Using Medicaid to Cover Services for Elderly Persons in Residential Care Settings: State Policy Maker and Stakeholder Views in Six States

APPENDIX B. FLORIDA



TABLE OF CONTENTS

I. OVERVIEW OF LONG TERM CARE SYSTEM
Nursing Homes
Waiver Programs
Personal Care Option
Long Term Care Programs Funded with State Revenues Only
II. RESIDENTIAL CARE SETTINGS
Adult Family Care Homes
Adult Congregate Care Facilities/Assisted Living Facilities
III. SUMMARY OF INTERVIEWS
General Comments About the State's Residential Care System
General Comments on Medicaid's Role in Residential Care Settings
Licensing and Regulatory Requirements
Admission and Retention Requirements, and Aging in Place
Barriers to Serving Medicaid Clients in Residential Care Settings
Suggested Changes to Improve the Medicaid-Funded Residential Care System
Future Plans
SOURCES
Publications
Websites
Formal and Informal Interviews
ENDNOTES


The information in this appendix is presented in three major sections:

Because the information in the first two sections is intended to serve as a reference, some information is presented under more than one heading to reduce the need for readers to refer back to other sections for relevant information.

Unless otherwise cited in endnotes, all information presented here was obtained from the sources listed at the end. Supplemental Security Income levels, the federal poverty level, federal spousal protection provisions, state supplemental payments, and state reimbursement rates are for 2003, unless otherwise noted.


I. OVERVIEW OF LONG TERM CARE SYSTEM

Nursing Homes

Florida has two types of nursing homes--Skilled Nursing Facilities and Skilled Nursing Units. Skilled Nursing Facilities (SNFs) are either freestanding or part of a continuing care retirement community (CCRC) and are governed through special contracts. Skilled Nursing Units (SNUs) are based in hospitals. They typically provide only short term care and rehabilitation services. The skilled nursing unit is licensed as part of the hospital.1 The state has a moratorium on nursing home construction, effective July 1, 2001 through July 1, 2006.

Medicaid reimburses for nursing facility services for Medicaid clients who meet Florida's Institutional Care Program (ICP) eligibility requirements. There are three levels of nursing facility care--Skilled, Intermediate 1, and Intermediate 2. Approximately 77 percent of the state's 2002-03 long term care budget is for nursing home services.

Financial Eligibility

Three groups are financially eligible for Medicaid-covered nursing home care:

Group A includes individuals who are receiving Supplemental Security Income (SSI), and those who have incomes no higher than the SSI payment combined with the State Supplemental Payment (SSP).

Group B includes persons with incomes up to the special income standard of 300 percent of SSI, which is $1656. This group is subject to cost sharing. After certain deductions are made for a personal needs allowance, and a spouse or dependent allowance, any remaining income must be spent on nursing home care.

Group C includes individuals with incomes up to 88 percent of the Federal poverty level (FPL).2 The State uses 1902(r)(2) less restrictive income and resource methodologies for this group. Spousal impoverishment protections apply to community spouses.

Spousal Protections

Family Supplementation

Family supplementation is allowed for services not covered by Medicaid and to pay the difference in cost between a shared and private room, as long as the payment is made directly to the facility.

Level of Care Criteria

To determine eligibility for both nursing home care and waiver services, applicants must be assessed through the Comprehensive Assessment and Review for Long Term Care Services (CARES) program administered by the Department of Elder Affairs. To be eligible, individuals must meet one of the following criteria:

CARES will periodically perform assessments on nursing facility residents to ascertain that they continue to meet the eligibility criteria, and to assess their potential for returning to the community. Private pay individuals may be assessed at their request at no charge. The goal of CARES is to place the applicant in the least restrictive, most appropriate setting with a preference for community placement whenever possible.

Waiver Programs

Florida has twelve home and community-based waiver programs, including several that serve substantial numbers of elderly persons or only elderly persons.3 The two major waiver programs that serve older persons are:

When the ALE waiver was initiated in 1995, the State planned to serve 220 individuals with a $2.3 million appropriation, averaging $10,454 per person a year. In 2001, the state served 3,179 ALE recipients receiving an average annual ALE reimbursement of $9,937.

Financial Eligibility

Cost Sharing Requirements

Persons who qualify for waiver services under the special income rule of 300 percent of SSI have a cost sharing obligation. The amount depends on the specific waiver and the monthly protected income, which varies according to a number of factors, including the person's living arrangement and the number of dependents.5

Spousal Protections

The state does not use the option to provide federal spousal impoverishment protections for the incomes of spouses of waiver clients. The state allows a maximum of $552 per month in protected income for an HCBS waiver spouse, whereas the community spouses of nursing homes residents have a maximum protected income of $2,232 per month. This policy creates an economic incentive to enter a nursing home even though a person could receive services at home or in an assisted living facility.

