The information in this appendix is presented in three major sections:
The first section provides an overview of the state's long term care system, with a primary focus on the Medicaid program. Although a state may pay for services in residential care settings through the Medicaid program, the program's financial eligibility criteria and related financial provisions for home and community services can present barriers to serving Medicaid clients in these settings. Thus, the first section of each state's description presents detailed information about rules related to financial eligibility, spousal financial protections, and cost sharing requirements.
The second section describes the state's residential care system.
The final section presents the views of respondents interviewed for this study on a range of issues related to Medicaid coverage of services in residential care settings in their state.
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.
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.
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.
Florida has a Medically Needy program for the aged, blind, and disabled, but nursing home care is not a covered service for the medically needy. In accordance with federal law, categorically eligible individuals in need of nursing home care--whose income exceeds the special income standard but is insufficient to cover the cost of care--may place income in excess of the special income level in a Qualified Income Trust, known as a Miller Trust, and receive Medicaid coverage for nursing home care and other Medicaid state plan services.
The monthly personal needs allowance (PNA) is $35 for individuals and $70 for couples. Persons who lose their federal SSI monthly payment upon entering a nursing home receive a federal PNA of $30. For these individuals, the state provides a supplement of $5 per month.
Community spouses may keep any income in their own name. The State allows the institutionalized spouse's income to supplement the community spouse's income up to a maximum of $2267.
The community spouse of a nursing home resident may keep up to the federal maximum of $90,660 in assets. The institutionalized spouse may keep $2,000 of assets or $5,000 if the individual's income is less than 88 percent of FPL. All assets over these amounts must be spent on nursing home care before Medicaid will begin to pay.
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.
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:
Require assistance with four or more activities of daily living (ADLs) or three ADLs plus assistance with medication administration; OR
Require total help with one or more ADLs; OR
Have a diagnosis of Alzheimer's Disease or another type of dementia and require assistance with two or more ADLs.
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.
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:
The Aged/Disabled Adult (ADA) waiver, which was implemented statewide on April 1, 1982. Generally, it does not serve people in residential care settings, only eligible individuals in their own homes.
The Assisted Living for the Elderly (ALE) Waiver serves recipients who reside in qualified Assisted Living Facilities (ALFs). The waiver program was implemented in 1995 as a small pilot and was expanded to statewide waiver status in 1997.
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.
Three groups are financially eligible for waiver services:
Group A includes individuals who are receiving SSI, and those who have incomes no higher than the SSI/SSP level.
Group B includes persons with incomes up to the special income standard of 300 percent of SSI, which $1656.
Group C includes individuals with incomes up to 88 percent of the Federal poverty level (FPL).4 The State uses 1902(r)(2) less restrictive income and resource methodologies for this group. Spousal impoverishment protections apply to community spouses.
Florida has a Medically Needy program for the aged, blind, and disabled, but HCBS waiver services are not covered for the medically needy. In accordance with federal law, categorically eligible individuals in need of nursing home care--whose income exceeds the special income standard but is insufficient to cover the cost of care--may place income in excess of the special income level in a Qualified Income Trust, known as a Miller Trust, and receive Medicaid coverage for waiver services and other Medicaid state plan services.
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
For those receiving waiver services in their own homes there is no cost-sharing obligation.
If an assisted living facility accepts the optional state supplement (OSS) rate for payment of room and board, OSS recipients may keep a personal maintenance allowance of $630.40, of which $54.00 is retained as a personal needs allowance, and the remainder-$576.40-is paid to the facility for room and board. Any income over $630.40 must be paid to the facility as the resident's share of service costs.
Assisted living facilities may not charge more than the OSS rate for room and board for Medicaid eligibles. There is no limit on the amount they can charge private pay residents for room and board.
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.
The maximum income protected for a community spouse--whether the waiver client is receiving services at home or in an assisted living facility--is the SSI standard, which is $552 per month. If the community spouse has less than this amount, the spouse in the assisted living facility can make up the difference. For example, if a waiver client living in an assisted living facility has a monthly income of $1200.40, and the community spouse has an income of only $200, the following calculations would be made:
Subtract $630.40 from $1,200.40 for the recipient's personal maintenance allowance (of which $54.00 will be retained by the resident as the PNA and $576.40 will be paid for room and board). The remainder is $570.00.
