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Medicaid and Assisted Living: Challenges and Solutions in State Programs

Explore the dynamic relationship between Medicaid and assisted living facilities, focusing on factors driving demand and the complexities of Medicaid coverage. Delve into perspectives from lenders, consumers, and more. Evaluate Medicaid issues, coverage sources, waivers, and rate considerations in this comprehensive analysis.

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Medicaid and Assisted Living: Challenges and Solutions in State Programs

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  1. Medicaid and Assisted Living Robert L. Mollica October, 2002

  2. Demand factors • Population growth • Declining nursing home occupancy rates • Shifting balance from NFs to residential and in-home settings • Medicaid nursing home transition grants

  3. Perspectives • Lenders/investors • Developer/manager • State licensing agency • State Medicaid • Consumers/family/advocates • Local service delivery system

  4. The Perfect Storm? • Target population: “light” care • Continuous or intermittent nursing care requirement • Is Medicaid rate adequate, reliable? • State Medicaid: nursing home alternative, cost effective • Consumer expectations: Aging-in-place and “Olmstead” decision

  5. Low income coverage • 41 states cover under Medicaid and/or state funds • 4 states planning/discussing coverage (AL, CA, KY, LA) • 3 states making grants to convert nursing homes

  6. Medicaid considerations • State plan or waiver coverage • Waiver level of care criteria • Assisted living or broader waiver • Room and board cap? • Rate methodology • Service only or service and room and board

  7. Medicaid issues... • Temporary absences • Family supplementation • Eligibility process - “fast track” • Nursing homes relocation programs a priority

  8. Medicaid coverage for assisted living

  9. Source of coverage: Medicaid and state revenues WaiverAK IL NDAZ KS ORCO MD PACT MN RIDE MS SDFL MT TXGA NE UTHI NV VT*IA NH WAID* NJ WIIN NM WY State PlanState $ AR CT FL ME* ME MD MA MN MI* ND* MO SD* NY NC SC VT* Planned AL CA DC KY LA * Multiple sources CT under pending pilot program

  10. Making the case • Reduce Medicaid NF growth trend line NF reliance $$ Broad menu Time

  11. Public subsidy issues/options • SSI • Room and board only, or • Room and board and personal care services • Medicaid service options • Regular Medicaid state plan • 1915 (a) state plan amendment • Waiver approaches • HCBS Waiver - 1915 (c) • Managed care - 1115

  12. Medicaid state plan coverage • Cannot cover room and board • States cannot readily control spending • Entitlement program but may control provider type (FL, SC plan amendment) • Eligibility is based on need for a service • Available statewide - amount, scope, duration

  13. Medicaid waiver coverage • Cannot pay for room and board • No entitlement - can control spending • Can serve residents with income < $1,635/month ($19,620 annual) • Services include meal preparation and serving costs • Must meet nursing home level of care • Waive amount, scope, duration

  14. Rate issues • Some states include room and board paid by the resident in the rate • May be limited to SSI beneficiaries • Most cover Medicaid services only • R&B for SSI beneficiaries set by state policy • State SSI supplements may cover some personal care

  15. Cover R&B under Medicaid? • Requires change in statute • Basis in nursing home reimbursement • Weakens non-institutional preference • Shifts costs from Federal SSI to states • SSI benefit: personal needs allowance only • Likelihood of raising rates????

  16. Illinois • Pilot project • New licensing law does not allow Medicaid payments in licensed facilities outside of pilot • Regional payments: $45.54 - $61.94per day (2002) • Room and board: $455 ($90 PNA) • Food stamps: $96

  17. Chicago $61.941 Northwest $53.90 West/central $47.54 Central $51.05 St. Louis region $50.75 South suburban $59.11 South $45.54 Regional rates/day (2002) Rate increases tied to average nursing home rate increase

  18. Oregon (2002) Level Service R&B Total 5 $1840.46 $446.70 $2287.16 4 $1490.76 $446.70 $1937.46 3 $1139.93 $446.70 $1587.63 2 $ 861.74 $446.70 $1308.44 1 $ 651.69 $446.70 $1098.39

  19. Oregon... Level Impairment 5 Depend in 4-6 ADLs or dependent in behavior & 1-2 other ADLs 4 1-2 ADLs or assistance in 4-6 ADLs + behavior 3 Assist w/4-6 ADLs or assist w/toileting, eating & behavior 2 Assist w/behavior AND eating or toileting 1 Assist in 2 critical ADLs or any 3 ADLs or assist w/1 critical and 1 other ADL

  20. Washington 9/1/02 Level 1 Level 2 Level 3 King county $65.87 $73.36 $81.30 Metro counties $60.74 $67.l31 $74.29 Non-metro $59.52 $65.82 $72.22

  21. Family supplementation • Allowed in 19 states • Prohibited in 7 states • No policy - 4 states • Considered unearned income for SSI • Should be paid to facility rather than beneficiary • Federal SSI benefit reduced one-third

  22. Future issues.... • Quality assurance and outcome approaches • National or state standards • Aging in place challenge • Adequacy of Medicaid rates • Affordability and access • Housing subsidy and Medicaid linkages

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