In a recently implemented pilot nursing home transition program, which was part of the Assisted Living for the Elderly waiver, nursing home residents who were suitable and willing to be moved to an assisted living facility were identified. Four hundred nursing home residents were moved, some of whom had been in the nursing home for two or more years. However, there were others who wanted to transition but could not because their community spouse would lose too much income as a result.

Florida is in the process of implementing revised spousal impoverishment policies in the Assisted Living for the Elderly waiver program. However, the community spouse will still have less income to keep than if their spouse is in a nursing home.

Family Supplementation

The Medicaid program does not consider money paid to an assisted living facility for a private room or for services and supplies not covered by Medicaid to be in-kind income to the Medicaid beneficiary. However, payments must be entirely voluntary and not a condition of providing services, and must be paid directly to the residential care setting.

Regardless of state rules regarding family supplementation, SSI recipients will have their federal benefit reduced by the amount of the family supplement--to a maximum of one third of the SSI payment. The family has to pay the facility the amount that is reduced as well as its initial contribution.

Level of Care Criteria

Waiver applicants have to meet the same level of care criteria as nursing home applicants. Two additional criteria are applicable for Assisted Living for the Elderly waiver applicants:

Personal Care Option

Personal care services were added to the Medicaid state plan in 2001 and are provided through a program called Assistive Care Services. Persons who live in their own homes are not eligible to receive personal care services through the Assistive Care Services program. Only persons who need an integrated set of services on a 24-hour basis and who live in licensed assisted living facilities or licensed adult family care homes may receive Medicaid funded personal care services. These services are also available to residents of some mental health residential treatment facilities, which serve primarily younger adults with mental illness. Services must be based on need as confirmed by an assessment and provided in accordance with an individual service plan for each resident.

Prior to the addition of personal care services to the Medicaid state plan, the state paid for some personal care services in residential care settings with a state supplement through the Optional State Supplementation (OSS) program, which is funded by general revenue funds. (OSS is not provided to individuals who live in their own homes.) Once personal care services were added to the Medicaid program, the state reduced the OSS payment and used the money saved to provide the state match for Medicaid personal care services.

Prior to Medicaid coverage of personal care services, residential care facilities that provided room and board and some personal care could receive up to $730 a month (the combined SSI+OSS payment level). Although the maximum OSS payment has been reduced,6 with the addition of Medicaid personal care service payments, residential care providers can now receive up to $847.80 per month to cover room and board and personal care services. This amount includes $569.40 paid from the resident's income for room and board, plus $9.28 per day for personal care services paid by Medicaid.

Financial Eligibility

Two groups are financially eligible for Medicaid state plan services, including Assistive Care Services:

Florida's Medically Needy program does not cover Assistive Care Services.

Spousal Protection

There are no spousal income and asset protections for Medicaid state plan services, including Assistive Care Services. When spouses live together in a home, a spouse's income is counted in determining whether a person meets the income eligibility standard. However, if one of the spouses enters a residential care facility, they are each treated as an individual and the community spouse's income is not counted in determining eligibility.

Family Supplementation

For individuals receiving Optional State Supplementation (OSS), Florida allows third party supplementation for room and board and services not covered by Medicaid.7 Supplementation can be made by family or friends to cover the costs of room and board that the low OSS payment does not cover (e.g., for a private room) under the following conditions:

  1. Payments shall be made to the assisted living facility, or to the operator of an adult family-care home, family placement, or other special living arrangement, on behalf of the person and not directly to the optional state supplementation recipient.

  2. Contributions made by third parties shall be entirely voluntary and shall not be a condition of providing proper care to the client.

  3. The additional supplementation shall not exceed two times the provider rate recognized under the optional state supplementation program.

  4. Rent vouchers issued pursuant to a federal, state, or local housing program may be issued directly to a recipient of optional state supplementation.

When contributions are made in accordance with the statutory provisions listed above, the state does not count them as income to the client for purposes of determining eligibility for Medicaid or for OSS benefits. However, the SSI program does consider in-kind supplementation to be income to the client and reduces the SSI benefit by one third. Florida does not increase the OSS payment to offset the reduction in SSI benefits that occur due to third-party contributions. Thus, in addition to the original contribution, the third party has to pay the facility the amount that is reduced as well as its initial contribution.