The SSI income standard of $552 is applied to the spouse, minus the spouse's $200 income, leaving $352.00 which can be diverted from the waiver recipient's remaining income ($570 minus $352 = $218).
The waiver client's cost-sharing responsibility is $218.
With few exceptions, all waiver programs consider applicants/recipients as individuals and only the assets in their names count in determining if their assets fall within program limits. The applicant/recipient may transfer assets to their spouse without penalty up to the federal maximum of $90,660.
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.
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:
Has a diagnosed degenerative or chronic medical condition requiring nursing services that cannot be provided in a standard licensed assisted living facility but are available in assisted living facilities licensed to provide Limited Nursing Services or Extended Congregate Care Services; or
Is a Medicaid-eligible resident awaiting discharge from a nursing home who cannot return to a private residence because of the need for supervision, personal care services, periodic nursing services, or a combination of the three; and
Is receiving case management, is in need of assisted living services as determined by the community case manager, and is determined to meet eligibility criteria.
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.
Two groups are financially eligible for Medicaid state plan services, including Assistive Care Services:
Group A includes individuals eligible for Supplemental Security Income (SSI) ($552) or those determined eligible for optional state supplementation (OSS).
Individuals who have monthly incomes below $630.40 ($1260.80 for a couple) and who live in residential care settings are eligible for OSS. They are allowed to keep a $54 personal needs allowance and the remainder ($576.40) is used to pay for room and board, which is the maximum that Medicaid residents can be charged.
Group B includes individuals with incomes up to 88 percent of the federal poverty level ($659.00 for an individual and $888 for a couple) who are enrolled in the Medicaid for Aged or Disabled program. The State uses 1902(r)(2) less restrictive income and resource methodologies for this group.
Florida's Medically Needy program does not cover Assistive Care Services.
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.
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:
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.
Contributions made by third parties shall be entirely voluntary and shall not be a condition of providing proper care to the client.
The additional supplementation shall not exceed two times the provider rate recognized under the optional state supplementation program.
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.
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
Health Support Component--defined as requiring the provider to observe the recipient's whereabouts and well-being on a daily basis; remind the recipient of any important tasks on a daily basis; and record and report any significant changes in the recipient's appearance, behavior, or state of health to the recipient's health care provider, designated representative, or case manager.
Assistance with Activities of Daily Living (ADLs) Component--defined as providing individual assistance with ambulating, transferring, bathing, dressing, eating, grooming, and toileting. At least one service component must be required daily.
Assistance with Instrumental Acts of Daily Living (IADLs) Component--defined as providing intensive assistance with shopping for personal items, making telephone calls, and managing money.
Assistance with Self-Administration of Medication Component--defined as assistance with or supervision of self-administration of medication at least daily in accordance with licensure requirements applicable to the facility type.
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
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 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
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.
An adult family care home must be enrolled as a provider in order to bill for Medicaid personal care services through the Assistive Care Services (ACS) program.
Services covered under ACS are expected to take an average of about one hour per day and are reimbursed at a single per diem rate of $9.28. There is a recommendation to increase the daily rate by $2.00.
ACS providers who serve Medicaid clients receive a total of $854.80 for 30 days to cover room and board and services.
No payment is made for ACS services if the resident is absent for as few as 24 hours. However, the ACS program builds an allowance into the rate that assumes the resident will be absent about 10 days a year.13
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.
The ECC licensure category was designed to allow residents to age in place but was not intended to be a scaled down nursing home license. Rather, it was intended to create a residential care entity that incorporated the values of the state's in-home programs: autonomy, privacy, dignity and aging-in-place in the least restrictive environment.
Initially, ECC services were only available to private pay residents. Few facilities serving lower-income residents applied for the license until the Assisted Living for the Elderly (ALE) waiver program was implemented as a small pilot in 1995 and was then expanded statewide in 1997.
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.
Four ALF licensure types are available: standard, limited nursing service, limited mental health, and extended congregate care. Facilities applying for a specialty license must first meet the criteria for a standard license.
