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.
Minnesota has relied extensively on the institutional model of long term care since the 1960s, when the availability of federal funds for nursing home care spurred considerable growth in the state's nursing home industry. Nursing homes provide a more medical model of long term care than many elderly persons need or want, but have often been the only option available.
A moratorium on new nursing home beds has been in effect since 1983, and even though the elderly population is increasing, nursing home utilization has dropped. Because projected utilization indicates that Minnesota's current bed supply will be adequate through 2025, the moratorium on new nursing home beds will continue, except in situations of "extreme hardship," e.g., when a county's ratio of beds per 1,000 is very low.1
Because Minnesota still has the 6th highest number of beds per 1,000 persons age 85 and over in the nation, two recent initiatives have been undertaken to reduce the number of beds. First, in 2000, the state created the nursing home bed layaway program, permitting nursing homes to take licensed beds temporarily out of service and have those beds treated as though they were de-licensed. In the 18 months since enactment about 2,350 beds have been put in layaway and the occupancy level of remaining beds has reportedly increased substantially. Given the nursing home moratorium, without this program, nursing homes would be reluctant to de-license beds.
Second, in 2001, with the goal of accelerating the re-balancing of the state's long term care system, the state provided incentives for the closure of up to 5,140 nursing home beds during fiscal years 2002 and 2003. This program was combined with initiatives to conduct local long term care systems planning and to develop and expand home and community service programs. As of June 30, 2003, Minnesota had already closed 2,500 beds and had received applications to close another 2,000.
Three groups are financially eligible for nursing home services:
Group A includes persons with incomes no higher than the Federal poverty level (FPL), of $749. Individuals receiving federal Supplemental Security Income benefits (SSI) or state supplement payments (SSP), or who have incomes no higher than the combined SSI/SSP level ($552 + $81 = $633) are automatically included in this group.
Group B includes persons with incomes up to the special income standard of 300 percent of SSI ($1,656).
Group C includes medically needy individuals who spend down to 75 percent of the FPL. There is no upper limit on income, but income can be no greater than $562 after deducting medical expenses.2 The applicant may choose a 1 month or 6 month budget period for determining medical need.
Asset limits for all three groups are $3,000 for an individual and $6,000 for a couple.3
The monthly personal needs allowance for nursing home residents is $72. The Minnesota Supplemental Aid program, which is the state's SSP program, will pay a maximum of $42 to supplement the federal SSI $30 PNA for individuals who are no longer eligible to receive SSI because they are residing in an institution.
Community spouses may keep any income in their own name, and the state allows the institutionalized spouse's income to supplement the community spouse's income up to the federal maximum permitted, which is $2267 per month.4
The spouse of a nursing home resident may keep the greater of $25,601 or one-half of the couple's assets, up to a maximum of $90,660. All assets over this maximum must be spent on nursing home care before Medicaid will begin to pay.
Minnesota allows family supplementation for nursing home residents. A family can pay the difference in cost between a standard semi-private or a "nicer" semi-private or private room. The family can pay the difference as long as it is clear that the resident is receiving additional amenities only due to family supplementation.
The eligibility determination is made on the basis of a comprehensive assessment and the professional judgment of the assessors who use guidelines provided by the state. The criteria considered in the level of care determination include health and nursing needs, physical and mental functioning, and behavior. The state uses a case mix classification to determine eligibility. A person must have either functional or nursing needs to be eligible.5
Minnesota has had an Elderly Waiver program since 1988, which funds home and community services not normally covered under Medicaid for seniors who are at risk of nursing facility placement. The waiver program covers two types of services: those necessary to avoid institutionalization that are not offered in Minnesota's state plan, and those that are extensions of Minnesota's state plan services--"extended" to avoid institutionalization. Extended services allow more than the state plan in terms of type, amount, duration and scope of services and are only available to people eligible for waiver services.
The program is administered by the counties, and has a set number of slots. To date there has been no waiting list for waiver services in Minnesota. In the event that the state sees that the waiver slots are filling up, the state amends the waiver to include additional slots because it believes that the waiver services will save money by keeping people in the community. In FY 2002, the state served 12,208 waiver clients.
The Elderly Waiver program covers a wide range of services in a person's home or in certain residential care settings. Residential care settings include adult foster homes, both family and corporate, board and lodging homes, non-certified board and care homes, and apartment complexes called residential centers. Services include: skilled nursing, home health aide, homemaker, companion services, personal care assistants, adult day care, case management, home-delivered meals, respite care, supplies and equipment, transportation, limited modifications to the home and training for caregivers.
There are two packages of waiver services called Assisted Living and Assisted Living Plus, both of which are provided in approved residential care settings.
