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MEDICAL SERVICES POLICY MANUAL,SECTION F F 100 Non Financial Eligibility Requirements

Redetermination of Functional Need The DPSQA Office of Long-Term Care (OLTC) will periodically review and redetermine patient classification and necessity for continued stay in a facility when required. Classification and functional need reviews will be made only for individuals whose condition changes and for those admitted for convalescent care. When OLTC finds that reclassification of a recipient is warranted, the reclassification information will be provided to the facility and to the eligibility worker who will make an adjustment to the vendor payments. When continued stay in a facility is determined not to be functionally necessary including a determination due to a PASARR evaluation, OLTC will notify the facility administrator and the County Office by sending the DHS-0704. If it is a PASARR determination, OLTC will notify the recipient or their legal guardian by letter. Recipients determined not in need of facility services will be allowed thirty (30) calendar days continued facility eligibility to arrange for relocation.

F-152 DCO Institutional Status MS Manual 01/01/22 Evidence of institutional status includes without limitation, any written document or record from a hospital or nursing facility that verifies that the individual was in the hospital or nursing facility for thirty (30) consecutive calendar days. Refer to MS F-150.

When an individual cannot meet the institutional status requirement, the application will be denied, unless the individual dies before meeting the thirty-day requirement. In that case, certification may be made for the actual days spent in the facility. With medical documentation, such as a physician’s statement, hospital records, etc., that the patient is “likely to remain” in the institution or facility for a period of thirty (30) days, the rules may be applied and the individual may be certified, if the individual is otherwise eligible, before a period of thirty (30) days has passed. If the case was opened and the patient does not remain institutionalized thirty (30) days, no penalty will be imposed on the patient if there is likely to remain documentation in the case record. “Likely to remain” applies only to individuals in facilities with community spouses. Single individuals must meet the thirty (30) day institutionalization requirement.