8112 Medicaid Approved Institutions - This category applies to those institutional arrangements in which Medicaid, or state only assistance where noted, can make payments on behalf of eligible individuals' care in that institution. These arrangements include Medicaid certified adult care homes (including facilities under a Denial of Payment for New Admissions penalty), hospitals, state institutions and Medicaid enrolled free-standing psychiatric hospitals. It also includes hospice care provided within an adult care home.

For residents of assisted living/residential health care facilities, independent living budgeting applies and Medicaid payment is not available unless approved through an HCBS plan (see 8200).

Care may be either temporary or long term as defined by 8113 below. Except where noted, approval for payment of LTC expenses is dependent upon authorization on the KAECSES LOTC screen. See the KAECSES Code Cards for appropriate coding combinations for the specific level of care. Payment for MediKan applicants/recipients may be approved if all the requirements for the specific facility are met, including those authorized by Health Care Policy-Medical Policy, and the length of stay will not exceed the month of entrance and two following months as per 4130 (4).

8112.1 Adult Care Homes (ACH) - An adult care home may be either a nursing facility (NF), intermediate care facility for the mentally retarded (ICF-MR) or nursing facility for mental health (NF-MH). Two state hospitals have been certified as ICF-MRs. (See 8112.4.) Eligibility for medical assistance for ACH residents is determined using the long term care procedures and guidelines contained in this section. See 8114 for screening requirements.

8112.2 State Facilities Certified as ICF-MR - Parsons State Hospital and Kansas Neurological Institute have been certified as intermediate care facilities for the mentally retarded. Although they are state institutions, eligibility for medical assistance for residents is determined using the long term care procedures and guidelines contained in this section and there is no age limitation related to eligibility.

8112.3 Long Term Care in Hospitals - Long term care may be provided in a distinct or separate unit of a general hospital or in a swing bed in certain general hospitals.

1. Swing Bed Hospital - No screening requirements exist for residents of a swing bed hospital. Eligibility for medical assistance shall be determined based on long term care procedures and guidelines for stays which exceed the time frames in 8113, including LTC budgeting and patient liability. Appropriate level of care information must be present regardless of the length of stay.
    

2. Head Injury Rehabilitation Facilities - All placements in a head injury/rehab facility must be approved by the Independent Living Resource Counselor. A CARE assessment is not necessary. Eligibility for medical assistance shall be determined based on long term care procedures and guidelines for stays which exceed the time frames in 8113, including LTC budgeting and patient liability. Appropriate level of care information must be present regardless of the length of stay.
    

3. General Hospitals - No screening requirements exist for inpatients of a general hospital. Eligibility for medical assistance shall be determined based on long term care procedures and guidelines for stays which exceed the time frames in 8113, including LTC budgeting. However, no patient liability is established. If countable income exceeds the income standard, Medically Needy/spenddown processes apply. Level of care information is not necessary for provider reimbursement.
   
   The institutional base period provisions of 8130 and subsections do not apply to general hospital stays. A short term stay as described in 8113 shall be budgeted as independent living with a six month base period. A long term stay shall be budgeted as institutional living with a one month base period beginning with the month after the month hospitalization began.

8112.4 Institutions for Mental Diseases (IMD) - "See Policy Memo #99-10-02 re: "Law Enforcement Custody and State Psychiatric Hospital Admissions".

An IMD is a hospital, nursing facility or other institution engaged in providing diagnosis, treatment or care of persons with mental diseases. Except for certain situations involving state hospitals, as noted in item (3) below, FFP is not available for a person between the ages of 21 and 64 residing in an IMD. However, state-only coverage is provided to some persons. Persons otherwise ineligible cannot obtain eligibility until release from the facility. Temporary absences to seek medical or other care, such as a general hospital admission, unless the person has been formally released from the IMD, are not covered. These individuals continue to be considered patients of the facility. Persons absent from the facility due to a trial home visit are also considered patients of the facility. However, persons who are released under the condition of outpatient treatment are not considered patients of the facility and may be eligible for medical assistance. Eligibility for medical coverage may begin the month of release from the facility. The general types of IMD arrangements and the general eligibility rules of the arrangements follow.

1. State Psychiatric Hospitals - Individuals age 65 or older or under age 21 (age 22 if receiving psychiatric services on their 21^st birthday) may be determined eligible for medical. All other patients of a state hospital for the mentally ill are not eligible for medical assistance until release, except for persons who continue to receive a cash grant as provided in 4130.
   
   There are currently three state hospitals with inpatient psychiatric units meeting the criteria of this item: Larned State Hospital, Osawatomie State Hospital, and Rainbow Mental Health Center. Persons admitted to these facilities are not eligible if they are under the jurisdiction of law enforcement. See Policy Memo 99-5-03 for a list of civil and criminal commitments. Persons in the sexual predator treatment unit at Larned State Hospital are not considered to be under the jurisdiction of law enforcement and may be eligible for medical assistance.
   