In 2002, Florida had 2307 ALFs with 77,369 beds; of these, 3,207 were ALE waiver beds. In 2002, ALFs reported 13,338 potential beds for persons eligible for OSS and ACS, though as of June 2002, not all were filled.16 During the state fiscal year 2001-2002, the Assisted Living for the Elderly waiver program served 3,982 individuals.
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.
ECC facilities must provide rooms or apartments with lockable doors unless the resident's safety would be jeopardized. Residents not in private units must have a choice of roommates. Those that offer rooms rather than apartments must have bathrooms shared by no more than four residents. Private rooms must offer 80 square feet and shared rooms 60 square feet per resident.
Non-ECC facilities licensed after October 1, 1999, shall have a maximum bathroom occupancy of two persons. A toilet and sink must be provided for every six residents, and one bath tub or shower for every eight residents.
Facilities licensed prior to October 1999 may allow four people to share a bedroom.
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.
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 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.
Services in ALFs can be paid through a number of mechanisms:
Combined SSI/OSS payment for room and board
Assistive Care Services (ACS) under the Medicaid Personal Care option
Medicaid Assisted Living for the Elderly (ALE) waiver program
Payment from private resources of the resident or family for the full cost of room and board and services, or to supplement public payment sources. About 80 percent of ALF residents are 100 percent private pay.
Requirements include the following provisions:
An ALF must have an ECC or LNS license and must be enrolled as a provider in order to bill for services under the Medicaid Waiver program. The ALF must also provide private or semi-private rooms and bathrooms for all waiver clients.
Medicaid residents may be required to share the cost of services depending on their cost sharing obligation. The ALF can bill the maximum billable amount of $28.00 per day less the resident's required cost share. The ALF is responsible for collecting the cost share obligation from the resident. In addition to the daily rate, ALFs may bill Medicaid up to $125.00 per month for incontinence supplies.
Case management activities are provided by enrolled case management agencies and are paid on a fixed monthly rate of $100. Case Management agencies must be enrolled as Medicaid waiver providers and maintain a contractual relationship with the state. No cost-sharing is required for case management services.
Assisted Living Facilities participating in the ALE Waiver are required to bill Medicaid for both the ACS state plan service and the ALE waiver services for recipients who are enrolled in the waiver and have income below $730 per month. The services must be specified in the resident's plan of care and must not be duplicative. ACS is billed first, which in effect, saves waiver dollars.
An assisted living facility must be enrolled as a provider in order to bill for Medicaid personal care services through the Assistive Care Services (ACS) program.
Services covered under ACS are expected to take an average of about one hour per day and are reimbursed at a single per diem rate of $9.28. There is a recommendation to increase the daily rate by $2.00.
ACS providers who serve Medicaid clients receive a total of $854.80 for 30 days to cover room and board and services.
No payment is made for ACS services if the resident is absent for as few as 24 hours. However, the ACS program builds an allowance into the rate that assumes the resident will be absent about 10 days a year.18 There is no similar allowance built into the waiver rate.
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:
"Managed risk" means the process by which the facility staff discuss the service plan and the needs of the resident with the resident and, if applicable, the resident's representative or designee or the resident's surrogate, guardian, or attorney in fact, in such a way that the consequences of a decision, including any inherent risk, are explained to all parties and reviewed periodically in conjunction with the service plan, taking into account changes in the resident's status and the ability of the facility to respond accordingly.
"Shared responsibility" means exploring the options available to a resident within a facility and the risks involved with each option when making decisions pertaining to the resident's abilities, preferences, and service needs, thereby enabling the resident and, if applicable, the resident's representative or designee, or the resident's surrogate, guardian, or attorney-in-fact, and the facility to develop a service plan which best meets the resident's needs and seeks to improve the resident's quality of life. In 2001, a requirement to report adverse incidents to the licensing agency was added to the statute.
ALFs may admit and retain residents with dementia. No special license is required for dementia care unless an individual with dementia does not meet standard residency criteria. Training requirements have been increased for ALFs that market themselves as providing special care for persons with Alzheimer's disease or other dementias.19
ALFs with ECC licenses can adopt their own requirements for continued residency within regulatory guidelines and must provide each resident with a written copy of facility policies governing admission and retention. However, they may never retain residents who require 24-hour nursing supervision, which is equivalent to a skilled nursing level of care.