Service Criteria

To be eligible for Assistive Care Services individuals must need an integrated set of services on a 24-hour basis and must have a health assessment establishing the medical necessity of at least two of the program's four service components, which are described below.8

Long Term Care Programs Funded with State Revenues Only

The state has three major programs for elderly persons funded solely by state general revenues, namely, Alzheimer's Disease Initiative, Community Care for the Elderly, and Home Care for the Elderly.9 Local areas, called Planning and Service Areas, provide a range of services that are instrumental in keeping frail elders out of nursing homes, including: Personal Care, Homemaker, Chore, Respite, Case Management, Skilled Nursing, Home Health Aide, Home Delivery Meals, Transportation, Adult Day Care, Emergency Alert Response, and Home Repair and Modifications.

Alzheimer's Disease Initiative (ADI) provides services to people with Alzheimer's Disease and other types of dementia who do not meet Medicaid financial criteria or who are waitlisted for HCBS waiver services. Respite services are provided to caregivers in all 67 counties of the state, with a service limit of 30 consecutive days for extended (24 hour) respite.

Although there is no income eligibility ceiling for ADI, cost sharing is required, beginning at 150 percent of FPL and ending at 300 percent FPL, at which point the consumer pays 100 percent of costs. If assets are over $2,000, 5 percent of the value divided by 12 is added to the monthly income amount. The maximum cost-sharing amount that an individual pays is 15 percent of adjusted monthly income.

Community Care for the Elderly (CCE) is a program for frail elderly persons, age 60 and older, who do not meet Medicaid financial or service criteria, or who are waitlisted for HCBS waiver services. Eligibility is based, in part, on a client's inability to perform certain daily tasks essential for independent living, such as meal preparation, bathing, or grooming. This program provides case management along with additional home and community services. Financial eligibility criteria are the same as for the ADI program and cost sharing is required on the same sliding scale basis. Agencies may use the CCE program while waiting for a waiver slot, but sometimes the CCE program also has a waiting list.

Home Care for the Elderly (HCE) provides a subsidy ($104 per month in 2002) to help relatives keep a low-income elderly person in their own home or in the home of a caregiver. There is also a special subsidy available as a supplement for specialized health care needs. The program serves individuals aged 60 or older who do not meet Medicaid service criteria. HCE has an income eligibility ceiling of $1,635 per month (300 percent of SSI) with an asset limit of $2,000 in countable assets. An eligible HCE participant must be at risk of nursing home placement.10


II. RESIDENTIAL CARE SETTINGS

Florida has two major types of residential care settings primarily for elderly persons: assisted living facilities (ALFs), which were called adult congregate living facilities until 1997, and adult family-care homes (AFCHs). Each type of setting has similar but separate licensing and regulatory requirements. ALFs that meet basic license requirements may apply for a special license for specific purposes, as described below.

Residents in AFHCs and ALFs can receive personal care state plan services as long as they meet Medicaid's eligibility requirements and the facilities meet the regulatory requirements for providing these services.

Residents in only two types of ALFs--those with a Limited Nursing Services (LNS) license and those with an Extended Congregate Care (ECC) license--can receive Medicaid waiver services, as long as they meet the nursing home level-of-care criteria and the facilities meet the regulatory requirements for providing these services.

Adult Family Care Homes11

Adult family-care homes (AFCHs) are defined as a family-type living arrangement in a private home providing room, board, and personal care for no more than five disabled adults or frail elderly persons. Persons who provide room, board and personal care services in their own homes must obtain an AFCH license unless they are caring for one or two adults who do not receive a state supplement, or they are caring only for relatives. Persons who wish to care for more than five disabled adults or frail elders must obtain an assisted living facility license. A maximum of two residents may share a room.

AFCHs are an alternative to more restrictive, institutional settings for individuals who need housing and supportive services, but who do not need 24-hour nursing supervision. The personal care available in these homes, which may be provided directly or through contract or agreement, is intended to help residents remain as independent as possible in order to delay or avoid placement in a nursing home or other institution. A terminally ill resident who no longer meets the criteria for residency may continue to reside in the AFCH if receiving hospice services from a licensed provider who coordinates any additional care needed. In 2002, the state had 416 adult family care homes with 1784 beds.12

Room and Board

The state limits the amount that can be charged to OSS recipients and Medicaid ACS clients for room and board to the amount of SSI, which is $552 plus the maximum Optional State Supplement of $78.40, which equals $630.40, minus a $54 personal needs allowance (PNA), which equals $576.40. Licensed AFCHs are required to designate at least one of their beds for an individual receiving OSS.

Family supplementation--capped at twice the amount of the SSI/OSS combined payment for room and board--is allowed. The state does not limit room and board charges for private pay residents.

