Eligibility Online Manual

M1001D Inpatient Hospital Care

Purpose: This section will assist in determining whether individuals are eligible for Inpatient Hospital Care.

Current Policy Effective Date: November 1, 2015

Date Last Reviewed: November 12, 2015

Previous Policy: April 1, 2013


1. Applicants Must Meet Basic Eligibility Factors

Refer to Section M600 for a description of all basic eligibility factors.

2. Applicants Must Be Aged, Blind Or Disabled

Applicants must meet one of the following factors

    • Aged – 65 or older.

    • Blind – legally blind based on Social Security standards.

    • Disabled – person who receives disability benefits from SSA or is determined disabled by WDH.

3. Applicants Must Meet 30-Day Requirement

Applicants must meet a 30-day requirement by any of the following:

    • Remain in a medical institution for 30 consecutive days.

    • Not completing the 30-day requirement due to death.

    • Verified as SSI eligible.

4. Applicants Must Meet Income Requirements

Require the countable income to be within the maximum income standard per month. Refer to Medicaid Table 1A to see income standards. Refer to Section M901 to determine if income is countable.

5. Applicants Must Meet Resource Requirements

Require the countable resources to be within the maximum resource limit. Refer to Medicaid Table 7 to see resource standards. Refer to Medicaid Table 8 to determine if assets are countable.

6. Applicants May Receive Retroactive Medicaid

Applicants may receive retroactive Medicaid benefits if they incurred medical bills during any of the three months prior to application.

Both approved and denied applicants must be reviewed. Reviewer must verify and determine eligibility separately for each retroactive month to determine whether the case would have been eligible if an application had been made.

7. Benefits Begin First Of Month After Meeting 30-Day Requirement

Once applicants meet the 30-day requirement, benefits must be authorized back to the first day of the month in which the institutionalization began, if eligible.

8. Clients Pay Patient Contribution

Client is required to pay a contribution toward the cost of care.

Refer to Section M906 for details on calculating the patient contribution.

9. Clients May Pay Prorated Amount

Prorate the patient contribution when the client does not reside in a hospital for a full month or Medicare pays for the cost of care. Refer to Section M906 for details on calculating the patient contribution.

10. Applicants May Have Eligibility For 12 Continuous Months

Eligibility continues for 12 months from the effective date of eligibility, or for 12 months from the last periodic review, for children under the age of 19.

11. Clients Must Be Reviewed

Clients must be periodically reviewed every 12 months to determine continued eligibility. Refer to Section M1403 for information on reviewing eligibility.

A review is not required for SSI clients.

Clients must be reviewed for other Medicaid program eligibility before closing cases.

12. Clients May Lose Benefits

The case will close on the first day of the next month when any of the following occur:

    • Client leaves hospital.

    • Client enters a public institution, excluding the Geriatric Hall at the State Hospital in Evanston.

    • Client dies.

    • Client does not complete review.

    • Client determined no longer eligible.


Defining Group: 42 CFR 435 Subpart F

42 CFR 435.236

Income: 42 CFR 435 Subpart K

Resources: 42 CFR 435 Subpart L

Clarifying Information:

Resource Transfer Provisions Do Not Apply.

Worker Responsibilities:

Closing Cases

1. Finalize eligibility and close benefits in WES when the applicant is no longer eligible.

2. Allow 15-day closure notice when an adverse action has occurred.