As stated in the assisted living statute, aging in place means the process of adjusting or increasing services to a person to compensate for the physical or mental decline that may occur with the aging process, in order to maximize the person's dignity and independence and permit them to remain in a familiar, non-institutional, residential environment for as long as possible.
ECC ALFs are required to promote aging in place by determining the appropriateness of continued residency based on a comprehensive review of the resident's physical and functional status; the ability of the facility, volunteers, family members, friends, or any other pertinent individuals or agencies to provide the care and services required; and documentation that a written service plan consistent with facility policy has been developed and implemented to ensure that the resident's needs and preferences are addressed.
A facility is not required to retain residents who require more services or care than the facility is able to provide in accordance with its policies and criteria for admission and continued residency.
Terminally ill residents may continue to reside in any assisted living facility if a licensed hospice agency coordinates services, an interdisciplinary care plan is developed, all parties agree to the continued residency, and all documentation requirements are maintained in the resident's file.
If an ALF resident no longer meets the criteria for continued residency, or the facility is unable to meet the resident's needs, the resident may be discharged as long as the facility provides at least 45 days' notice of relocation or termination of residency. Special provisions apply in specific situations, e.g., emergency relocations for medical reasons and harmful behavior.
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.
Because residential care facilities serve both private pay and Medicaid residents, a few respondents expressed views about the industry as a whole.
There is confusion among the public about long term care options.
One study showed that the most satisfied folks were those in assisted living, whereas people at home were not doing so well, primarily because there is a tremendous amount of unmet need at home.
Adults receiving HCBS services at home are like latch-key adults, they should be in an ALF, where we provide emotional security.
A number felt that the state was achieving its goals and being responsive to stakeholders.
I have been writing regulations since 1990 and supervising statewide training, and implementing the ACS program. It takes a long time but you do get to see some goals accomplished.
I am pleased with the willingness of the state to look at ideas and experiment and come up with different concepts, to listen to providers, and to be flexible; there is a good dialogue.
Comments about privacy in residential care settings indicated disagreement among providers and other respondents.
It is very clear that people want private rooms; it is so important in terms of their dignity. But sometimes, there are more than four in a room in an ALF, it looks like a ward.
The ECC regulations define "privacy" as encompassing dual-occupancy with a choice of roommate where possible. This is the stated philosophy of "privacy."
Sometimes when we're conducting surveys we see more than four individuals sharing a room in ALFs. In our work, we have found that the issue of privacy is very important to consumers, and single rooms are definitely preferred.
Some elderly people prefer to have a roommate as it gives them a sense of security.
There was disagreement about the need for additional adult foster care homes.
We should expand the use of adult foster care homes. They have slightly less stringent regulations, and are very successful in Oregon. In Florida the AFCH program has been shown to have good outcomes.
I disagree 100 percent that adult foster care homes should be expanded because they do not have enough oversight.
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.
The state added Medicaid funded personal care services because the state supplement was woefully inadequate to cover services.
People were becoming more frail and needing more services, but not qualifying for a nursing home, and couldn't afford a private ALF. Under ACS they can now get some services.
The waiver program has achieved the primary goals of cost saving, reduction in the nursing home bed base, and more humane alternatives. Each dollar spent on the waiver would have cost $2.70 cents in the nursing home. The Nursing Home Medicaid average cost is $2,835 per month.
More exciting than the ALE waiver was the inclusion of personal care in the Medicaid state plan and the creation of the Assistive Care Services program. It is the key to the state's efforts to provide additional revenues to ALFs.
ACS has been instrumental in attracting providers who were reluctant to take state supplement recipients in the past and provides Medicaid funding for frail elders who are not as impaired as waiver clients.
We have made some real strides, even in the last 5 years; it was a big step to get Medicaid funds into assisted living.
However, there were criticisms regarding unequal treatment for those with mental health diagnoses, and other inequities.
The biggest barriers in Medicaid are for those with serious mental illness (SMI). A high percentage of people receiving state supplements have SMI and have not been able to access Medicaid-funded services.
There is an arbitrary definition of mental illness according to income. In the statute it specifically states that persons with "certain psychiatric impairments who receive a state supplement" must be served in a facility with a Limited Mental Health (LMH) license. Because facilities that serve private pay residents did not want to meet LMH requirements, only poor people get a mental health diagnosis.
