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Aged, Blind, and Disabled Manual; Section: Institutional Medicaid; Policy Manual Number: 125.005; Chapter: INSTITUTIONAL STATUS
Legal Authority: 42 CFR 435.1009; 42 CFR 435.1010; 42 CFR 435.236; 42 CFR 435.622; Tenn. Comp. R. & Regs. 1200-13-20-.08
1. Policy Statement
An individual must be institutionalized in order to receive benefits in the Institutional Medicaid category.
An individual is considered institutionalized when he has:
a. Been admitted to a medical institution (i.e. hospital, Nursing Facility (NF) or Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID)), and has been continuously confined for at least 30 days or admitted to a medical institution for hospice services; b. Been admitted to a Nursing Facility (NF) or Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) and has been or determined by TennCare to be likely to be continuously confined for at least 30 days going forward; c. Applied to enroll in the Home and Community-Based Services (HCBS) waiver program, and has been determined to need and likely to receive services for a continuous period of at least 30 days going forward as demonstrated by an approved PAE in an applicable Level of Care; or d. Died while in long-term care nursing facility prior to meeting the 30 days continuous confinement requirement.
2. Continuous Confinement
a. Individuals with a Pre-Admission Evaluation (PAE)
An individual with a PAE is considered continuously confined when she has:
i. Been admitted to a NF or ICF/IID and has been determined by TennCare to be likely to be continuously confined for at least 30 days going forward, demonstrated by an approved PAE which is effective for at least 30 days ii. Been admitted to a NF or ICF/IID and the period of time spent in a medical institution combined with the period of time for which an approved PAE is effective exceeds 30 days; or iii. Been determined to need and likely to receive HCBS for a continuous period of at least 30 days going forward, demonstrated by an approved PAE and a CHOICES Enrollment form.