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TITLE 16 HEALTH AND SAFETY DELAWARE ADMINISTRATIVE CODE 1 DEPARTMENT OF HEALTH AND SOCIAL SERVICES Division of Social Services Division of Social Services 20000 Medicaid Long Term Care 20100 Long Term Care Introduction Programs under Long Term Care (LTC) Medicaid include: • Diamond State Health Plan Plus • Nursing Facility Program • Long Term Care Community Services • Program of All-inclusive Care for the Elderly (PACE) • Developmentally Disabled Waiver • Long Term Acute Care Program Common to all long term care programs is the requirement to be medically and financially eligible. 15 DE Reg. 1716 (06/01/12) 20100.1 Nursing Facility Program - General Information Persons who need nursing facility care, and who would be eligible for SSI if they were not institutionalized, are eligible for Medicaid. Nursing facility care may be needed if an individual is too disabled to be cared for in a home care situation but does not need acute care hospitalization. 20100.2 Categorically Eligible Groups 20100.2.1 SSI Recipients 20100.2.2 Individuals Whose Income is 250% of SSI 20100.2.3 Institutionalized Individuals Who Were Eligible in December 1973 20100.2.1 SSI Recipients Residents of skilled or intermediate nursing facilities who would be eligible for SSI if they were not institutionalized, are eligible for Medicaid. DSS does not make the SSI eligibility determination. If an individual has less than $50.00 income, she/he may be eligible for an SSI payment while in the institution. In this case, the client may be requested to make an application for eligibility determination. 20100.2.2 Individuals Whose Income is 250% of SSI Effective 1/1/96, two income limit standards will be applied to the LTC Acute Care Program. The 250% standard applies only to nursing facility residents. Individuals hospitalized for 30 consecutive days may be eligible only if their monthly income is 100% of the SSI standard or less. Effective October 1, 1994, the eligibility standard for individuals in nursing facilities and HCBS Waiver programs became 250% of the SSI standard. On October 1, 1993, the eligibility standard for individuals in nursing facilities was raised to 230% of the current SSI standard. The income standard had been at 210% of the SSI standard since January 1, 1991. All other SSI standards (resources, living arrangements, etc.) apply to this group of eligibles. For cases prior to 1/1/96, in accordance with Public Law 99-272, the 250% standard starts with the beginning of any consecutive 30-day period of institutionalization (nursing facility or hospital or combination of both) counting only the date of admission and not the date of discharge. For example, if a patient enters an institution on July 2nd and is continually institutionalized until August 2nd, eligibility is based on the 250% standard from July 2nd on. Workers may assume, when an applicant enters a nursing facility, that the applicant will remain institutionalized for 30 consecutive days and authorize vendor payment. This assumption can only be made for nursing facility placement and does not apply to hospitalization. Vendor payment cannot be authorized unless the individual's income is below the SSI standard or the individual has been or is assumed will remain institutionalized 30 consecutive days. 20100.2.3 Institutionalized Individuals Who Were Eligible in December 1973 Federal Regulation 42 CFR 435.132 The agency must provide Medicaid to individuals who were eligible for Medicaid in December 1973, or any part of that month, as inpatients of medical institutions or residents of intermediate care facilities that were participating in the Medicaid program and who: For each consecutive month after December 1973

Office of the Registrar of Regulations, Legislative Council, State of Delaware