The waiting list for waiver services is prioritized by acuity levels. Based on acuity some people can wait two years for waiver services and others can be served straight away.
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.
ECCs should be regulated because they are providing nursing services. The only difference between nursing homes and ALFs is that nursing homes are an entitlement program. But many people served in both settings have the same needs.
Really sick people are being served in Extended Congregate Care ALFs, but you can find nursing home residents having a drink in a bar. Some nursing home residents have cars, one man was running his business from the nursing home.
ECC ALFs do not want to become mini nursing homes, we want to be part of home and community services. But in most peoples' eyes we are considered institutions; we need to get out of our 400 chapter, and into the 430 chapter.20
My biggest concerns about all these studies is that they will lead to additional requirements. We need to be aware of the diversity of ALFs in Florida. Prescriptive regulations do not help anyone. We need to be creative and respond to needs. Making facilities take more impaired people isn't a good idea either.
One had very strong recommendations about licensing and regulation.
We should abolish specialty licenses, that is, limited nursing services, limited mental health, and extended congregate care. ALFs are the residents' home and we should apply the same approach that is used when relatives can no longer provide proper care in the home, i.e., acquire more services through alternate resources. The individual should have a choice and the caregiver should have a choice. Delivery of care should be based upon the agreed tenets of shared risk or negotiated risk.
By moving ALFs out of Chapter 400 (Public Health, Nursing Homes and Related Health Care Facilities) and into Chapter 430 (Social Services, the Department of Elder Affairs), there would be more sharing of resources and consumers could be offered a greater selection of programs. I also suggest amending Chapter 430 to allow the governor to appoint an additional member to the Department of Elderly Affairs Advisory Council from the Florida Assisted Living Association. This would allow the assisted living industry to represent this continuum within the department's structure.
Several expressed concerns about specific licensing and regulatory requirements that were considered unnecessary and in some cases, added unnecessarily to costs.
We are in the people profession and we are being controlled by the politicians. You cannot legislate heart and caring, only criminal intent. How do you keep a homelike environment with all these signs on the walls?
Regulations should not get in the way of quality of life; they should address health and safety issues but not constrain the facility's ability to meet residents' preferences.
Rigid nutrition regulations are one of the industry's pet peeves. Facilities are required to prepare meals based on the pyramids, but nutritious meals may not provide the food that people like to eat.
I had a diabetic on medicine, she was in her 80s. The inspector wanted to know why she was eating chocolate cake. The question is, "Whose choice is it, the frail elder who requires services, the provider of the service, or the Government who is paying for the service?"
The rules state that a stock supply of over-the-counter medications for multiple resident use is not permitted in any facility and non-prescription drugs, when centrally stored, must be labeled with the resident's name. In practice, this means that I cannot give a resident an aspirin for a headache from a stock bottle.
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.
There are many unlicensed board and care homes providing services for private pay. It is an underground network; you can see them all around the neighborhood; they are family businesses, Filipino and Hispanic, which provide services to members of their communities.
There are board and care homes, unlicensed, that are not supposed to provide personal care services. But they do and try to get away with it. Residents with incomes higher than SSI will pay for services. But OSS and Medicaid won't pay for anyone in a facility that is not licensed.
No respondents mentioned lack of enforcement as an issue. A few said the state was doing alright and most facilities were in compliance.
Since Spring 2000, there has been statewide training for ALF surveyors to educate them on the different philosophy for assisted living as compared to nursing homes. They reorganized the survey offices so that there was a designated supervisor and primary surveyors for ALFs in each office.
The state just implemented Assistive Care Services a year ago, and did its first preliminary monitoring in August. Compliance was pretty good.
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.
In my facility 22 people came in unannounced.
Operation Spot Check was not cost effective and it was frightening for the residents. They didn't find anything wrong in most ALFS; there were more problems with the nursing homes.
All respondents felt there was a need to increase staffing levels in ALFs.
Nursing homes have minimum staffing requirements and are paying higher wages with better benefits. ALFs are vying for the same pool of staff and have no way of competing.
We need to increase the staffing levels; ALFs cannot have high quality without better staffing.
Two respondents mentioned abuse of residents by staff, but stated that it was atypical.