Three groups are financially eligible for waiver services:
Group A includes persons with incomes no higher than the Federal poverty level (FPL), which is $749. Individuals receiving SSI/SSP benefits, or who have incomes no higher than the combined SSI/SSP level ($552 + $81 = $633) are automatically included in this group.
Group B includes persons with incomes up to the special income standard of 300 percent of SSI ($1,656).6
Group C includes medically needy individuals who spend down to 75 percent of the FPL. There is no upper limit on income, but income can be no greater than $562 after deducting medical expenses.7 The applicant may choose a 1 month or 6 month budget period for determining medical need.
Asset limits for all three groups are $3,000 for an individual and $6,000 for a couple.8
For persons in Group B, there is a cost sharing requirement. Once individuals are receiving Elderly Waiver services, if they are living at home, they may keep $752 as a personal maintenance allowance in order to pay room and board and personal expenses. The remaining income, if any, must be paid toward the cost of care.
Elderly Waiver clients living in residential care settings also retain $752 as the personal maintenance allowance from which $72 is deducted as their Personal Needs Allowance, leaving $680 for room and board costs, which is the maximum that the state-funded Group Residential Housing supplement program will pay for low-income residents. The remaining income, if any, must be paid toward the cost of care.9
The spouses of waiver clients have the same spousal impoverishment protections as the spouses of nursing home residents, but only if the waiver client is 65 or older.10
Community spouses may keep any income in their own name, and the state allows the waiver client's income to supplement the community spouse's income up to the federal maximum permitted, which is $2,267 per month.
The community spouse of an Elderly Waiver client may keep the greater of $25,601 or one-half of the couple's assets, up to a maximum of $90,660. All assets over this maximum must be spent before Medicaid will begin to pay for services.
Minnesota allows family supplementation for the housing costs of waiver clients in residential care settings. Those receiving family supplementation remain eligible for waiver services.
Waiver applicants have to meet the same level of care criteria as nursing home applicants. The eligibility determination is made on the basis of a comprehensive assessment and the professional judgment of the assessors who use guidelines provided by the state. The criteria considered in the level of care determination include health and nursing needs, physical and mental functioning, and behavior. The state uses a case mix classification to determine eligibility. A person must have either functional or nursing needs to be eligible.11
A reassessment of an Elderly Waiver client is conducted at least every 12 months and when there has been significant change in the client's functioning, e.g., after a hospital discharge.
Minnesota covers personal care services under the Medicaid state plan through the Personal Care Assistance program. This program provides services to individuals who need help with daily activities to allow them be more independent in their own home. A personal care assistant is an individual who is trained to help with some basic daily routines for individuals who have a physical, emotional or mental disability, a chronic illness or an injury.
Two groups are financially eligible.
Group A includes persons with incomes no higher than the Federal poverty level (FPL), which is $749 as of July 2003. Individuals receiving federal Supplemental Security Income benefits (SSI) or state supplement payments (SSP), or who have incomes no higher than the combined SSI/SSP level ($552 + $81 = $633) are automatically included in this group.
Group B includes medically needy individuals who spend down to 75 percent of the FPL. There is no upper limit on income, but income can be no greater than $562 after deducting medical expenses. The applicant may choose a 1 month or 6 month budget period for determining medical need.
Asset limits for both groups are $3,000 for an individual and $6,000 for a couple.12
There are no spousal income and asset protections for community spouses of persons receiving personal care services in their home or in residential care settings. Only the spouses of nursing home residents and waiver participants receive income and asset protections.
Family payments made for support and maintenance may be counted when determining Medicaid eligibility, in accordance with SSI policy.
To be eligible for the Personal Care Assistance program, a person must require services that are medically necessary and ordered by a physician; and be able to make decisions about their own care or live with someone who can make decisions for them.
The services include assistance with:
Activities of daily living, including eating, toileting, grooming, dressing, bathing, transferring, mobility and positioning.
Health related functions, that, under state law, can be delegated or assigned by a licensed health care professional to be performed by a Personal Care Assistant.
Instrumental activities of daily living, including meal planning and preparation, managing finances, shopping for essential items, performing essential household chores, communication by telephone and other media, and getting around and participating in the community.
Redirection and intervention for behavior, including observation and monitoring.
The state has a Long Term Care Consultation Services (LTCCS) program that is funded by a combination of federal, state, and privately paid funds. Formerly called Preadmission Screening, the purpose of LTCCS is to assist persons with long term or chronic care needs in making long term care decisions and selecting options that meet their needs and reflect their preferences. The availability of, and access to, information and other types of assistance is also intended to prevent or delay certified nursing facility placements, thereby containing costs associated with unnecessary nursing facility admissions. In FY 2001, LTCCS conducted 62,570 assessments.
