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Institutional Long Term Care

Medicaid covers certain inpatient, comprehensive services as institutional benefits. The word "institutional" has several meanings in common use, but a particular meaning in federal Medicaid requirements. In Medicaid coverage, institutional services refers to specific benefits authorized in the Social Security Act. These are hospital services, Intermediate Care Facilities for People with Intellectual disability (ICF/ID)Nursing Facility (NF)Preadmission Screening & Resident Review (PASRR)Inpatient Psychiatric Services for Individuals Under Age 21, and Services for individuals age 65 or older in an institution for mental diseases.

  • Institutions are residential facilities, and assume total care of the individuals who are admitted.
  • The comprehensive care includes room and board. Other Medicaid services are specifically prohibited from including room and board.
  • The comprehensive service is billed and reimbursed as a single bundled payment. (Note that states vary in what is included in the institutional rate, versus what is billed as a separately covered service. For example, physical therapy may be reimbursed as part of the bundle or as a separate service.)
  • Institutions must be licensed and certified by the state, according to federal standards.
  • Institutions are subject to survey at regular intervals to maintain their certification and license to operate.
  • Eligibility for Medicaid may be figured differently for residents of an institution, and therefore access to Medicaid services for some individuals may be tied to need for institutional level of care.