Staff abusing residents is the exception to the norm. We try to do criminal background checks. Given that Florida has over 2,200 ALFs, 600 nursing homes, and numerous home health agencies, the number of horrific incidences is not high. Florida is pretty safe.
Periodically, there are horror stories of violence occurring with no prior indicators--but they don't always involve staff--sometimes other residents and sometimes family. The same things that happen in the home and community can happen in a residential care setting. Just like you can't expect the police to have 24 hours oversight of your neighborhood, you can not expect that level of vigilance to prevent incidents in an ALF.
Many respondents felt the state needs to help individuals pay for medications if they are in a standard ALF and not eligible for Medicaid.
Residents living in ALFs or AFCHs who do not qualify for Medicaid because of too much income (e.g., those Medicaid clients who lost eligibility when the criteria was reduced from 90 percent FPL to 88 percent FPL) or who do not meet level of care criteria for the waiver, have only a personal needs allowance, which all residents retain regardless of income. This is totally inadequate to pay for medications as well as shoes or dentists. Sometimes elderly persons need to get new dentures because of old age or illness.
One of my residents no longer qualifies for Medicaid because she turned 62 and received an increase in her Social Security payment. Her medicines are over $400 per month and the facility is now having to pay for them, so I am losing money, but I can't throw her out on the street.
There is a regulation that could be interpreted to mean the facility is responsible for payment of medications. I went to a workshop on these rule changes and the trainer said that if the family or the individual does not pay for medications, the facility would be responsible for it.21
For people without families and resources, there is no backup, and it is left to the scruples of the provider whether to pay medication expenses themselves or discharge the resident.
I go to the drug companies with hardship cases, which requires loads of paperwork. I get samples from physicians and use generics. I also maintain a good relationship with the pharmacy to facilitate late payments of bills.
Most respondents were not in favor of adopting national standards or model standards for assisted living.
Every state has its own set of issues and conditions. For example, Florida has a higher percentage of elderly persons and the climate increases utility costs because we need air conditioning almost year round.
With assisted living there is no uniform type of resident, and unless we changed the entire program, there is no uniform type of provider.
Assisted living serves a very heterogeneous population: with and without families, demented, wards of the state. It wouldn't be fair to the people receiving the service to have standards that didn't take this into account. The states should be charged with setting the standards, using set guidelines under Medicaid, and incorporating relevant national standards. Each state has its own issues and problems.
There are different needs in different areas of the country. If you have a national standard, it has to be regionalized, to meet each state's unique needs.
However, a small number of respondents stated they would like to see federal standards.
We need regulations like the nursing home; we are deficient in ALF regulation; the state makes excuses saying the federal government does not say we have to do certain things.
I believe that there should be federal regulations for the type of staff because I am concerned about uncertified staff giving assistance with medication, particularly staff who don't know how to look for signs of adverse reactions.
I did a side-by-side comparison of draft national model standards and Florida's regulations, and Florida's were more stringent. I think model standards are good. If I had a facility I would want to use the national standards for guidance for running the facility.
Most respondents were satisfied with admission and retention regulations, but several raised concerns.
They are about right, I would like minor variations for standard ALFs. For example, under current regulations, if a resident's doctor orders support hose, that person needs to go into an ECC. Also, portable oxygen is controversial, but you see people in the supermarkets with it, so why not in a standard ALF?
I think the regulations for retention are fair, but when residents deteriorate staff may not pick up on it. The press have reported horror stories of people in ALFs who did not get the care they needed.
Mixing old and young folks in the same facility can work but can also cause problems between residents and there are no regulations for discharging an undesirable resident. Facilities need to give notice of 30 to 45 days, and it must be an appropriate discharge.
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.
Managed risk agreements do not hold up in law and there is opposition to them from trial lawyers.
There is confusion amongst consumers about negotiated risk agreements.
I have a friend whose mother has mild dementia and lives in an ALF. The facility wants to restrict her movements to a particular area. She doesn't wander but the facility is one mile from a highway, and the ALF is afraid she'll wander and be hit by a car. I advised the friend that if he believed his mother's quality of life is more important than her safety, to instruct a lawyer to draft an agreement that the family will sign to release the ALF from liability if the resident gets run over. But, typically, he hasn't done anything about it. The families want freedom for the residents, but they don't want to sign any special agreements releasing the facility from liability.
