8182 Long Term Care Insurance - Insurance coverage is available to help pay the cost of long term care. Generally, most of these policies allow for payments to be made either to the client or the nursing facility. These are treated as a third party liability and need to be noted in the MMIS. As such, the client should be instructed to have the benefits assigned directly to the facility.

Financial eligibility shall continue to be determined based on the provisions of 8172 allowing for the full cost of the nursing facility care even though a portion or all of that cost is being covered by the insurance. This is similar to how Medicare days are treated per 8181 above. Thus, for persons where liability is less than the DCF approved rate per 8172 (2). If insurance benefits exceed the applicable DCF rate for the facility, no further payment is due from either the client or the agency. If the benefits fall below the DCF rate, the client and/or agency will then be responsible for the remaining payment up to the DCF rate based on the amount of client liability.

Regardless of the situation, a patient liability should always be calculated and transmitted via the LOTC screen as well as notification provided to the nursing facility for persons meeting the provisions of 8172 (2). The liability and payment effective dates should also correspond to the date the client enters the facility.

Notification to the client should follow the guidelines set in 8181.

8183 Children in an Institutional Setting - As noted in 2666, medical assistance is available to a child or young adult under the age of 21 residing in a Medicaid approved institution for long term care. Eligibility shall be determined based on the provisions contained in this section (8100) including the establishment of appropriate eligibility periods outlined in 8130, the absence of a resource test as indicated in 8142(2), the separate treatment of income in accordance with 8143 (3), the long term care income standards of 8160, and the determination of financial eligibility per 8170. See also 2666 and 8112.4 concerning children in an institute for mental disease.

For individuals age 18 and over, the temporary stay policies of 8113 are also applicable if the individual qualifies under another medical program (e.g., MS or MP).