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Effective: December 1, 2006 |
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03.45.25ar1 - Institutions for Mental Diseases (IMD) (Archive) |
Archived: June 1, 2011 |
An Institution for Mental Diseases (IMD) is defined as a hospital, nursing facility, or other institution of 17 beds or more that is primarily engaged in providing diagnosis, treatment, or care of people with mental diseases. People who live in an IMD may be eligible for federally funded Medical Assistance (MA), state-funded MA, or General Assistance Medical Care (GAMC).
Eligibility factors and links to standard program guidelines are provided below.
Citizenship/Immigration Status.
Insurance and Benefit Recovery.
Relationship to Other Groups/Bases.
l Federally Funded MA (Program MA).
The following people who live in an IMD have a basis of eligibility for federally funded Medical Assistance (MA).
n People age 65 or older.
n Children up to age 21 who are living in an IMD that is an accredited inpatient psychiatric hospital.
n People up to age 22 who have resided in an IMD that is an accredited licensed inpatient psychiatric hospital who received MA covered services prior to their 21st birthday and continue to receive these services after age 21 in the same facility.
n People who receive MA, are enrolled in managed care, and were placed in an IMD by the health plan, or for whom the health plan was court-ordered to pay for treatment in the IMD. These people remain enrolled in the health plan with the same major program and budget as they had before placement.
l State-Funded MA for People in an IMD (Program IM).
IMD residents are eligible for a state-funded MA benefit package that does not include coverage of nursing home cost of care if they meet both of the following conditions:
n Have an MA basis of eligibility.
n Are ineligible for federally funded or state-funded MA (program MA or NM) solely because they live in an IMD.
For state-funded MA for IMD residents, use major program IM (state-funded program for IMD residents) on MAXIS and MMIS. Determine eligibility using MA income and asset limits. Determine the MA basis of eligibility and apply the appropriate income standard, asset limit, and method.
Example:
Mary, age 26, receives MA for herself and two children. She is placed in an IMD for an estimated stay of three to four months. She is ineligible for MA solely due to IMD residence.
Action:
Determine eligibility for program IM eligibility using the parent/caretaker asset limit ($20,000 for Mary and two children) and income limit (100% FPG). Use Method A.
People who are otherwise eligible for Medical Assistance for Employed Persons with Disabilities (MA-EPD) but cannot get MA due to residing in an IMD may be eligible for program IM.
n Use MA-EPD asset limits and premium determination rules.
n Recalculate the premium if the MA-EPD enrollee is on a medical leave from employment of up to four months or has decreased wages while residing in the IMD.
l General Assistance Medical Care (GAMC).
IMD residents who do not meet the criteria for federally or state-funded MA benefits may be eligible for GAMC. Follow standard GAMC guidelines. People who qualify for GAMC are eligible for all GAMC-covered services.
Note: The IMD costs are not a GAMC-covered service and will be paid through other funding, such as Group Residential Housing (GRH), other state programs, or private pay. The IMD resident is eligible for GAMC services that are not included in the IMD treatment plan, such as doctor and dentist visits.
GAMC enrollees who enter an IMD should be referred to the State Medical Review Team (SMRT) for a disability certification. If they are certified disabled, they would change from GAMC to program IM while in the IMD. If still eligible when discharged from the IMD, they would then change to state- or federally funded MA (program NM or MA).
See the information below for additional eligibility requirements for federally or state-funded MA for IMD residents. For additional eligibility requirements for GAMC for IMD residents, see General Assistance Medical Care.
Application Process (standard guidelines)
Do not require an application for people who change from one major program to another when they enter or leave an IMD.
Example:
Julia is eligible for federally funded MA and enters an IMD. She does not meet the criteria to remain on federally funded MA, but does meet the criteria for program IM.
Action:
Change Julia's major program from "MA" to "IM," but do not require a new application.
The eligibility begin date for program IM is the date the client enters the IMD.
Note: Ten-day notice is not required for closing MA or the Medicare Savings Programs when a person enters an IMD.
Renewals (standard guidelines)
Follow standard MA/GAMC guidelines.
Follow standard MA/GAMC guidelines.
Social Security Number (standard guidelines)
Follow standard MA/GAMC guidelines.
Follow standard MA/GAMC guidelines.
Residency (standard guidelines)
Follow standard MA/GAMC guidelines.
People who would be eligible for the Medicare Savings Programs if they did not reside in an IMD may be eligible to have their Medicare premiums reimbursed as cost effective coverage.
Household Composition (standard guidelines)
Follow standard MA/GAMC guidelines.
For IMD residents, use the applicable eligibility method for the enrollee’s basis of eligibility.
Note: People in an IMD who are placed by a health plan do not change eligibility status.
Asset Guidelines (standard guidelines)
Use the applicable asset limit for the enrollee’s basis of eligibility.
Use the applicable income guidelines for the enrollee’s basis of eligibility.
Deductions/Disregards (standard guidelines)
Use the applicable deductions and disregards for the enrollee’s basis of eligibility.
Use the applicable spenddown or premium guidelines for the enrollee’s basis of eligibility.
Exception: Use a long-term care spenddown if MA is paying the cost of care in the IMD, unless the enrollee’s IMD costs are the responsibility of a health plan (including court-ordered placements for which the health plan is responsible).
Covered Services (Prepaid MHCP Manual)
People who are eligible for MA while living in an IMD are eligible for all MA-covered services. If MA is not paying the cost of care in the IMD, the person is eligible for all MA-covered services not included in facility costs, such as doctor and dental visits.
Note: MA pays the cost of care for individuals up to age 21, or up to age 22 if they meet the conditions noted earlier in this section when receiving treatment in an inpatient psychiatric hospital.
People who reside or expect to reside for 30 days or more in a medical institution (including IMDs that are psychiatric hospitals and Rule 36 residential treatment programs) are exempt from co-payments.
People who are residing in an IMD at the time of initial enrollment are excluded from managed care.
Note: People who are already enrolled in managed care when they enter state institutions will remain enrolled if the placement has been approved by the health plan.
Not applicable.
MinnesotaCare enrollees who enter an IMD but were not placed in the IMD by the health plan should have their MinnesotaCare closed at their next renewal and be evaluated for other potential health care program eligibility.
People who are enrolled in program IM are eligible for MA if they have been discharged from the IMD or are on convalescent or conditional leave.
People who are eligible for federally funded MA while in the IMD remain eligible for the Medicare Savings Programs.