Medicaid Reimbursement

Adult Congregate Care Facilities/Assisted Living Facilities

Adult Congregate Living Facilities (ACLFs) have operated in Florida since 1975. In 1992, the state had 1500 facilities (most of which had 16 or fewer beds) serving approximately 50,000 people a year, most of them private pay. These facilities provided room and board, assistance with one ADL plus personal services, and supervision of self-administered medication.14

In 1993, a new licensing category of ACLF was implemented, called Extended Congregate Care (ECC).15 The rationale for the creation of this new category was that the state did not have a residential care option for people who needed substantial levels of personal or home health care, but not the level of skilled nursing care provided in nursing homes. Consequently, individuals with this level of impairment had to enter a nursing home, at a much greater expense to the state. The ECC licensing category addressed this gap.

In 1995, adult congregate living facilities were renamed assisted living facilities (ALFs). ALFs are defined as a residential care setting that provides housing, meals, personal care services, and supportive services to one or more adults of all ages who are typically unable to live independently and are not related to the owner or administrator by blood or marriage. ALFs are for elderly or disabled persons who do not need 24-hour nursing supervision, except for those receiving hospice services from a licensed hospice, who may continue to reside in an assisted living facility.

Physical Plant Requirements

The rules require ALFs to be located, designed, equipped, and maintained to promote a residential, non-medical environment, and provide for the safe care and supervision of all residents.

Medicaid sets a maximum of two persons per room for waiver clients. One respondent noted that the maximum was strictly enforced and that facilities with more than two residents sharing a room could not participate in the program. When drafting rules for the waiver, discussions about privacy were contentious and advocates were unsuccessful in their attempts to make single occupancy a requirement of the waiver program. However, many providers do offer private rooms to waiver clients as their standard practice.

Room and Board

The state limits the amount that can be charged to ALE waiver clients for room and board to the amount of SSI, which is $552.00 plus the Optional State Supplementation of $78.40, which equals $630.40, minus a $54 personal needs allowance, which equals $576.40.17 The facility is legally required to accept the OSS rates for waiver clients. Any income over this amount is required cost sharing.

Family supplementation--capped at twice the amount of the SSI/OSS combined payment for room and board--is allowed. The state does not limit room and board charges for private pay residents.

Services

Services provided in assisted living facilities (ALFs) vary depending on the type of license. Only facilities with an LNS or ECC license may provide services to waiver clients.

Standard License. Facilities with this license must provide housing, meals, and one or more personal care services. Personal care services include direct physical assistance with or supervision of a resident's activities of daily living and the self-administration of medication and similar services. The facility may employ or contract with a licensed person to administer medication and perform other specialized nursing tasks such as taking vital signs.

Any facility with a standard license can provide personal care services to Assistive Care Services (ACS) clients. All ALFs must have a standard license before they can apply for a specialty license.

Limited Nursing Services (LNS) License. Facilities with an LNS license may provide any of the services under a standard license and additional nursing services, such as ear and eye irrigations; replacing established self-maintained indwelling catheter or performing intermittent urinary catheterizations; applying and changing routine dressings for abrasions, skin tears, and closed surgical wounds; caring for stage 2 pressure sores; conducting nursing assessments if conducted by, or under the direct supervision of, a registered nurse; and for hospice patients, providing any nursing service permitted within the scope of the nurse's license, including 24-hour supervision.

Extended Congregate Care (ECC) License. Facilities with an ECC license may provide any of the services provided under a standard and LNS license including any nursing service permitted within the scope of a nurse's license, consistent with ALF residency requirements and the facility's written policy and procedures. A facility with this type of license allows a higher level of service, including total care with bathing, dressing, grooming and toileting, and enables residents to age in place in a residential environment despite mental or physical limitations that might otherwise disqualify them from residency under a standard or LNS license.

ECC facilities must make available a range of nursing services, including nursing diagnosis or observation and evaluation of physical conditions; ongoing medical and social evaluation to determine when the person's conditions cannot be met within the facility; routine measurement and recording of vital functions; administration of medications; and preventive regimens for residents likely to develop pressure sores.

The Medicaid waiver program reimburses for the following services for recipients in ECC settings: personal care, homemaker, attendant and companion, medication administration and oversight, therapeutic social and recreational programming, physical, occupational and speech therapy, intermittent nursing services, specialized medical supplies, specialized approaches for behavior management for people with dementia, emergency call systems, and case management.

Reimbursement

Services in ALFs can be paid through a number of mechanisms:

Requirements for Medicaid Waiver Reimbursement

Requirements include the following provisions:

Requirements for Medicaid Assistive Care Services Reimbursement

Negotiated Risk Agreements

Statutory requirements require ECC ALFs to allow residents to make a variety of personal choices, participate in developing service plans, share responsibility in decision-making, and implement the concept of managed risk. The statute defines the following:

Admission, Retention, Discharge Criteria, and Aging In Place


III. SUMMARY OF INTERVIEWS

In addition to consulting with thirteen state staff and policy makers regarding the technical details of the state's programs, we also interviewed seven of them. In addition, we interviewed seven key stakeholders, including representatives of residential care provider associations, residential care providers, consumer advocates, a consumer association, the state ombudsman program, and the agencies that administer the state's home and community services programs.

