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Short Stays-Temporary admissions into Medical Facilities

Revised October 28, 2007

Purpose: For clients who do not meet institutional status described in WAC 388-513-1320 but meet the functional eligibility requirement and are eligible for a Medicaid program.

Short Stays Some clients temporarily need care in a medical facility such as a nursing facility but it is not needed for a long period of time.    An example is someone on COPES or active S99 medical needing to be in a nursing home for a few days after a fall.  Generally, the financial worker learns of the nursing home admit after the client has already discharged and must issue a historical award letter so the nursing facility can bill DSHS.  Nursing facilities cannot bill the department using a medical id.    Clients must meet nursing facility level of care (NFLOC) in order for the department to pay for nursing facility care.  This approval is done by a DSHS designated social worker/case manager.  This is generally done by an HCS social worker but can come from a DDD case manager when placed in a nursing facility or on the Area Agency on Aging (AAA) case manager for MPC cases admitted for a short stay.   Short Stay time frames (For the purposes of using the short stay screen in ACES)   Institutional medical programs (C01, ,L01, L02, L95, L99, I01, K01, K95, K99) Up to 60 consecutive days Most non-institutional medical programs and General Assistance 29 consecutive days or less TANF and Refugee assistance 90 consecutive days or less     Institutional Services Prior Approval Requirements Receiving Medicaid does not automatically entitle recipients to coverage for Long Term Care Services.    All recipients needing nursing home and waiver services paid for by Medicaid, even if the need for services is temporary, must be assessed and approved as needing nursing facility level of care before services are authorized in ACES.  This includes clients receiving Medicaid while on TANF, GA, or any non-institutional medical program.   For nursing home coverage, HCS social services workers complete the assessment.     Nursing Home Approval and Institutional Start Date   Applicants Not Currently Receiving Medicaid   HCS Social Services must determine if the client is nursing home level of care (NFLOC) If yes, client is NFLOC, the start date can be the date the client is financially eligible AND in the facility receiving services. . If No, client is NOT NFLOC, the client is not eligible for institutional medical services.    Current Medicaid Recipients   HCS Social Services must determine if the client is nursing home level of care (NFLOC) If yes, the client is NFLOC. The institutional start date is the date the department was first notified of the Medicaid recipient’s admission into a nursing facility.  This notification can be via a DSHS 15-031 from the nursing facility, a request by the client or representative that a client has admitted into a nursing home, or a contact from the nursing facility to an HCS social worker.  The HCS social worker will complete a 14-443 indicating the level of care and the date notified of the admission into the nursing facility. If No, client is NOT NFLOC, the client is not eligible for institutional medical services.   Clients who are financially eligible but not functionally eligible (NFLOC) for nursing facility payment do not qualify under Medicaid payment.   Do not issue a nursing facility award letter.   Nursing facilities may make a request for A-19 payment through the budget and finance unit at ADSA Headquarters to cover up to 30 days.       Short Stay-Less than 30 days in a Nursing Facility   Clients who do not meet institutional status described in WAC 388-513-1320 but meet the functional eligibility requirement (NFLOC) can have the nursing facility covered if eligible for another Medicaid program.   For an active Medicaid recipient or active general assistance client, a medical redetermination is not required for nursing facility admissions under 30 days.   Short Stay-Less than 30 days in a Nursing Facility-has not met spendown   For a Medicaid client who has a spenddown base period and has not met their spenddown, the nursing home bill the individual is responsible to pay would be used to meet their spenddown.  The institutional and medicaid eligiblity date would be the same date as the spenddown is met.  Once a spenddown is open, the authorized date indicated on the short stay screen is the date the individual met their spenddown.  (see below). A NFLOC is needed for an NF award letter to be issued.