The residents are willing to live with the risk, but in Florida there are lawyers that advertise to the residents of nursing homes and ALFs. The Florida Supreme Court has ruled that however unethical it may be, it is not illegal. They suspended a license for 30 days when one lawyer was aggressively soliciting on people's doorsteps. The court said it was against the code; they are not supposed to solicit.
There is the case of a nursing home resident who got killed crossing the road in a wheelchair. They had crossed the road a thousand times before, so whose fault was it?
Neglect from a wet floor is one thing, but dying is a natural occurrence unless it happens in a licensed facility. Then it's something that is not supposed to happen.
Respondents noted a number of barriers.
The barriers to expanding assisted living for low-income elderly persons in general and Medicaid eligible persons in particular are limitations in the state budget and the cost of liability insurance.
Lack of money is the main barrier.
People in residential care are not eligible for public benefits such as food stamps. I think facilities don't qualify if they have over 22 beds. They also don't qualify for energy rebates, like the other community programs.
Combining funding streams would probably help, but it's extremely difficult to do so; most people do not have the inclination.
We had HUD housing and have applied to do a conversion, but in Florida the waiver is attached to a person not to a building. If I convert a floor using HUD dollars, I still need somebody to subsidize the care for the residents.
We need to get additional dollars, not just take money from the nursing home budget.
Expansion is very unlikely with current reimbursement rates. The biggest barrier that we have had in this state is the money. In 1994, when we started using the ALE waiver, payment was set at 62 percent of the nursing home rate; now it is 37 percent.
A big concern is that there has been only one cost of living adjustment since the waiver started. We had more providers involved, now it is decreasing. They can't afford to be in a program that pays you so far below the industry standard that it becomes impossible to make a living.
ALFs that serve people in Assistive Care Services and not the waiver do not get any reimbursement for incontinence supplies.
I could get more done if I had Medicaid dollars. I get no money for incontinence supplies, vitamins or preventive services.
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.
During monitoring visits, state staff sometimes find that residents' families are asked by the provider to contribute to the cost of a service when its cost exceeds the Medicaid cap. For example, the Medicaid cap for incontinence supplies is $125 but the resident may use $300 of supplies each month.
There is some confusion about whether family supplemental payments affect Medicaid eligibility. Up-charging is not strictly illegal, it is a stretch of state rules which allow third party supplementation.
Some higher pay facilities have contracts that will allow a resident to be in a private room if the family pays a supplement. Nobody is challenging it, and if we throw them off the program the resident will be on the street.
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.
My annual liability insurance premium has increased from $7,000 three years ago to $55,000.
Since January 1, 2002, no one can get ECC or LNS liability insurance. We are going backwards here in Florida, the closure of ECC beds will result in a reverse diversion of the low-income elderly on the waiver program back into nursing homes.
We are hearing that many facilities no longer have an interest in having ECC licenses, which will reduce the number of facilities licensed to serve waiver clients.
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.
I do not think that the new insurance will ultimately solve the problem. Tort reform is what is needed.
Risk Retention will solve the situation right now, but it is not the answer, we need tort reform.
Many respondents recommended tort reforms that would set a limit on compensation and punitive damages.
Now a plaintiff might get $150,000 for damages, but the facility gets hit with $2 million for punitive damages which goes to the plaintiff. Damage awards shouldn't just punish, they should be put into the industry to address the problems.
There were many different suggestions from providers, consumers and advocates, and not all were in agreement.
We want to see strict liability as specified in the statutes maintained as the standard for resident rights litigation. We do not want the medical malpractice model.
The same rules should apply to long term care facilities as to other health care providers, which are governed by negligence law rather than strict liability.
I would like to see the law changed so that facilities can be released from liability.
They should transfer liability to the state for people on Medicaid or add on the cost of insurance to the Medicaid reimbursement, similar to how they pay extra for case management.
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.
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.
The official line is to only go and look at the ECC residents, and for the most part the surveyors don't have time for much more, but some are overly zealous.
Another noted similar problems to participate in the waiver program.
Administrative headaches with the ALE waiver are a problem. The more hoops that you put up for the provider the less desirable it is to be enrolled in the program. The application process is very difficult.