The interviews focused on respondents' views about several key areas and issues. This section summarizes their views and provides illustrative examples of their responses. These comments are not verbatim quotes, but have been paraphrased to protect the respondents' anonymity and edited for brevity. A list of information sources for the state description and the individuals interviewed can be found at the end of this summary.

General Comments About the State's Residential Care System

Because residential care facilities serve both private pay and Medicaid residents, a few respondents expressed views about the industry as a whole.

A number felt that the state was achieving its goals and being responsive to stakeholders.

Comments about privacy in residential care settings indicated disagreement among providers and other respondents.

There was disagreement about the need for additional adult foster care homes.

General Comments on Medicaid's Role in Residential Care Settings

On the whole, most respondents were pleased with the success of the Assisted Living for the Elderly waiver program and the more recently introduced Assistive Care Services (ACS) program. They felt that these Medicaid programs have made a real contribution to long term care options for low-income elderly.

However, there were criticisms regarding unequal treatment for those with mental health diagnoses, and other inequities.

Licensing and Regulatory Requirements

Respondents had conflicting views about licensing and regulatory requirements. Many expressed concerns that the combination of ECC licensing and Medicaid waiver funding is moving some assisted living facilities more towards a medical model.

One had very strong recommendations about licensing and regulation.

Several expressed concerns about specific licensing and regulatory requirements that were considered unnecessary and in some cases, added unnecessarily to costs.

One noted that regulations were always needed to deal with bad providers, and said that the best regulations can do is to require the key indicators of health and safety and then "get out of the way" and let providers deliver care. Another noted that the ombudsman program used to take a problem solving approach, but recently have adopted an adversarial approach.

A number expressed concerns about the proliferation of unlicensed (i.e., illegal) facilities.

Oversight and Enforcement

No respondents mentioned lack of enforcement as an issue. A few said the state was doing alright and most facilities were in compliance.

Several respondents described a government quality assurance initiative called Operation Spot Check, which found that 98 percent of facilities were in compliance with regulations. However, some providers had problems with how the initiative was carried out.

Staffing Requirements

All respondents felt there was a need to increase staffing levels in ALFs.

Two respondents mentioned abuse of residents by staff, but stated that it was atypical.

Medication Issues

Many respondents felt the state needs to help individuals pay for medications if they are in a standard ALF and not eligible for Medicaid.

National Standards

Most respondents were not in favor of adopting national standards or model standards for assisted living.

However, a small number of respondents stated they would like to see federal standards.

Admission and Retention Requirements, and Aging in Place

Most respondents were satisfied with admission and retention regulations, but several raised concerns.

Negotiated Risk Agreements

A number commented on the potential role of negotiated risk agreements to reduce the number of lawsuits; others felt they would not have any impact.

Barriers to Serving Medicaid Clients in Residential Care Settings

Respondents noted a number of barriers.

General Lack of Funding

Service Rates

One respondent noted that in response to low service rates some providers ask families to contribute to the cost of services. This practice is called either "family supplementation" or "up-charging." Others expressed concerns about the practice.

Liability Insurance

The increase in the cost of liability insurance was cited by most respondents as the biggest problem facing Florida's assisted living industry, and a major barrier to assuring the availability of residential care options for older persons who do not want to live in a nursing home.

Recently, ALFs licensed to provide Extended Congregate Care or Limited Nursing Services have been notified by insurers they will be charged the same rate as nursing homes because insurers now consider them to be equally at risk for lawsuits because they are licensed to serve waiver clients who meet the state's nursing home level-of-care criteria.

In 2002, the Florida legislature authorized a state insurance program called the Long Term Care Risk Retention Group (RRG). RRG is an insurance product that could provide as many as 800 assisted living facilities with affordable general and professional liability insurance with good coverage and reasonable premiums. RRG was also developed to offer coverage for facilities with Extended Congregate Care and Limited Nursing Services licenses, which are practically uninsurable at this time. The cost for initial capitalization of the Long Term Care Risk Retention Group is $6 million. There was disagreement among respondents about whether the RRG program would adequately address the liability insurance crisis.

Many respondents recommended tort reforms that would set a limit on compensation and punitive damages.

There were many different suggestions from providers, consumers and advocates, and not all were in agreement.

Many respondents said they would support federal action to address the liability insurance crisis, and expressed the need for some real leadership in Congress to address the issue.