Agency Responsibilities Clients who are active on Medicaid in the CSO are issued a nursing facility award letter by the CSO for short stay under 30 day admissions.  There is no institutional eligibility determination needed by HCS.  (Institutional eligibility means using institutional rules for eligibility, a client must be institutionalized or projected to be institutionalized 30 days or more to use institutional Medicaid rules).  Institutional Medicaid programs are L, C and K track.    The HCS office located in the area of the nursing facility is notified by the facility of the admission.   The HCS office is responsible to notify the CSO financial worker via the 14-443 financial/service communication form of the CA request date and if the client meets NFLOC.  The 14-443 has a section for admission date and discharge date.    The HCS office will notify the CSO or 076 MEDS office when a short stay under 30 day letter is needed.    The CSO retain all records that are active TANF related or children/family related Medicaid.    The CSO retain cases for non nursing facility medical institutions such as Hospitals, Hospice Care Centers, Hospice admissions into a nursing facility, DDD Rehabilitation Habilitation Centers (RHC), DDD Institution for Mentally Retarded (IMR), Institutions for the Mentally Diseased (IMD).   Active cases with the 076 MEDS unit are retained by the MEDS unit.  HCS and MEDS share cases when a case is maintained by 076 MEDS and a parent in the household is in need of nursing home or HCS waiver services.    076 MEDS is responsible to issue an under 30 day short stay letter for individuals active on their program who admit into a nursing facility under 30 days.    HCS retain cases for clients on a Waiver or MPC services through HCS who enter a hospital and they are expected to be discharged back into the community on HCS services within 60 days.   If a client is admitted into a nursing facility and is projected to be in the nursing facility or has been in the nursing facility over 30 days, the HCS office is responsible to do a redetermination of Medicaid using institutional rules.  This includes DDD clients who are admitted into a nursing facility and their stay is over 30 days or expected to beyond 30 days.  On active Medicaid cases that are not TANF/family related, the HCS financial worker will request the record from the CSO.    There may be a delay of issuing a nursing facility award letter as a determination is made as to whether the client will be in the nursing facility over or under 30 days.  If a notice of action is received by the HCS office and it is unknown whether Medicaid client will be in the nursing facility over 30 days, an alert will be set to check the status by the 30th day.  A nursing facility would need to wait for the award letter to bill in this instance as a determination is needed as to the correct medical program to consider for eligibility.

Worker Responsibilities  For applicants:   Determine eligibility for Medicaid as if he/she lives in his/her own home based.   Consider the income and resources of family members who would be in the client's assistance unit if he/she lived at home. Use the standard based on the number who would be in the assistance unit if he/she lived at home.          For applicants and recipients: Request a nursing facility level of care (NFLOC) determination from the HCS social worker assigned to the nursing facility using the ACES LTC referral. When verification from a HCS social worker is received that a Medicaid eligible client meets NFLOC generate an ACES LTC approval letter showing zero participation to the nursing facility. The institutional date on the letter is based on the 1st date the department was notified by the nursing facility of the admission. The medical date is day of the month eligible for the Medicaid. This date is usually on the 1st day of the month unless it is a general assistance unemployable client where the medical starts the date of eligibility or if a client meets a spenddown on a day other than the 1st. The nursing facility name and address must show in the address of the generated letter. The nursing home, client and client's representative all need a copy of the nursing home award letter. Nursing homes must have an award letter in order to bill the department. Clients eligible for a non SSI related Medicaid program do not need to meet aged/blind/disabled criteria for a short stay nursing home letter to be issued.  Clients must meet NFLOC in order for the department to issue an award letter to the nursing home.  This includes state funded medical and cash programs.  The exception is the pre-approval process for AEM. A short stay nursing facility letter is required in order for the nursing facility to bill the department.  Nursing facilities cannot bill the department using a medical id.  Once a client meets institutional status described in WAC 388-513-1320, institutional rules must be used for eligibility.

ACES Processing of Short Stays ACES-Short Stay Screens in ACES - Short Stay-STAY screen Screens in ACES - Short Stay Cost of Care - SSCC screen

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Modification Date: October 28, 2007

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