Most of the recommendations were tied to funding and eligibility issues.
I would like to see greater expansion of assisted living by tapping into all the potential funding sources. We need to have Housing and Elder services talking to each other.
People should be able to get the state supplement and remain in their homes. Sometimes, a nursing home resident is discharged to a homeless shelter because they don't have enough money to pay rent.
I would raise the financial eligibility to 400 percent of SSI. There are many people who are middle class and have a parent who can pay $1,000 a month for an ALF, but they have no extra money to pay for medications, etc. I recommend a sliding scale for cost sharing.
The budgetary and insurance barriers could be overcome through cost of living adjustments and tying waiver reimbursement to a percentage of nursing home costs in each area. We also need tiered rates, and reimbursement that covers the extra cost of liability insurance.
The number one reason that people go into nursing homes is that they don't have a caregiver. I would change the Aged and Disabled Adult waiver, because it does not pay a caregiver subsidy like the state programs do, which is significant in keeping frail elders out of a nursing home.
I wish there were more targeting of the lower income folks. Right now, one-third of the folks on the waiver qualify at the 88 percent Poverty Level, and the other two-thirds are above that threshold. The waiting list should not be prioritized by acuity but by income.
The reimbursement for providers participating in the Assisted Living Waiver should be adjusted annually to cover increases in expenses, including liability insurance costs.
You need a program that says here is a pot of money, not earmarked for nursing homes, tie the money to the individual not to the program. Tie the Medicaid to an individual care plan, not to a program
We need tiered rates and we require a case manager to assess on a semi-annual basis, so the provider can report changes in levels of care.
Most respondents were optimistic about the future of assisted living, although realistic about the barriers to Medicaid funding as noted in the previous section.
Assisted living has to expand because it is cost effective. It is the best option for nursing home diversion.22
State plans to expand have not been articulated in writing, but are being discussed. There is a work group now trying to control the growth of nursing home beds. There is a moratorium on new beds, but some were already planned before the moratorium went into effect.
Right now there is a task force meeting to study ways to reduce the nursing home bed base. The nursing home industry doesn't want more Medicaid clients because the reimbursement is well below real costs. They are making money with Medicare, but they can't expand because of the moratorium.
Expansion of publicly-funded assisted living is inevitable. The future looks great, we have to look at how we spend our dollars because there are going to be less of them.
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.
The Robert Wood Johnson Coming Home program has helped to develop affordable assisted living in rural areas where before there was only the nursing home option. Grant dollars are available to develop programs that are maybe a little different then what we have seen already.
One respondent reported that the state could expand in-home services.
There is an amendment to the state constitution which would exempt from zoning regulations people applying for the conversion of single family residences to two family homes, so they can keep an elderly relative at home. It will be significant. It would not need licensing if it was only for relatives, and services could be funded through some of the State programs or the Aged and Disabled Adult waiver.
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.
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
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
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)
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.
Two additional waiver programs that serve elderly persons are:
The Consumer-Directed Care Research and Demonstration Waiver is an 1115 waiver program, which is available in certain counties for individuals receiving services through the Aged/Disabled Adult and other waivers. Individuals chosen to participate in the experimental group are allowed to "cash out" services on their current care plans and receive a monthly benefit through a fiscal intermediary to purchase services directly from a provider of their choice. The program was implemented in 2000. There was difficulty in getting CMS to approve operational protocols related to coverage of services in assisted living facilities.
The Medicaid Nursing Home Diversion (NHD) Waiver provides services to 868 functionally impaired elderly persons age 65 and over who are at risk of nursing home placement in Palm Beach and the Orlando area. Dual eligible (Medicare and Medicaid) individuals that meet clinical eligibility criteria may choose to receive both long-term care and acute care services under the NHD Waiver. Managed care providers that have contracted with the state under the NHD Waiver are responsible for Medicare co-payments and deductibles. Providers are reimbursed at a capitated rate, on a per member, per month basis to enrolled Medicaid providers.
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.
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.
The maximum payment is $78.40 per month.
Florida Statutes, Title XXX, Chapter 409.212.
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.
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.
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.
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.
Personal communication.
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.
Manard, B. et al., op.cit.
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.
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.
The maximum OSS payment is $78.40 per month.
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.
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).
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.
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).
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.
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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