U.S. Department of Health and Human Services
This report was prepared under contracts #HHS-100-94-0024 and #HHS-100-98-0013 between the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, Office of Disability, Aging, and Long-Term Care Policy (ASPE) and the Research Triangle Institute. Additional funding was provided by American Association of Retired Persons, the Administration on Aging, the National Institute on Aging, and the Alzheimer's Association. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the ASPE Project Officer, Gavin Kennedy, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. His e-mail address is: Gavin.Kennedy@hhs.gov.
The opinions and views expressed in this report are those of the authors. They do not necessarily reflect the views of the Department of Health and Human Services, the contractor or any other funding organization.
This study reviewed the assisted living and board-and-care policies in each of the 50 states. States reported a total of 28,131 licensed facilities with 612,063 units or beds.1 Over 25% of the beds are located in three states: California (123,238), Florida (66,293), and Pennsylvania (62,241). Twenty-two states have existing licensing regulations using the term assisted living, up from 15 in the previous study. Wisconsin has re-named their assisted living regulations as residential-care apartment complexes. Draft regulations using the term assisted living have been developed by an additional nine states including Maryland which is significantly expanding the scope of an earlier program which a state agency considered assisted living. Four states are revising existing assisted living regulations; one state, West Virginia, is developing rules for a new category and New Hampshire will revise rules which sunset in 1998.
Thirty-five states reimburse, or plan to reimburse, services in assisted living or board-and-care facilities as a Medicaid service. Eleven states had created a task force or a process within a state agency to make recommendations for developing assisted living rules.
While a common or standard definition of assisted living is still unlikely, state approaches share some common components. This new model for providing long-term care is developing as a residential, rather than institutional, model. While many observers equate institutional with medical, the distinction between medical and social lies less with the services delivered than the setting itself. State rules generally require residential settings in which personal care and health related services are provided. Even though the setting is residential, health or medical services are provided, either by facility staff or through contracts with community agencies.
The major issues addressed by state policies concern requirements for the living unit, for tenant admission/retention, for the level of services allowed, and for administrator and staff training.
Living Unit: Existing or proposed policy--regulations or Medicaid standards--in thirteen states would require apartment settings, while fourteen states allow facilities with apartments and facilities with shared rooms to be licensed or reimbursed as assisted living. In seven states with assisted living rules, shared bedrooms meet the minimum standards. Sixteen states with boardand-care standards allow shared rooms. Licensing standards in Arizona, Minnesota, North Dakota, and Washington allow shared rooms, although facilities contracting with Medicaid must offer apartments.
Admission/Retention: These standards can be grouped into five categories: general, health conditions, functional capacity, Alzheimer's disease and dementia, and behavior. Recent rules in Kansas, Nebraska and Maine and draft rules in Arizona, Hawaii and Vermont will join Oregon and New Jersey as states with the broadest parameters for admission/retention. These states allow extensive services to be provided, sometimes with a review by the licensing agency for certain conditions. State regulations set the parameters for assisted living, while owners/operators define the practice. Despite regulations that may allow a higher level of care, facilities themselves may set their admission/retention policy to care for less impaired residents than the rules allow and provide a less intensive service package than allowed. Though strong market demand from moderate- and upper-income residents for residential settings supports this practice, changes are likely over time as the number of facilities expand, residents age in place, and providers adjust to maintain high occupancy rates.
New Jersey's rules require 20% of the residents in each facility to meet the nursing home level of care criteria within three years of licensing.
Policies in 22 states include a statement of philosophy that describes assisted living as a model which emphasizes consumer or resident independence, autonomy, dignity, privacy, and decision-making.
Level of service: Increasingly, state rules allow higher levels of care, sometimes equivalent to the care a person receives in their single-family home or apartment. While a few states require that health related services be delivered by a licensed home health agency, many allow assisted living facilities to hire nursing professionals to provide, supervise, or direct care.
Administrator credentials/training: Compared to board-and-care rules, assisted living regulations are more likely to require higher credentials and often training in the philosophy of assisted living. Criminal background checks of administrators and staff are being required to respond to concerns for safety and quality care for residents.
Staff training: These requirements vary extensively. Resident rights is the most frequently cited area for required training. Many states are now adding requirements that staff in facilities serving people with Alzheimer's disease receive special training to respond to their unique needs.
Public subsidies: The booming assisted living market has raised questions about its relevance for older persons with low incomes. By the spring of 1998, 28 states covered services in assisted living and/or board-and-care settings, and nine states were planning to add coverage during the year. There are two primary options for covering services under Medicaid: state plan services and home and community waiver programs. Six states use the Medicaid state plan, and 23 states use the waiver. (Maine covers services under both options and is therefore counted twice).
Although Medicaid coverage is widespread and growing, the number of participants is just over 40,000 beneficiaries, roughly half of whom are in North Carolina. States using personal care under the state plan to cover care have higher participation than states using the waiver. Factors affecting waiver participation may include the higher level of impairment required, the assessment and screening process, lack of familiarity with assisted living among waiver case managers, and the ceiling on waiver expenditures.
