16 Del. Admin. Code § 20000-20800
LTC POL-
This policy applies to all applications received for Medicaid payment of Inpatient hospitalization or rehabilitation.
Thirty Consecutive Days of Hospitalization
Eligibility for this program will only be determined once the individual has been hospitalized for 30 consecutive days, unless:
the discharge plan is for nursing home placement; or
the individual is seeking out of state inpatient rehabilitation placement.
Licensed and Certified Hospital or Rehabilitation Facility
The medical facility must be licensed and certified as a Title XIX Acute Care or Rehabilitation Medical Facility.
The Acute Care facility must be engaged in providing diagnostic and therapeutic services for medical diagnosis, treatments, and care of injured, disabled, or sick persons. These services must be provided by or under the supervision of physicians. Continuous twenty-four (24) hour nursing services are provided.
The Rehabilitation facility may be a freestanding rehabilitation hospital or a rehabilitation unit in an Acute Care hospital.
Medical Eligibility Requirements For In State Hospitalization and/or Rehabilitation
Medical eligibility for Inpatient hospitalization/rehabilitation services received within the state is determined by the Division of Medicaid and Medical Assistance Pre-Admission Screening (PAS) units. The individual must have required the level of care provided by a hospital during the time of his/her hospitalization, as determined by the PAS units.
Anyone 65 years of age or older, or statutorily blind would meet the medical eligibility criteria if they were in need of acute care services during the time of their hospitalization.
Medical Eligibility Requirements For Out of State Rehabilitation
Medical eligibility for Inpatient Rehabilitation services to be received out of state is determined by the Division of Medicaid and Medical Assistance Medical Director. The individual must require:
| · | close medical supervision by a rehabilitation physician; |
| · | twenty-four (24) hour nursing supervision; |
| · | an intensive level of physical, occupational or speech therapy; or |
| · | psychological services; or |
| · | prosthetic-orthotic services. |
The individual must be able to tolerate and participate in all required therapies or services.
Medical eligibility must be reviewed on a bi-weekly basis.
Prior authorization must be requested and approved before out of state placement is made.
Financial Eligibility Requirements
Financial eligibility is determined by the Division of Medicaid and Medical Assistance Financial units. An individual must meet income and resource guidelines.
Income Guidelines
The income limit is equal to 100% of the Federal SSI Standard. However, if the individual is going to a nursing home directly from a hospital or rehabilitation facility, the higher income limit of 250% of the Federal SSI standard will be applied.
For out of state rehabilitation the income limit is 250% of the Federal SSI standard.
Refer to DSSM sections 20200, 20210, and 20240 for additional guidelines regarding income.
Resource Guidelines
The resource limit is $2,000.00. Refer to DSSM sections 20300 - 20360, and 20400 for additional information on determining countable resources.
Spousal
If applicable, Spousal Impoverishment rules should be followed. (DSSM 20900)
Financial Redetermination
A redetermination of the individual's financial eligibility should be completed at six month intervals.
Post Eligibility Budgeting
There is a patient pay requirement for these individuals. The patient pay amount is determined in accordance with DSSM section 20600 - (Post-Eligibility Definitions/Procedures). Notification of patient pay amount and approval must be sent to the appropriate hospital/rehabilitation social worker.
Medicaid Eligibility Effective Date
In no case shall the effective date of eligibility be earlier than the first day of hospitalization.
16 Del. Admin. Code § 20000-20800