Paperwork

Some felt that quarterly inspections for ECCs are a deterrent to obtaining an ECC license, because of the substantial paperwork required. Some ECC providers have reported extensive survey action on the part of surveyors conducting the quarterly monitoring visits.

Another noted similar problems to participate in the waiver program.

Suggested Changes to Improve the Medicaid-Funded Residential Care System

Most of the recommendations were tied to funding and eligibility issues.

Future Plans

Most respondents were optimistic about the future of assisted living, although realistic about the barriers to Medicaid funding as noted in the previous section.

Other reasons given for optimism is that the ALE waiver is popular with the legislature and Assistive Care Services has received real support.23 One respondent was very optimistic about expansion in rural areas.

One respondent reported that the state could expand in-home services.


SOURCES

Publications

Gibson, M. J. and Gregory, S. R., Across the States 2002: Profiles of Long-Term Care, AARP, 2002.

Kassner, E. and Williams, L., Taking Care of their Own: State-funded Home and Community-based Care Programs for Older Persons, AARP, September 1997.

Kassner, E. and Shirley, L., Medicaid Financial Eligibility for Older People: State Variations in Access to Home and Community-Based Waiver and Nursing Home Services, AARP, April 2000.

Manard, B. et. al., Policy Synthesis on Assisted Living for the Frail Elderly: Final Report, submitted to Office of the Assistant Secretary for Planning and Evaluation, December 16, 1992. [Executive Summary]

Mollica, R.L., State Assisted Living Policy: 1998, Report (ASPE and RTI) June 1998. [Full Report]

Mollica, R.L., State Assisted Living Policy: 2000, National Academy for State Health Policy; funded by The Retirement Research Foundation (LTC13). August 2000.

Mollica, R.L., and Jenkens, R., State Assisted Living Practices and Options: A Guide for State Policy Makers, A publication of the Coming Home Program, funded under a grant from The Robert Wood Johnson Foundation, September 2001.

O'Keeffe, J., People with Dementia: Can They Meet Medicaid Level-of-Care Criteria for Admission to Nursing Homes and Home and Community-Based Waiver Programs?, AARP, August 1999.

Polivka, L., et. al., Long Term Care for the Frail Elderly in Florida: Expanding Choices, Containing Costs, Long-Term Care Policy Series, Volume I, prepared for the Commission on Long-Term Care in Florida, Florida Policy Exchange Center on Aging, 1996.

Polivka, L., et. al., Assisted Living and Extended Congregate Care: The Florida Experience, Long-Term Care Policy Series, Volume II, prepared for the Commission on Long-Term Care in Florida, Florida Policy Exchange Center on Aging, 1996.

Salmon, J., et. al., Affordable Assisted Living Facilities: Government-Sponsored Benefits for Reimbursing Assisted Living Services, Room, and Board, conducted for the Department of Elder Affairs, Committee on Affordable Assisted Living Facilities, Florida Policy Exchange Center on Aging, 2002.

Smith, G. et. al., Understanding Medicaid Home and Community Services: A Primer, U.S. Department of Health and Human Services, Office of the Assistant secretary for Planning and Evaluation, October 2000. [Full Report]

State Assistance Programs for SSI Recipients, January 2001, Social Security Administration, Office Of Policy, Office Of Research, Evaluation, and Statistics, Division Of SSI Statistics and Analysis.

Stone, J.L., Medicaid: Eligibility for the Aged and Disabled, Congressional Research Service Report for Congress, updated July 5, 2002.

Websites

Aged, Blind and Disabled Medicaid Eligibility Survey http://www.masterpiecepublishers.com/eligibility/

Agency for Health Care Administration, Alternatives to Nursing Homes http://www.fdhc.state.fl.us/nhcguide/alternatives.cfm

Agency for Health Care Administration, Assisted Living Facilities http://www.fdhc.state.fl.us/MCHQ/Health_Facility_Regulation/Assisted_living/index.shtml

Agency for Health Care Administration, Assistive Care Services http://www.fdhc.state.fl.us/Medicaid/asc/index.shtml

Assistive Care Services And Assisted Living For The Elderly Waiver Services Coverage And Limitations Handbook, http://floridamedicaid.consultec-inc.com/html/Florida_Medicaid/Provider_Support/Handbooks/ Assistive_Care_Services_and_Assisted_Living_for_the_Elderly_Waiver_Services.pdf

Department of Children and Families, SSI-Related Programs, Fact Sheet, July 2002 http://www5.myflorida.com/cf_web/myflorida2/healthhuman/ess/ssifactsheet.pdf

Department of Elder Affairs, Adult Family Care Homes http://www7.myflorida.com/doea/healthfamily/learn/elderservices/doeaafch.html

