rehab. (Refer to III. if the facility is not yet certified.)

NOTE: A hospice recipient is considered long term care if the person is admitted to a hospice inpatient facility or is a patient in a hospital/nursing facility under contract with hospice. If not an inpatient, budget PLA.

b. Skilled nursing care in a general hospital (called a swing bed or inappropriate level of care bed).

c. Psychiatric unit in a state mental hospital (Dix, Broughton, Umstead, and Cherry) when the a/r is:

(1) Age 65 or older, or

(2) Under age 21, or

(3) Under age 22, and had 21st birthday while a patient in the state mental hospital.

REISSUED 11/01/07 – CHANGE NOTICE 25-07

(II.A.1.d)

d. Psychiatric Residential Treatment Facility (PRTF) when the a/r is:

(1) Under age 21, or

(2) Under age 22, and had his 21st birthday while a patient in the psychiatric residential treatment facility.

e. General/Acute Care Hospital

OR

2. The a/r is admitted to a general/acute care hospital, psychiatric unit of a state mental hospital, or PRTF and his inpatient stay (of any length) ends with a direct move to one of the medical facilities listed in II.A.1.a. or 1.b. above,

OR

3. The a/r is admitted to a general/acute care hospital, psychiatric unit of a state mental hospital, or PRTF and his inpatient stay exceeds 30 continuous days, regardless of whether he goes home or into an adult care home.

B. The a/r must have a completed FL-2/MR-2, if required, with at least telephone prior approval. The FL-2 may also be an electronic version and should be printed and put in the record. (See Table D) The county DSS may accept telephone and fax verification of the prior approval from the facility. The IMC must document who he spoke with, that person’s position, the facility he works with and the service review number (SRN).

The hospital social worker, county dss, medical facility representative, physician or Local Management Entity (LME) must initiate and complete an FL-2/MR2. The FL-2 is forwarded to the Claims Processing Contractor Prior Approval Unit and the MR-2 is forwarded to the Murdoch Center for approval (refer to XV., below). The FL-2 is the Long-Term Care Services prior approval form and the MR-2 is the Mental Health Services prior approval form. It gives a summary of the patient's medical requirements. Medicaid will help to pay cost of care for an eligible individual with an approved FL-2/MR-2. FL-2 is required for a swing bed.

FL-2/MR-2 is not applicable to psychiatric residential treatment facilities. PRTF services have a separate prior approval process. The county department of social services is not responsible for PRTF prior approval. Do not delay long term care budgeting for PRTF approval.

C. Effective date of LTC Budgeting

Long Term Care Budgeting begins:

1. The month after the CPI begins when placed in a Medicaid certified nursing facility or swing bed or inappropriate level of care bed in a general hospital.

2. The month after the CPI begins when the a/r is admitted to a general/acute care hospital, psychiatric unit of a state mental hospital, or PRTF and his inpatient stay (of any length) ends with a direct move to one of the medical facilities listed in II.A.1.a. or 1.b. above.

REISSUED 11/01/11 – CHANGE NOTICE 17-11

(II.C.)

3. The month following the month of the 30th continuous inpatient day when placed in a general/acute care hospital, psychiatric unit of a state mental hospital, or PRTF.

For example, an a/r enters a general/acute care hospital on March 18^th. The 30^th continuous inpatient day is April 16^th. Long-term care budgeting begins May 1^st.