O-5000, Waiver Programs and 30 Consecutive Days

Revision 18-1; Effective March 1, 2018

An institutional setting is a living arrangement in which a person applying for or receiving Medicaid lives in a Medicaid-certified long-term care facility or receives services under a Home and Community-Based Services waiver program. See Section G-6200, Special Income Limit for the Eligibility Budget.

To qualify for the special income limit, a person or couple must:

  • have countable income that exceeds the reduced Supplemental Security Income federal benefit rate;
  • receive a level of care or medical necessity determination that qualifies the person or couple for Medicaid; and
  • reside in:
    • a Medicaid-certified long-term care facility for 30 consecutive days; or
    • a Medicaid-certified institution for mental diseases for 30 consecutive days, if the person is age 65 or older,

For Medicaid under a Home and Community-Based Services waiver program, the person must be approved by a Texas health and human services agency to receive services for a waiver program and receive the services within one month after approval. The count of the 30 consecutive days starts at either:

  • entry into a Medicaid-certified long-term care facility and the person moves into an approval status for a waiver program; or
  • an approval to receive services under a waiver program and receive the services within one month after approval.

The 30 consecutive days are not disrupted if the person:

  • makes a three-day therapeutic home visit with a planned return to the facility;
  • is admitted to a hospital with a planned return to the facility; or
  • moves from a Medicaid-certified long-term care facility:
    • to a Home and Community-Based Services waiver program; or
    • to another Medicaid-certified facility.

If a person dies before meeting the 30-consecutive-day requirement without moving to a noninstitutional setting, the person is considered to have met the requirement for application of the special income limit.

Note: Consider potential retroactive coverage for the three months prior to the date of application if the person entered a nursing facility, ICF/ID or state supported living center and then transitioned into a waiver setting before being certified. Use the special income limit for the month of entry to the Medicaid-certified long-term care facility (Medicare-SNF, NF or ICF/ID) if it is anticipated that the person will remain in a Medicaid-certified long-term care facility for at least 30 consecutive days. When eligibility is based on the special income limit, finalization of the person’s eligibility cannot be processed or disposed in the system of record until the 30 consecutive days have been met.