Five approaches are used to pay for services in assisted living settings: flat rates, flat rates that vary by the type of setting, tiered rates, case-mix related rates, and care plan or fee for service rates. Flat monthly rates are the most prevalent.
Twenty-six states have special provisions for facilities serving people with Alzheimer's disease. These provisions cover disclosure, admission/retention, staffing and training, activities, and the environment.
This paper describes the primary approaches states are taking to license assisted living, discusses Medicaid reimbursement and other selected areas, and summarizes each state's licensing rules.
|SUMMARY OF STATE ASSISTED LIVING AND BOARD AND CARE ACTIVITY|
|Drafting or Revising Regulations1||Medicaid Funding||Studying
|ASSISTED LIVING AT A GLANCE: STATUS OF STATE ACTIVITIES|
|Alabama||Multiple categories of assisted living are licensed based on size. The Public Health Department is developing revisions to the regulations.||No|
|Alaska||Regulations were effective in 1995. Criminal background checks are required by legislation passed in 1997.||Waiver|
|Arizona||A major consolidation of multiple categories will be effective in November 1998. Services are reimbursed as a Medicaid service through the ALTCS managed care program (1115 waiver).||Waiver|
|Arkansas||Licenses residential care facilities. State agencies are exploring licensing and Medicaid reimbursement for assisted living.||State plan|
|California||A work group was formed in 1996. The state's budget bill directed the Department of Health to submit a report in January 1997. Currently licenses residential care facilities for the elderly.||No|
|Colorado||Licenses personal care boarding homes.||State plan|
|Connecticut||The state has licensed assisted living services agencies since 1994. Legislation creating a Medicaid pilot program was signed in June 1998.||Pilot|
|Delaware||New regulations were effective in 1998.||Waiver submitted|
|Florida||Regulations issued in 1992. Legislative amendments were passed and new regulations issued in 1996 and 1998.||Waiver|
|Georgia||Licenses personal care homes.||Waiver|
|Hawaii||Legislation creating assisted living was passed 1995. Draft regulations are pending.||Waiver planned|
|Idaho||Regulations revising residential care facility rules were adopted in 1997.||No|
|Illinois||Two five-year demonstration programs are underway to test alternative assisted living models.||Waiver for demonstration|
|Indiana||A disclosure bill passed in 1997. State agencies are continuing to study assisted living.||No|
|Iowa||SF 454 was signed by the governor in May 1996. New regulations were effective in 1997.||Waiver|
|Kansas||Law was passed in 1995 defining assisted living. Regulations were effective in 1997. Revisions are being considered.||Waiver|
|Kentucky||Legislation was passed in 1996. Regulations for voluntary certification were adopted in 1997.||No|
|Louisiana||New regulations creating core licensing requirements and modules for assisted living have been filed. A pilot project for Medicaid beneficiaries is being designed based on legislation passed in 1997.||Waiver for demonstration planned.|
|Maine||Final regulations creating several categories of assisted living (congregate housing, residential care facilities, and adult family homes) were effective May 1998.||Waiver and state plan|
|Maryland||New regulations based on legislation were passed in 1996, have been issued, and are expected to become final in June 1998.||Waiver|
|Massachusetts||Legislation creating an assisted living certification process was signed in January 1995. Regulations implementing a certification process created for settings meeting specified criteria are in place.||State plan|
|Michigan||Following a reorganization of state agencies, an interagency group is reviewing licensing rules.||No|
|Minnesota||Assisted living has been implemented as a Medicaid service. New licensure rules of assisted living service providers have been drafted.||Waiver|
|Missouri||No current activity to create assisted living is underway. Medicaid reimbursement is available for residential care facilities.||State plan|
|Mississippi||A report on assisted living is expected in June 1998.||No|
|Montana||Assisted living is covered in personal care facilities under a Medicaid waiver.||Waiver|
|Nebraska||Regulations implementing legislation creating assisted living are effective July 1998. Legislation authorizing $40 million in grants and loan guarantees to convert nursing homes to assisted living was signed in April.||Waiver planned|
|New Hampshire||Rules for two levels of supportive residential and residential care facilities will be revised in 1998 or early 1999. A Medicaid HCBS waiver to cover assisted living was planned.||Waiver planned|
|Nevada||Licenses residential care facilities for groups. Limited Medicaid reimbursement is available.||Waiver|
|New Jersey||Regulations creating an assisted living licensing category were implemented.||Waiver|
|New Mexico||Residential shelter care facility rules have been revised.||Waiver|
|New York||New regulations consolidating several existing categories are being developed. A report assessing the assisted living industry is expected in the summer of 1998.||State plan|
|North Carolina||Chapter 535 (1995) defines assisted living residence as a category of adult care homes. Regulations revising the adult care home model and registration requirements for assisted living in elderly housing sites have been issued.||State plan|
|North Dakota||Assisted living services are funded through the state's Medicaid waivers and two state funded service programs.||Waiver and state funds|
|Ohio||Residential care facility rules have been revised. A decision on submitting the Medicaid waiver has been delayed pending a study of the entire Medicaid program.||No|