   For eligible patients, long term care procedures and guidelines are applicable, including financial eligibility in 8160 and 8170 and the spousal impoverishment provisions of 8144. Payment to these facilities is established by appropriate coding on the KAECSES LOTC screen.
   
   For individuals receiving coverage through Title 21 who enter a state mental health hospital, Title 21 coverage continues through the month of entrance and following month, regardless of anticipated length of stay. Title 21 coverage terminates at the end of the period and any continuing eligibility is determined under the Medicaid program. No patient liability is determined during this period, however, any premium obligation continues.
    

When a current Medicaid recipient between the ages of 21 and 65 is admitted to a psychiatric unit of a state hospital, eligibility shall be terminated effective the last day of the month the client was admitted and the case may be closed.
 

2. Nursing Facilities for Mental Health (NF MH) - There is no age restriction for eligibility in an NF MH. However, there is no FFP for persons residing in these facilities between the ages of 21 and 64. The Medicaid fiscal agent is responsible for separating funding sources. Long term care procedures and guidelines are applicable for persons meeting the pre admission screening criteria described in 8114, including financial eligibility per 8172. See 8171 for financial eligibility for person who do not the appropriate level of care.
   
   For eligible patients, long term care procedures and guidelines are applicable, including financial eligibility in 8160 and 8170 and the spousal impoverishment provisions of 8144. Payment to these facilities is established by appropriate coding on the KAECSES LOTC screen.
    

3. Psychiatric Residential Treatment Facilities (PRTF) - A PRTF is a facility designed to provide active treatment in a structured therapeutic environment for children and young adults with significant functional impairments resulting from an identified mental health diagnosis, substance abuse diagnosis, or a mental health diagnosis with a co-occuring disorder. A list of facilities licensed as PRTF is found at http://csp.kdads.ks.gov/services/Pages/MapPRTF.aspx.

Note that a Youth Residential Center is not a PRTF and is considered a community based placement. Independent living rules are applicable for youth living in these arrangements.
 

Residents of a PRTF who are under age 21 (age 22 if receiving treatment in a PRTF or state hospital on their 21st birthday) are potentially eligible for Medicaid assistance. Older individuals are not eligible.
 

Residents must be screened eligible for admittance into the PRTF by a certified individual approved by DCF-HCP. In limited situations, emergency admissions may be allowed. A contracted entity is responsible for entering all prescreening results in the MMIS, where payments are edited to ensure the child meets the necessary level of care.

 

The facility is responsible for submitting an MS-2126 for each resident in which Medicaid assistance is requested. The PRTF must indicate if a screening has been completed. If it is reported a screening has been completed, then the individual is deemed to meet appropriate level of care for purposed of the eligibility determination. If they report the screening has not been completed, contact the Mental Health Consortium to determine if an exemption is applicable.

 

If the stay is anticipated to last at least 30 days, long term care procedures and guidelines are applicable for the eligibility determination. In most instances, coverage under the CI program (see 2663 and 8183) is available. If the stay is anticipated to last less than 30 days, the stay is considered temporary and independent living budgeting applies. In these cases, eligibility is determined according to the prior living arrangement.

 

For youth entering a facility for a stay anticipated to exceed 30 days and who is receiving Medicaid prior to entering the facility, the case must be adjusted according the following rules:

 

1. For youth in state custody receiving foster care or adoption support related medical assistance, coverage may continue under these categories for the duration of the stay, unless coverage ends due to other program requirements.
    
2. For youth receiving medical under the SI program, coverage may continue under the SI program as long as the child remains in SSI recipient status.
    
3. For youth receiving medical assistance under HCBS, the institutional protected income limit is applicable beginning the month of entrance. The eligibility worker may maintain eligibility under the MS program through the first month of the stay and establish coverage under the CI program beginning the second month. A new application is not required.
    
4. For youth receiving medical assistance under other programs, including the MA CM or poverty level program, the child must be removed from the original assistance plan beginning with the month in which the arrangement begins. A separate determination is required for the PRTF resident. As different eligibility criteria are used to establish eligibility for a PRTF resident, a new application is required.
    

 

A patient liability must be determined for all residents whose stay will exceed 30 days (including all CI eligibles). For persons eligible under the temporary care provisions, the patient liability is $0 unless the youth is part of a medically needy plan with an unmet spenddown. In these instances, medically rules are applicable.

 
 

Example: Jana is a 15 year old MP recipient who receives $160.00/month is child support. She enters a PRTF for a stay not expected to exceed 30 days. Because this is a temporary stay, she remains part of the original MP plan. Jana's patient liability is $0, as there is no medically needy plan.

 

If Jana's stay is expected to exceed 30, she is removed from the MP plan and a new application is requested to determine eligibility based on institutional rules. Jana is determined eligible under the CI program and her patient liability is $100.00 ($160 - $60).

 

The KAECSES LOTC screen must be completed for all PRTF placements:

The facility is responsible for notifying the eligibility worker of the PRTF dismissal as quickly as possible. The eligibility worker shall adjust eligibility appropriately, with independent living rules applicable beginning the month of discharge for HCBS, MP and MA CM determinations and the month following the month of discharge for all others.