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State of Maryland Medical Assistance Manual Revised April 2014

For a person who has resided in the LTCF less than 30 days, the CM must determine if the person is likely to remain for 30 consecutive days. This information may be obtained from the person’s physician, a social worker who is familiar with the person’s current medical condition and living arrangement, or the Utilization Control Agent. Documentation that has been collected to determine other eligibility factors may be used to determine if the person is expected to be in LTC for at least 30 consecutive days. Examples: Physician’s Report (DHMH 4245) LTC Patient Activity Report (DHMH 257) Notice of Medical Review Decision (DHMH 4246 (LTC)). If these documents do not establish that the person is expected to remain at least 30 consecutive days, a written statement must be obtained from a knowledgeable source (physician, social worker, or the Utilization Control Agent. This statement must include the name of the person in LTC, date of admission, anticipated length of stay, and the name, title, and dated signature of the person making the statement. The statement must be based on recent medical and social data available to the writer. A period of institutionalization is interrupted by absences from the LTCF of 30 consecutive days. When a person is discharged from the LTCF to an acute hospital, institutional status is not interrupted regardless of the length of hospital stay. Transfer from one LTCF to another does not interrupt institutional status. A person who was considered institutionalized based on the documentation described above, and who is subsequently discharged to the community before actually residing in the LTCF for 30 consecutive days, does not lose institutional status until the first full month after discharge. Any institutionalized person who is discharged to the community loses institutional status in the first full month after discharge unless readmitted within 30 days of the date of discharge. Upon readmission to an LTCF after an absence of 30 days or more, a new period of institutionalization begins. An unmarried person under 21 is considered institutionalized when he/she: • Resides in a licensed and certified long term care facility (LTCF); • Resided there on the first day of the month and throughout the entire month; and • Has a medical need for Long Term Care (LTC). Any person who does not meet all of the above criteria cannot be considered institutionalized and that person’s eligibility must be determined under Section 900. LTC is considered a medical need when a person requires an intermediate, skilled or chronic level of care. Residence in the LTCF and level of care are verified by the Utilization Control Agent (UCA), a private organization that is contracted by the Department to provide this information to the LDSS. Licensed and certified LTCFs are listed in Schedules MA-4 and MA-5. A person’s institutional status is not interrupted by: • Medicare or other health insurance coverage;