LONG TERM CARE FACILITIES

What is the CMS definition of long term care facilities?

Long term care facilities include nursing facilities, Intermediate Care Facilities for the Mentally Retarded (ICFs/MR), inpatient psychiatric hospitals and other medical institutions that receive Medicaid payments for institutionalized individuals.  Specifically not included are individuals who are supported by Home and Community Based Waivers.  The definition of long term care facilities also excludes other types of residential settings such as assisted living homes and other group homes that are regulated by the state.

Why is it important to know whether an individual lives in a long term care facility?

·        Individuals who reside in long term care facilities do not have to pay co-pays.

·        Dual eligibles receiving waiver services, living with their families, living in group homes that are not ICFs/MR, and other residential services will have to pay co-pays. 

·        Emergency supplies of medications are available to individuals who reside in long term care facilities during transition periods but are not guaranteed in other settings.

·        PDPs are required to provide convenient access to network long term care pharmacies, which means that the PDP will pay for the services that long term care pharmacies typically provide.

·        PDPs are encouraged - but not required - to pay for these services when they are offered to non ICFs/MR or other residential providers.  Individuals will need to check their PDPs to ensure that their residential provider uses their plan’s long term care pharmacy.