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.)
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/Intellectual Disabilities (ICF/ID) 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/ID 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.)
Institutions for individuals with developmental disabilities or for individuals with other related conditions (ICF/IDs, 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.
392.33 Pediatric Care Facilities
A pediatric care facility is a medical institution that provides services such as long-term care (LTC), physical and occupational care, transitional care and respite services to children up to age 21. Pediatric care facilities are licensed by the Office of Children Youth and Families (OCYF) and the Office of Developmental Programs (ODP). Children residing in these facilities may receive MA in a non-Long-Term Care (LTC) category if otherwise eligible. See Appendix C for a list of pediatric care facilities.
Since pediatric care facilitiesare not licensedwith the Commonwealth as nursing facilities, children residing in these facilities must NOT be authorized in a LTC facility category of MA, a LTC facility code must NOT be entered on the Facility Placement screen in eCIS, the MA 51 Medical Evaluation form will NOT be requested and is NOT necessary, and NO cost of care Third Party Liability (TPL) will be determined.
NOTE: The CAO must enter Facility Code 09 – Educational Placement on the Facility Placement screen in eCIS for childrenin pediatric facilities. Using FacilityCode 09 ensures the individual is enrolled in a physical and behavioral health ManagedCare Organization (MCO) in their countyof placement.
55 Pa. § Code 3800 55 Pa. Code § 6400
Updated November 9, 2021, Replacing September 25, 2020