For MA purposes, the governmental unit that controls a public institution is usually responsible for the care given to an individual living in the facility. Such institutions include the following:
Tuberculosis (TB) clinics.
NOTE: Individuals in TB clinics are not eligible for MA, because the Department of Health contracts with general hospitals to provide treatment.
County nursing facilities.
NOTE: These facilities are nursing care facilities and are subject to the MA rules in the Long Term Care Handbook. People living in these facilities can apply for and get MA, if they meet all other rules for eligibility.
Reminder: An institution for individuals with developmental disorders is not an institution for mental diseases. 55 Pa. Code § 161.22 55 Pa. Code § 161.73(a)
An individual age 22 to 64 who is living in a public institution for mental diseases may be eligible to apply for and get MA if he or she meets the conditions for inpatient hospital care and nursing facility care.
Reminder: An individual in a correctional institution is not eligible for MA other than for inpatient hospital services. (See Section 392.2 and 392.21)
An individual age 22 to 64 who is living in an institution may apply for and get MA if he or she meets all other rules for eligibility and if all the following conditions are met:
The individual needs inpatient hospital care.
The institution cannot provide the needed medical services.
The hospital is outside the institution and is staffed by individuals who are not on the institution's staff.
For individuals in correctional institutions, See Sections 392.2 and 392.21.
The CAO must decide MA eligibility for inpatient hospital services for residents of other institutions as follows:
1. Process the Application for Benefits (PA 600) as directed in Chapter 304, Application.
2. Decide whether the individual is eligible for MA.
3. If the individual is eligible, approve MA as a noncontinuous eligibility (NCE) opening. Enter a closing date effective the last calendar day of the month of eligibility.
4. If the individual needs inpatient hospital services after the end of the month, approve additional NCEs. 55 Pa. Code § 161.73(a)
An individual age 22 to 64 who is living in a public or medical institution may get MA LTC if both of the following conditions are met:
The individual is getting skilled care, heavy-care/midlevel services, or midlevel care for at least 30 days in a row.
The bed, ward, or wing of the institution is used only for nursing facility care patients under state rules.
Reminder: Spousal impoverishment rules apply. (See the Long Term Care Handbook, Section 440.3.) 42 CFR 435.1008 42 CFR 435.1009
Updated February 14, 2012, Replacing February 8, 2002