State of Wisconsin Department of Health Services

HISTORY

The policy on this page is from a previous version of the handbook. 

22-03 Version of 27.1 Institutions

27.1.1 Institutions Introduction

For Medicaid purposes, "institution” means medical institution.  A medical institution can be, but is not limited to, skilled nursing facilities (SNF ), intermediate care facilities (ICF ), institutions for mental disease (IMD), and hospitals.

Medical institution means a facility that:

1. Is organized to provide medical care, including nursing and convalescent care,
2. Has the necessary professional personnel, equipment, and facilities to manage the medical, nursing, and other health needs of patients on a continuing basis in accordance with accepted standards,
3. Is authorized under State law to provide medical care, and,
4. Is staffed by professional personnel who are responsible to the institution for professional medical and nursing services.

27.1.2 Institutions for Mental Disease

IMDs are medical institutions that care for persons with mental illness.  See the list of IMDs (27.11 Institutions for Mental Disease (IMDs)).

27.1.2.1 Eligible Age

IMD residents under age 21 and over age 64 may be Medicaid eligible. Persons aged 21 through 64 are not eligible unless:

1. They are receiving residential substance use disorder treatment in the IMD; or
2. They were IMD residents immediately prior to turning age 21. If they were, they are eligible until discharge (a 21 year old can be transferred from one IMD into another and remain eligible for Medicaid) or until turning age 22, whichever comes first.

27.1.2.2 Temporary Leave

A person aged 21 through 64 who is not eligible for Medicaid can go on conditional release from an IMD or convalescent leave and become eligible for Medicaid while on leave.

1. Conditional release means a temporary release from an IMD for a trial period of residence in the community.
   1. The trial period must last no less than four days.  It must be no longer than 30 days.
   2. The trial period begins after the initial three days of community residence following discharge.
   3. A person under age 22 who leaves the IMD for a trial period remains eligible as an IMD resident until he or she is unconditionally released from the IMD, or turns 22, whichever comes first.
   For purposes of Medicaid, conditional release is permitted only once every calendar year.
2. Convalescent leave means a period of time following inpatient admission of a resident of an IMD to a general hospital for the purpose of treatment for a physical medical condition of a severity which medically contraindicates treatment of the condition in the IMD. A person under age 22 who leaves the IMD on Convalescent Leave remains eligible as an IMD resident until he or she is unconditionally released from the IMD, or turns 22, whichever comes first.   

27.1.2.3 Minors in IMD

When a minorA minor is a person less than age 18. applies for Medicaid after being discharged from the IMD, certify the individual as a member, if eligible, for the inpatient IMD days only.  Certify for the remainder of the month if he or she would be eligible after being tested for Family Medicaid with his or her parents and siblings.

27.1.3 Hospitals

Hospitals are medical institutions that:

1. Provide 24-hour continuous nursing care,
2. Provide dietary, diagnostic, and therapeutic services, and,
3. Have a professional staff composed only of physicians and surgeons, or of physicians, surgeons and doctors of dental surgery.

A person residing in a hospital is an institutionalized person (27.4.1 Institutionalized Person) if he or she:

1. Has resided in a medical institution for 30 or more consecutive days, or
2. Is likely to reside in a medical institution for 30 or more consecutive days.

The 30-day period includes situations in which the person resides in more than one medical institution during 30 or more consecutive days. However, an individual is not considered “institutionalized” if he or she meets this 30-day test but is in a medical institution solely for the purpose of receiving residential substance use disorder treatment.

27.1.4 Minors in a Medical Institution

Minor children who reside (or are likely to reside) in a hospital or other medical institution for 30 or more days can be eligible for Institutional Medicaid if they are determined disabled or presumptively disabled (see SECTION 5.2 DETERMINATION OF DISABILITY and SECTION 5.9 PRESUMPTIVE DISABILITY). 

For Institutional Medicaid, a blind or disabled minor is a one-person fiscal test group. Only the child’s income is counted. No parental income is deemed to the institutionalized minor. 

Hospitalized children under the age of 19 who have not been determined disabled or presumptively disabled must be tested for BadgerCare Plus with their families. 

See Process Help, Section 11.2.4 Health Care Applications for Institutionalized Children for processing instructions.

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The information concerning the Medicaid program provided in this handbook release is published in accordance with: Titles XI and XIX of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapters 46 and 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2, 10 and 101 through 109 of the Wisconsin Administrative Code.

Notice: The content within this manual is the sole responsibility of the State of Wisconsin's Department of Health Services (DHS). This site will link to sites outside of DHS where appropriate. DHS is in no way responsible for the content of sites outside of DHS.

Publication Number: P-10030