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UPDATED: JANUARY 2012

549.1

OTHER ELIGIBILITY REQUIREMENTS

MAINTAINING MEDICAID ELIGIBILITY FOR INDIVIDUALS ADMITTED TO A PSYCHIATRIC CENTER

Description: Generally, Medicaid coverage must be suspended for recipients age 21-64 admitted to a psychiatric center and reinstated at the time of release from such facility.

Policy: When a district is notified that a Medicaid recipient age 21-64 is a resident of a psychiatric center, the district must suspend Medicaid coverage, barring certain exceptions. Upon notification of discharge from the psychiatric center, Medicaid coverage must be reinstated in the district of fiscal responsibility immediately prior to admission.

NOTE: Districts will be notified of admissions and discharges from State Operated Psychiatric Centers by the State Department of Health in conjunction with the Office of Mental Health (OMH). However, should a district become aware that an individual age 21-64 has entered a private (non-state operated) psychiatric hospital, Medicaid coverage must also be suspended and re-instated.

References: SSL Sect.

365.2 (a) & (b)

366 (1) (c) & (d)

Dept. Regs. 360-3.4 (a) (2)

ADMs

11 OHIP/ADM-3

INFs

89 INF-43

Interpretation: Suspension of Medicaid:

On a monthly basis DOH will run a file provided by OMH to identify individuals age 21-64 who have been in a State psychiatric center for at least 30 days and have an active Medicaid/FHPlus case.

Medicaid must be suspended for Case Type 20 (MA) recipients with one of the following Coverage Codes: 01 (Full), 02 (Outpatient), 06 (Provisional), 10 (All Services Except Nursing Facility Services), 11 (Legal Alien), 15 (Perinatal), 18 (Family Planning Services Only), 19 (Community Coverage With Community-Based Long-Term Care), 20 (Community Coverage Without Long-Term Care), 22 (Outpatient Coverage Without Long-Term Care), 21 (Outpatient Coverage With Community-Based Long-Term Care), 23 (Outpatient Coverage With No Nursing Facility Services), 24 (Community Coverage Without Long- Term Care, Legal Alien During Five-year Ban, NYC only), and 30 (Pre- paid Capitation Plan). Also, Family Health Plus (FHPlus) coverage will (MRG)