Department of Elder Affairs, Assisted Living http://www7.myflorida.com/doea/healthfamily/learn/elderservices/doeaalf.html

Department of Elder Affairs, Programs and Services http://www7.myflorida.com/doea/healthfamily/learn/elderprograms/doeaprogramsandservices.html

Florida Assisted Living Association (FALA), Member Legislative Update-May 15 http://www.falausa.com/legupdates/legupdate14.php4

Florida Administrative Code, Chapter 58A-5, Assisted Living Facilities and Chapter 58A-14, Adult Family Care Homes http://fac.dos.state.fl.us/faconline/chapter58.pdf

Florida Health and Human Services, Adult Family Care Homes http://www9.myflorida.com/Environment/facility/group/afch.htm

Florida Health and Human Services, Assisted Living Facilities http://www9.myflorida.com/Environment/facility/group/alf.htm

Florida Medicaid Program Summary of Services, 2002 http://www.fdhc.state.fl.us/Medicaid/sos.pdf

2002 Florida Statutes, Title XXIX Chapter 400, Nursing Homes And Related Health Care Facilities, Part III, Assisted Living Facilities http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=Ch0400/ch0400.htm

2002 Florida Statutes, Title XXX Chapter 409.212, Social and Economic Assistance, Optional Supplementation http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=Ch0409/SEC212.HTM&Title=-%3E2001-%3ECh0409-%3ESection%20212

Task Force on the Availability and Affordability of Long-term Care, House Bill 1993 http://www.fpeca.usf.edu/Task%20Force/Background/Legislation.htm

Recommendations from the Florida Assisted Living Association (FALA) http://www.fpeca.usf.edu/Task%20Force/Public%20Recommendations/recommendationsrecieved/Multi/falarecommendations.pdf

Recommendations from the Florida Association of Homes for the Aging (FAHA) http://www.fpeca.usf.edu/Task%20Force/Public%20Recommendations/recommendationsrecieved/Multi/faha.pdf

Recommendations from the Florida Life Care Residents' Association (FLiCRA) http://www.fpeca.usf.edu/Task%20Force/Public%20Recommendations/recommendationsrecieved/Multi/flicra.pdf

Recommendations from Larry Sherberg, Member http://www.fpeca.usf.edu/Task%20Force/Public%20Recommendations/recommendationsrecieved/Multi/sherberg.pdf

Formal and Informal Interviews

Shelly Brantley, Bureau Chief for Medicaid
Health Systems Development
Agency for Health Care Administration

Kathy Chisolm, Medicaid Waiver Specialist
Division of Statewide Community-Based Services
Department of Elder Affairs

Frank Ciotti, Program Specialist
SSI-Related Programs
Department Of Children and Families

Gayle Culpepper, Program Specialist
SSI-Related Programs
Department Of Children and Families

Martie Daemy, Florida Interim State Ombudsman
Department of Elder Affairs

Catherine M. Drompp, Program Specialist
Adult Services
Department of Children and Families

Mary Ellen Early
Senior Vice President of Public Policy
Florida Association of Homes for the Aging

Alberta G. Granger, Manager
Assisted Living Unit
Bureau of Health Facility Regulation

Julie G'Vitale, RN,
Owner and Administrator
Cambridge Inn Inc, ALF with ECC license, 46 beds

Bill Hiepe, Program Specialist
SSI-Related Programs
Department Of Children and Families

Bill Lupo, Executive Director
Rocky Creek Retirement Village

Larry Polivka, Director
Florida Policy Exchange Center on Aging

Jennifer R. Salmon, Assistant Director
Florida Policy Exchange Center on Aging

Larry Sherberg, President, FALA
Owner and Administrator
Lincoln Manor, ALF with LMH license, 55 beds

Victoria M. Sims, Medical Health Care Program Analyst
Health Systems Development
Agency for Health Care Administration

Horacio Soberon-Ferrer, Director of Planning and Evaluation
Department of Elder Affairs

Henry Taylor, Contract Management Administrator
Statewide and Community Based Services
Department of Elder Affairs

Jeannie Taunton, Supervisor
Comprehensive Assessment and Review for Long Term Care Services (CARES)
North West Florida Office

Keith Young, Medical/Health Care Program Analyst
Health Systems Development
Agency for Health Care Administration

e-mail respondent, not actually spoken to:

Bennett Napier, Executive Director
Florida Life Care Residents Association


ENDNOTES

  1. There were 703 SNFs (including SNUs) in the year 2000 in Florida, with 81,163 beds; 52,649 were Medicaid beds. (Personal communication, Jennifer Salmon)

  2. Due to state budget shortfalls, the income eligibility criteria was reduced in April 2002 from 90 percent to 88 percent of FPL (from $662 to $651), which resulted in a loss of Medicaid eligibility for an estimated 5,000 people in Florida.

