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
POL M1001D: DETERMINING ELIGIBILITY FOR INPATIENT HOSPITAL CARE
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
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 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
Resource Transfer Provisions Do Not Apply.
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.