For purposes of MA eligibility, a medical institution is a facility that has the professional staff and equipment needed to provide medical care, including nursing and recovery care, and that is allowed to provide such services under state law.
An individual who lives in a medical institution can apply for and get MA, if he or she meets all other MA requirements.
NOTE: A public institution for mental diseases is a medical institution. ( Section 392.31.) 55 Pa. Code § 161.72
Spousal Impoverishment rules apply if the institutionalized individual is getting skilled care, heavy-care/midlevel services, or midlevel care in a nursing facility or other medical institution, including care in an Intermediate Care Facility/Mentally Retarded (ICF/MR) or an Intermediate Care Facility for Persons with Other Related Conditions (ICF/ORC), for at least 30 consecutive days. ( Section 392.32 and the Long Term Care Handbook, Chapters 440 and 450.)
NOTE: An ICF/MR or ICF/ORC facility is a medical institution. ( Section 392.32.) 55 Pa. Code § 161.22 42 CFR 435.1009
A public institution for mental diseases is a medical institution. A psychiatric after-care facility is a licensed nursing care unit or designated bed on the grounds of a public institution for mental diseases and is a medical institution. An individual’s age and the level of care received while living in such institutions are important in deciding whether the individual is eligible for MA.
An individual who is living in a public institution for mental diseases or a psychiatric after-care facility may apply for and get MA if he or she is under age 22 or is age 65 years or older.
An individual who is living in a psychiatric after-care facility and getting nursing facility care may apply for and get MA, no matter how old he or she is.
Spousal Impoverishment rules apply if the individual meets the conditions in the Long Term Care Handbook, Section 440.3.
An individual who gets psychiatric care while living in a public institution for mental diseases and who is between ages 22 and 64 is not eligible for MA.
Exception: An individual in this age group may apply for MA for inpatient hospital care if that care is provided outside the institution by individuals who are not on the institution’s staff. (See Section 392.41.) 55 Pa. Code § 161.73(a)(3)
Institutions for individuals with developmental disabilities or for individuals with other related conditions (ICF/MRs, or ICF/ORCs) offer the following services:
Diagnosis, treatment, or other help for individuals with developmental disabilities or individuals with other related conditions.
Ongoing evaluation, planning, 24-hour supervision, coordination, and integration, in a protected residential setting, of health or other services to help each individual function to his or her greatest abilities.
NOTE: Spousal impoverishment rules apply if the individual meets the conditions in the Long Term Care Handbook, Section 440.3.
Updated February 14, 2012, Replacing February 8, 2002