  3. Two additional waiver programs that serve elderly persons are:

  4. Due to state budget shortfalls, the income eligibility criteria was reduced in April 2002 from 90 percent to 88 percent of FPL (from $662 to $651), which resulted in a loss of Medicaid eligibility for an estimated 5,000 people in Florida.

  5. Cost sharing is required in only three waivers: Long Term Care Diversion Project (Nursing Home Diversion Waiver), Assisted Living for the Elderly and Cystic Fibrosis. There is no cost sharing required in other waiver programs, unless the individual qualified under an income trust.

  6. The maximum payment is $78.40 per month.

  7. Florida Statutes, Title XXX, Chapter 409.212.

  8. Chapter 59G-1.010, Florida Administrative Code, defines medical necessity as medical or allied care, or services furnished or ordered that must be necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain.

  9. The financial and service eligibility information is taken from Kassner, E. and Williams, L., Taking Care of their Own: State-funded Home and Community-based Care Programs for Older Persons, AARP, September 1997. Other details of the programs are from the Department of Elder Affairs website and personal communications.

  10. One respondent felt that this program is more cost effective than the waiver program in preventing nursing home placement because many caregivers become financially dependent on the subsidy, which while not large, can be critical for a poor family. If this situation occurs, it may not always be in the best interests of the elderly person who needs services that the family can not provide.

  11. The information in this section draws heavily from Manard, B. et al., op.cit., with some additional comments from personal interviews with current state staff. Adult Family Care Homes were originally called Adult Foster Home (AFHs), a licensing category created in 1968 to provide a community housing alternative for mental hospital patients being de-institutionalized. While some de-institutionalized mental health clients were also sent to Adult Congregate Living Facilities, proportionally more were in Adult Foster Homes. Over time the program evolved to serve elderly persons almost exclusively.

  12. Personal communication.

  13. One respondent stated that providers do not seem to understand that the rate is a little higher based on the assumption that residents will be away from time to time.

  14. Manard, B. et al., op.cit.

  15. The information on the creation of the ECC licensing category is drawn from a report prepared for the Commission on Long Term Care in Florida, Assisted Living and Extended Congregate Care: The Florida Experience, by Larry Polivka, Victoria M. Sims and Jennifer R. Salmon, Florida Policy Exchange Center on Aging, August, 1996, with additional comments from a number of personal interviews conducted in October 2002.

  16. Salmon, J. R., et al., Affordable Assisted Living Facilities: Government-Sponsored Benefits for Reimbursing Assisted Living Services, Room, and Board, Florida Policy Exchange Center on Aging, Tampa, Florida, September 15, 2002.

  17. The maximum OSS payment is $78.40 per month.

  18. One respondent stated that providers do not seem to understand that the rate is a little higher based on the assumption that residents will be away from time to time.

  19. Staff must receive four hours of initial training covering understanding Alzheimer's disease; characteristics of the disease; communicating with residents; family issues; resident environment; and ethical issues. An additional four hours of training must be obtained within nine months of employment covering behavior management; assistance with ADLs; activities for residents; stress management for the caregiver; and medical information. Four hours of annual training must be obtained on topics specified by the Department of Elder Affairs (DOEA).

  20. Florida Statutes, Chapter 400 is the "institutional" chapter and covers nursing homes, adult day care centers, adult family care homes, and assisted living facilities. Chapter 430 covers the community based services, such as Community Care for the Elderly, Home Care for the Elderly, Alzheimer's clinics, Respite for elders, and others.

  21. F.A.C. 58A.5.0185(7)(f) states: "The facility shall make every reasonable effort to ensure that prescriptions for residents who receive assistance with self-administration or medication administration are refilled in a timely manner." The respondent was not sure if the rule is actually interpreted this way and if facilities are doing it or making sure families understand that this is a reason for discharge (i.e., not paying their medication bills).

  22. The Nursing Home Transition Program, which began last year, provides funding for eligible nursing home residents who can be cared for under the ALE Medicaid Waiver. Separate funding for these residents was again provided for the 2002-2003 fiscal year at $2,300,000. The Capitated Nursing Home Diversion Program increased funding to $30,916,013 and will create approximately 100 additional slots for this program. The state also directed AHCA and DOEA to jointly develop a plan to expand the opportunities for diversion projects in rural and underserved areas of the state.

  23. The Assisted Care Services (ACS) State Plan Amendment maintained current funding for the 2002-2003 fiscal year at $32,871,249, which includes $3,200,000 for program growth. The Assisted Living for the Elderly (ALE) Medicaid Waiver maintained current funding for the 2002-2003 fiscal year at $30,754,351.

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