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CHAPTER 2 - LONG-TERM CARE/IMPOVERISHED SPOUSE

INTRODUCTION 2.1

In addition to meeting the needs of families and individuals who reside in the community, the MA program provides coverage of some or all of the costs of care for persons who reside in certain LTC facilities.

In order to receive coverage, LTC residents must establish both MA eligibility and LTC eligibility (also referred to as payability). Individuals eligible for MA but over-income are eligible for LTC coverage. The LTC Eligibility Unit handles all LTC cases. The LTC unit determines MA eligibility for LTC residents (if they have not already established MA eligibility) and payability. Exhibit VII-2: Diagram of LTC Processing depicts how LTC processing differs depending on how the LTC resident enters LTC status.

LTC residents are eligible for additional income allowances when determining LTC eligibility or payability; these additional income allowances are used in the calculation of the Patient Pay Amount (PPA). The PPA is another way in which LTC differs from standard MA. Unlike standard MA coverage, eligible LTC residents often contribute to their cost of care by paying the PPA.

LTC residents also spend-down their income in a different manner than in standard MA. Unlike standard MA where total countable income must meet a certain standard, LTC spend-down is governed by the comparison of the PPA to the cost of care rate.

LTC facilities are licensed by the District and have provider agreements with the Department. Types of LTC facilities authorized to accept District residents who are eligible for LTC coverage include:

 nursing facilities,  intermediate care facilities for the mentally retarded (ICF/MR),  institutions for mental diseases (person under age 21 or age 65 or older only), and  certain youth residential treatment facilities.

For the purposes of this chapter, the following terms are used:

 LTC recipient: an individual who and residing in a LTC facility;  institutionalized spouse: an individual who is married and is: o residing in a LTC facility, o likely to be hospitalized for at least 30 days, or o likely to reside either in a hospital or a LTC facility for at least 30 consecutive days;

 community spouse: an individual who is married to an institutionalized spouse and who is living in the community, and  family member: any minor or dependent child, dependent sibling, or dependent parent of the institutionalized spouse or community spouse who is claimed as a dependent for tax purposes.

Example Mr. Newman is married and enters the hospital on June 25th. His doctors expect that he will be discharged on July 10th to a LTC facility and that he will stay at the LTC facility for three weeks. Even though he is expected to stay in the hospital for only 15 days, he is considered an institutionalized spouse because he is likely to spend a total of 36 days in either a hospital or a LTC facility.