Individuals residing in State facilities operated by the Office of Mental Health and Substance Abuse Services (OMHSAS) are eligible for MA LTC if they are 65 years of age or older or under 22 years of age and receiving inpatient psychiatric care.
Individuals who are age 22 to 64 are not eligible for MA LTC while residing in a state facility. They may be eligible for MA LTC if LTC facility services are required and the individual is residing in the LTC facility unit of the facility. In this situation, the age of the individual is not a factor.
Individuals who are age 22 to 64 may be eligible for MA if admitted to a hospital outside of the state facility.
All eligibility factors must be met by individuals requesting MA payment for LTC services.
For residents receiving inpatient psychiatric care who are moving into the LTC facility unit within the same facility, the CAO will transfer eligibility from inpatient psychiatric care for individuals under 22 years of age or 65 years of age or older to LTC facility services, if still financially eligible.
However, if the individual is between the ages of 22 and 64, an application for MA LTC benefits for LTC facility services payment must be initiated by the resident, the resident's representative, or the resident's guardian. A posteligibility determination of expected payment toward the cost of LTC facility services must be completed.
NOTE: If the individual is targeted on the PASARR-ID, AAA must complete the OBRA evaluation. Otherwise, there is no AAA involvement.
For residents who are receiving inpatient psychiatric care and are moving to an LTC facility unit in another State facility or restoration center, the CAO will transfer the case to the new county (see Section 423.63, Intercounty Transfer) and transfer eligibility from inpatient psychiatric care for persons under 22 years of age or 65 years of age or older to LTC facility services, if still financially eligible. However, if the resident is between the ages of 22 and 64, an application for MA LTC benefits for LTC facility services payment must be initiated by the resident, the resident's representative, or the resident's guardian. A posteligibility determination of expected payment toward the cost of LTC facility services must be completed.
NOTE: If an individual is targeted on the PASARR-ID, AAA must complete the OBRA evaluation. Otherwise, there is no AAA involvement.
For residents receiving LTC facility services payments in an LTC facility unit of a State facility who move into an LTC facility unit in another State facility or restoration center, the CAO will handle these situations as routine transfers.
NOTE: There is no AAA involvement in this case
NOTE: A non-State facility is a facility that is not operated by OMHSAS.
For residents who are receiving inpatient psychiatric care in a State facility and who are moving into an LTC facility unit in a non-State facility, the CAO will transfer eligibility from inpatient psychiatric care for individuals under 22 years of age or 65 years of age or older to LTC facility services payment if the individual is remaining in the same county and is still financially eligible.
For individuals under 22 years of age or 65 years of age or older who are moving to a non-State facility in another county, the CAO will transfer the case record to the new county (see Section 423.63, Intercounty Transfer) and transfer eligibility from Inpatient psychiatric care to LTC facility services payment if still financially eligible.
If the resident is between the ages of 22 and 64, an application for MA LTC benefits for LTC facility services payment must be initiated by the resident, the resident's representative, or the resident's guardian.
A post-eligibility determination of expected payment toward the cost of LTC facility services must be completed.
NOTE: AAA must be involved in these situations whether the individual is targeted or not, unless the individual is private pay.
For residents who are receiving LTC facility services payment in a State facility moving to an LTC facility services unit in a non-State facility, the CAO will consider this a routine transfer whether the non-State facility is in the same county or another county.
NOTE: A non-State facility is a facility that is not operated by the Office of Mental Health.
NOTE: There is no AAA involvement in these cases unless the LTC facility refuses to accept individuals without a Level of Care Determination (LCD) decision (from the county where the individual normally resides). In these cases, the AAA will be required to complete an assessment to facilitate access to care.
Updated April 2, 2015, Replacing March 12, 2012