The state's Alternative Care program is funded solely with state revenues. It was implemented in 1991 and provides certain home and community services for persons age 65 and over, who are at risk of nursing home placement, have low levels of income and assets, but do not meet Medicaid financial criteria. The program is administered by counties, which may offer consumer-directed service options. The state caps the monthly cost of Alternative Care services at 75 percent of the average state Medicaid payment made for persons age 65 and older with the same case mix classification residing in nursing facilities.
The program offers a comprehensive array of home and community services including home modifications, adult day care, adult foster care, assisted living and residential care services
A person is eligible if their income and assets would be inadequate to fund a nursing facility stay for more than 180 days. Premium payments equal to 25 percent of the monthly service costs are paid by some enrollees (those with assets greater than $10,000). There is no cost-sharing obligation if an individual's available income is less than 150 percent of the FPL.
The same spousal impoverishment rules apply as for nursing home residents and waiver clients.
A person age 65 and older who is assessed through the Long Term Care Consultation Services process is eligible for Alternative Care funding when the person is in need of a nursing facility level of care and admission is recommended; and the person chooses to receive community services instead of nursing facility services; and no other funding source is available for the community services.
In the mid-1980s, after a nursing home moratorium had been in effect for several years, the State was increasingly concerned that many frail elderly persons, who once would have lived in nursing homes, were now living in a variety of unregulated out-of-home residential settings that lacked supportive services. In order to assure that they were receiving appropriate and adequate services, the Minnesota Department of Health proposed that many of these settings be regulated as residential care homes, with requirements modeled after nursing homes. In response, the Residential Care Home Licensing Act (RCHLA) was enacted. Due to opposition to the act, implementation was postponed while an alternative act, the Housing with Services Contract Act,13 was considered.
After reviewing the institutional type of regulatory system proposed in the RCHLA, the Minnesota Health & Housing Alliance met with hundreds of providers, consumers, and others and concluded that a consumer-driven model, using the well-understood concept of a legal contract, was a preferable regulatory model.
Both consumers and providers identified choice as a value that should be a dominant aspect of any quality assurance system for housing-with-services providers. Important aspects of choice identified were:
People have a right to make choices for themselves.
People should be assumed to be competent to make their own choices. Those who may not be competent should receive assistance.
Consumers have a right to be educated and informed about providers' policies and procedures and the services they are purchasing.
Any system focusing on choices must consciously accept that choices entail risks and that consumers will sometimes make decisions that others perceive as "bad choices."
The Housing-with-Services Contract Act was developed by the MHHA over a four-year period and was passed in 1995, effective in 1996. The Act covers a broad spectrum of senior housing in Minnesota called "Housing-With-Services Establishments." The term was chosen because of its general nature, which can be applied to a wide range of settings and levels of services. Different types of residential care settings market themselves as "assisted living," but there is no category of licensure called "assisted living facility."
With the passage of the Housing-with-Services Contract Act, Minnesota initiated an innovative approach toward assuring quality in residential care settings by making a conscious decision to avoid a detailed, prescriptive regulatory system. Instead, Minnesota adopted a more flexible, consumer-driven model, which is based on the concepts of consumer choice and negotiated risk. This approach gives consumers a choice of a variety of physical settings and service packages, and permits providers to develop innovative housing with services models.
The contract between the housing provider and the resident is the primary mechanism for assuring quality. By reviewing information in their contracts and negotiating items related to their individual needs, consumers receive the information they need to make informed decisions about where to live and the services they want. The signed contract is a legal document that sets standards for the housing-with-services provider and, if necessary, can be legally enforced.
While the overall quality assurance mechanism for housing-with-services is under the control of the resident, the Minnesota Department of Health does regulate residential care settings and surveys health-related services, which are considered to be critical to the well-being of frail residents. (See Licensing below) In addition, Minnesota Department of Health has the authority to intervene if it appears that a building is out of compliance with the Contract Act.
The Contract Act requires all Housing-With-Services Establishments to:
No specific format is required for the contract. The state does not approve contracts but may review them upon request. The legally enforceable contract with the building owner has 17 mandatory items that must be addressed, including:
In addition to the requirements of the Contract Act, Housing with Services Establishments must comply with a variety of other state and federal laws, such as Minnesota's Vulnerable Adults Act, the Nurse Practice Act, landlord-tenant law, criminal background check laws, contract law, and civil rights laws such as Fair Housing and the Americans with Disabilities Act. State and local building and fire codes, lodging licensing, food/restaurant licensing, adult foster care licensing, zoning and other local requirements are applicable to these establishments as well.