|Oklahoma||New rules implementing assisted living are effective in 1998.||No|
|Oregon||Revisions to program rules are expected in early 1999.||Waiver|
|Pennsylvania||Personal care homes are licensed. An interagency task force will make recommendations on assisted living in 1998.||No|
|Rhode Island||About 45 residential care and assisted living facilities are licensed. A pilot project for low income residents, authorized by the legislature in 1997, is being designed by the state Department of Elderly Affairs and the RI Housing Finance Agency.||Waiver|
|South Carolina||A brief report describing assisted living was submitted in 1997.||No|
|South Dakota||Assisted living category exists in statute. Limited services allowed.||Waiver|
|Tennessee||New assisted living regulations were effective in April 1998.||No|
|Texas||Regulations were revised in 1998. Regulations covering special care facilities have been prepared.||Waiver|
|Utah||Program rules were approved in 1995. Rules governing the buildings were also approved by a state board.||Waiver under consideration|
|Vermont||Regulations developed by the Department of Aging and Disabilities will be effective following a hearing and approval by a legislative committee. Medicaid waiver coverage of services in enhanced residential care facilities has been added. Waiver coverage of assisted living is planned.||Waiver planned|
|Virginia||Regulations allowing assisted living services in adult care residences were effective in February 1996.||Waiver|
|Washington||Rules covering assisted living as a Medicaid waiver service were issued June 1996. Licensing responsibility has been transferred from the Department of Health to the Aging and Adult Services Administration.||Waiver|
|West Virginia||Licenses personal care homes. Legislation creating a new category--community residential care facilities--passed in 1997.||No|
|Wisconsin||Regulations implementing a new residential care apartment complexes registration program were implemented in 1997.||Waiver|
|Wyoming||Regulations upgrading board-and-care rules were issued. New rules allow skilled nursing and medication administration.||No|
|STATES TO WATCH IN 1997: WHAT HAPPENED?|
|Alabama||Report from State Health Coordinating Council; proposed changes by the Public Health Department||Draft regulations due in 1998|
|California||Report and draft legislation||Report issued. No legislative action|
|Delaware||Task force recommendations and legislative action||Regulations are final and a Medicaid waiver has been submitted|
|Hawaii||Implementation of regulations, Medicaid waiver submission||Regulations in comment period|
|Idaho||Recommendations from state agencies||Revised regulations|
|Illinois||Implementation of pilot projects||Implementation underway|
|Indiana||Task force recommendations||Legislature requested study and report|
|Iowa||Draft regulations||Regulations and Medicaid coverage effective|
|Kansas||New regulations||Regulations and Medicaid coverage effective|
|Kentucky||New regulations||Regulations for voluntary certification effective|
|Louisiana||Draft regulations||Law passed authorizing pilot project. Regulations filed in the register.|
|Maine||Draft regulations||Regulations effective October 1997|
|Maryland||Draft regulations||Regulations pending|
|Nebraska||Draft regulations by Health Department||Law passed and regulations effective July 1998.|
|New Jersey||Possible new rate methodology||Still under consideration|
|New Mexico||Possible new rate methodology||No changes made|
|Oklahoma||Legislative action pending||Legislation passed, regulations being drafted|
|Pennsylvania||Recommendations for changes in regulations||Task force working on recommendations|
|South Carolina||Task force recommendations||Report submitted|
|Tennessee||Draft regulations||Regulations final April 1998|
|Vermont||Task force recommendations and regulations||Regulations proposed for comment|
|Wisconsin||Draft regulations||Regulations and Medicaid coverage implemented|
|STATES TO WATCH IN 1998-1999|
|Alabama||Revised regulations expected|
|Arkansas||New category and Medicaid coverage being considered|
|Arizona||Multiple categories are being consolidated|
|Connecticut||Status of Medicaid pilot project|
|Hawaii||Finalize regulations and implement waiver coverage|
|Illinois||Implementation of pilot projects|
|Indiana||Task force recommendations, possible legislation|
|Kansas||Revisions to the regulations are being reviewed|
|Louisiana||Draft regulations should be finalized|
|Maine||Case mix reimbursement system pending|
|Maryland||Draft regulations should be final by July 1998|
|Michigan||Revisions being considered|
|Mississippi||Task force considering assisted living regulations|
|Nebraska||Grants available for nursing home conversion. Medicaid waiver coverage.|
|New Hampshire||New regulations will be drafted|
|New Jersey||Possible new rate methodology|
|New York||Draft regulations consolidating multiple categories|
|North Carolina||Case mix reimbursement system, possible changes in moratorium on new construction|
|Oregon||Revisions to regulations being developed|
|Pennsylvania||Draft regulations should be issued|
|Rhode Island||Implementation of demonstration with Housing Finance Agency|
|Texas||Draft requirements for special care facilities and amendments to personal care home staffing and training requirements will be adopted|
|Vermont||Implementation of Medicaid waiver coverage for assisted living and a tiered payment system|
|West Virginia||Draft regulations for a new category|
|The Full Report is also available from the DALTCP website (http://aspe.hhs.gov/_/office_specific/daltcp.cfm) or directly at http://aspe.hhs.gov/daltcp/reports/1998/98state.htm.|