State of Wisconsin Department of Health Services

Release 24-03 December 18, 2024

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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 Children and Young Adults in IMD

When a child or young adult applies for Medicaid while in an IMD or after being discharged from an IMD, the IM agency must determine eligibility for Institutional Medicaid for the inpatient IMD days, regardless of the length of stay.

Young adults aged 19-20 must be enrolled in Institutional Medicaid for the inpatient IMD days only, if eligible.

Children aged 18 or younger are subject to continuous coverage requirements (see SECTION 1.2 CONTINUOUS COVERAGE FOR QUALIFYING CHILDREN). This means that the child, if eligible, may be enrolled in Institutional Medicaid for the inpatient IMD days plus an additional period of time for a total of 12 full months of Institutional Medicaid eligibility, even when they are no longer in the IMD. However, the child’s enrollment should be changed to BadgerCare Plus or another form of Medicaid not based on institutionalization, if they are eligible. 

Example 1

Jax is 15 years old and was in an IMD from March 10 through March 18, 2024. On April 1, 2024, Jax applies for Medicaid and is determined eligible for Institutional Medicaid. Jax is enrolled effective March 10. Jax is not eligible for BadgerCare Plus or any other form of full-benefit Medicaid. Jax’s Medicaid coverage through Institutional Medicaid ends on March 31, 2025.

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.

Minors in a medical institution qualify for 12 months of continuous coverage. If they are discharged from a medical institution during their continuous coverage period and they do not qualify for any other form of full-benefit health care after they have been discharged, they remain eligible for Institutional Medicaid for the rest of their continuous coverage period.

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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