Residents in facilities that are not required to register as Housing With Services Establishments do not have the protection of a legal contract, and these facilities are surveyed only for environmental compliance in terms of the physical plant and kitchen. If a resident receives waiver services in these settings the services are provided by a licensed home health entity and the resident's case manager oversees the services.
In 2001, the state enacted legislation creating disclosure requirements for Alzheimer's special care units. The legislation states that Housing With Services Establishments that secure, segregate, or provide a special program or special unit for residents with a diagnosis of probable Alzheimer's disease or a related disorder or that advertise, market, or otherwise promote the establishment as providing specialized care for Alzheimer's disease or a related disorder are considered a "special care unit."14 Special care units are required to provide a written disclosure addressing the following areas:
The legislation also included requirements that the facility's direct care staff and their supervisors must be trained in dementia care. Areas of required training include: an explanation of Alzheimer's disease and related disorders; assistance with activities of daily living; problem solving with challenging behaviors; and communication skills. The establishment shall provide to consumers in written or electronic form a description of the training program, the categories of employees trained, the frequency of training, and the basic topics covered.15
Regulations implementing the Housing with Services Contract Act were effective in 1996 and required services to be provided through licensed home care provider agencies.16 A home care license may be obtained by the same entity that owns the housing, or the housing entity may develop an arrangement with an outside home care agency to provide the services. Categories of licensure for home care providers are as follows:
Class A provider--traditional professional home health agency that serves the community in private homes as well as in housing with services establishments. A subset of Class A providers are also Medicare certified. Home care agencies provide one or more home care services, at least one of which is nursing services, physical therapy, speech therapy, respiratory therapy, occupational therapy, nutritional services, or medical social services.
Class B provider--paraprofessional home care agency that provides only personal care or home management services.
Class C provider--a home care provider who is an individual providing only personal care or home management services.
Class D provider--a provider of a hospice program.
Class E provider--a provider of individualized personal care services or home management services to residents of a residential center in their living units, when the provider is either the management of the residential center or another provider under contract with the management. "Residential center" means a building or complex of buildings in which residents rent or own distinct living units.
Assisted Living Home Care Provider--means a home care provider who provides nursing services, delegated nursing services, other services performed by unlicensed personnel, or central storage of medications, solely for residents of one or more Housing With Services Establishments. The housing entity must be registered as a housing with services provider to be eligible for this license.
The Assisted Living Home Care Provider license was created in August, 1999, specifically for Housing with Services Establishments, to address the industry's desire to have unlicensed personnel provide the same services as a Class A agency, under the supervision of a registered nurse, thereby making the services less costly.
The Assisted Living Home Care Provider rules allow medication administration. Staff who administer medications and actively assist with self-medication must complete the appropriate assisted living training program and be instructed by a registered nurse in the procedures to administer the medications to each client/resident. The instructions are specific to each resident and must be written, and the person must demonstrate competence in following the instructions.
When the new category of licensure was created, the state also changed the licensing requirements for some settings, and added a new service, called Assisted Living Plus (AL+), to the menu of services already provided through the Elderly Waiver and the state's Alternative Care program. Assisted Living Plus can only be provided in Housing with Services Establishments that meet the home care provider standard of either a Class A license or the new Assisted Living Home Care license.
The most common licenses for Housing With Services Establishments are the Class A home care provider license, the Class E provider license, and the Assisted Living Home Care Provider license.
The registered nurses and licensed practical nurses who provide nursing services and oversee unlicensed caregivers in all residential care settings must comply with the Nurse Practice Act, which is monitored by the Minnesota Board of Nursing. The central storage of medications, which is permitted in a Housing with Services establishment under the Assisted Living Home Care Provider License, is managed under a system that is established by a registered nurse and addresses the control of medications, handling of medications, medication containers, medication records, and disposition of medications.
Minnesota envisions assisted living as a service not as housing. Assisted living services are available in multiple settings, including senior housing, foster care, purpose built settings and other congregate housing. In this way the state provides an option for people who are unable to remain in their own home and need supportive services to avoid nursing home placement. The state does not regulate a specific category of facilities called assisted living. Instead, the state regulates services provided in residential care settings through the various home care provider licenses described above.
Not all residential care settings are considered Housing-With-Services Establishments. The state specifically excludes the following residential care settings from the Housing-with-Services establishment category:
Not all Housing-With-Services Establishments have to be separately licensed in some way. For example, an apartment building with separate units has only to comply with local building codes. However, buildings with a central kitchen may be required to have a food license.
