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The policies in this chapter apply to LTC recipients and institutionalized spouses. However, the income and assets of institutionalized spouses who have a community spouse are treated differently if the institutionalized spouse was institutionalized after September 30, 1989. The income and asset allowances and deductions are designed to prevent the impoverishment of the community spouse. The policies regarding institutionalized spouses who have a community spouse and who entered a LTC facility after September 30, 1989 are referred to as the "Impoverished Spouse" provisions. For the purposes of this chapter, Impoverished Spouse provisions, which apply only to institutionalized spouses who entered a LTC facility after September 30, 1989 and who have a community spouse, will be set off by the italicized heading Impoverished Spouse. Unless otherwise noted, the policies in this chapter also apply to those individuals eligible for the Impoverished Spouse provisions.

Because there are very few individuals currently in LTC who were institutionalized before October 1, 1989 and have a community spouse, Exhibit VII-3: Provisions for Pre-October 1989 Institutionalization lists how policies are to be adjusted for these individuals by section. However, unless otherwise noted, the policies in this chapter also apply to these individuals.

The policies in this chapter supersede any MA policy which is inconsistent with these policies. The policies apply the first month the individual resides in a LTC facility and is MA-eligible and cease the first full calendar month following changes in circumstances (i.e., if changes occur in November, these policies would not apply in December).

LEGAL AUTHORITY 2.2

AREA/TOPIC DISTRICT FEDERAL Long-Term Care MA: 42 USC 1396a(a)(10); 42 USC 1396a(q)-(r); 42 USC 1396r; 42 USC 1396r-5; 45 CFR 435.700; 45 CFR 435.725; 45 CFR 435.726

MEDICAL CERTIFICATION FOR LTC 2.3

The Medical Assistance Administration (MAA), a part of DOH, certifies the individual's medical need for LTC prior to approval of coverage of the costs of care.

The MAA is responsible for:

 reviewing the medical documentation from the individual's physician, the acute hospital arranging the placement, or other competent medical authority to determine the level of care appropriate to the individual's needs; and  notifying the appropriate LTC facilities of the individual's level of care.

The facility which accepts the individual submits a Patient Start of Care Notice and a Level of Care Notice to the LTC Eligibility Unit in IMA indicating the assigned level of care and the date of admission or date of transfer to MA status.

The PSRO (at DOH) reviews the level of care determinations periodically. If the patient's medical needs change significantly and a different level of care is determined, the individual may be transferred to a different facility or discharged to a community placement. The PSRO submits a new level of care and the effective date of the change to the facility which in turn submits the information to the LTC Eligibility Unit.