In most cases, an "umbrella requirement" of Housing with Services registration is superimposed over the separate regulation of services and facilities. The state requires any establishment providing sleeping accommodations to one or more adult residents, at least 80 percent of whom are 55 years of age or older, and offering or providing, for a fee, one or more regularly scheduled health-related services or two or more regularly scheduled supportive services, to register with the Minnesota Department of Health as a Housing with Services establishment.18
Supportive services are defined to include only the following: help with personal laundry; handling or assistance with personal funds of residents; or arranging for medical services, health-related services, social services, or transportation to medical or social services appointments.19
Health-related services are defined to include professional nursing services; nursing services delegated to aides (such as medication administration), bathing and other personal care; and other services that may be performed by paraprofessional staff (stand-by assistance with dressing or grooming); and central storage of medications.
Services provided in Housing-With-Services Establishments must be provided through licensed home care provider agencies. The Housing with Services entity may obtain such a license or contract with a licensed agency. Services usually include some combination of supportive and health-related services. The various service programs may or may not have caregivers or other staff on-site 24 hours a day. Residents can contract for services with the owner of the building if the owner has a home care provider license or they can obtain services from an outside agency that has a Medicaid license.
Buildings registered as a Housing with Services Establishment may vary in size and type and include corporate adult foster care settings, board and lodging establishments (without individual kitchens), non-certified boarding care homes, and apartment buildings. Consumers choose the housing-with-services setting that they believe will best meet their needs. Medicaid pays for services through the Elderly Waiver and the Personal Care option for eligible individuals in all of these settings, which are described in the following sections.20
Adult foster homes provide food, lodging, supervision, and household services in a small, family-like setting. They may also provide personal care and medication assistance. Some adult foster homes have to register as Housing-With-Services Establishments and some do not. Effective August 2, 1999, the state made a distinction between family and corporate adult foster care, and authorized new services names as follows:
Family Foster Care is a service or group of services provided in a residence of 1 to 5 clients that is licensed by the Department of Human Services under Rule 20321 or certified by the county. The residence must be the primary residence of the license holder and the license holder must be the primary caregiver. The setting is exempt from registration as a Housing with Services Establishment.
Corporate Foster Care is a service or group of services provided to 1 to 5 clients in a home- like setting with shared common spaces where the license holder is not the primary caregiver and/or the residence is not the primary residence of the license holder. Hired staff provide care. A few adult foster care "suites" have been created within larger apartment buildings. Most of the corporate foster care homes in Minnesota are designed specifically to serve those with memory loss.
This setting is licensed by the Department of Human Services under Rule 20322 and is exempt from registration as a Housing with Services Establishment, unless 80 percent of the individuals served are 55 years of age or older and the provider offers one or more regularly scheduled health-related services or two or more regularly scheduled supportive services.
Any licensed adult foster care provider may provide family adult day care under their foster care license if all the recipients are 60 years and older, none of the recipients are seriously and persistently mentally ill or developmentally disabled and the combined number of people receiving adult foster care and adult day care does not exceed the number licensed for adult foster care.
Resident bedrooms must meet the following criteria: (1) A single occupancy bedroom must have at least 80 square feet of floor space with a 7-1/2 foot ceiling. A double occupancy room must have at least 120 square feet of floor space with a 7-1/2 foot ceiling.
Residential care homes are licensed as Board and Lodge Homes with Special Services under Chapter 157.17 and are not required to register as Housing with Services Establishments because they have their own regulations under that chapter.23 They serve a predominantly non-elderly population, but occasionally serve an elderly resident. The governing statute refers to these homes as Residential Care Homes, and the services provided are called residential care services.
If a Board and Lodge Home meets the housing-with-services criteria--i.e., 80 percent or more of its residents are aged 55 or older and they are providing services according to the rule--they must register as a Housing with Services establishment, obtain a home care license, and provide the services under that home care license. If a provider does not acquire a home care license, arrangements can be made for a licensed home care agency to provide the necessary services. Waiver services delivered in this setting are then no longer called Residential Care services, but are called either Assisted Living services or Assisted Living Plus services, depending on which package of services is provided.
Settings may vary greatly in size, some resembling small homes and others large apartment buildings. Residents have private or shared rooms, but do not have individual kitchens.
In addition to three meals per day, many settings offer a variety of supportive services (such as housekeeping and personal laundry) or home care services (such as help with dressing and bathing, medication administration, etc.) and may also provide a full range of health-related assisted living services.
Board and Lodge Homes in which assisted living waiver services are provided are mostly high-end homes which typically provide a private room and private bath with congregate dining, i.e., no private kitchen or kitchenette. Older settings will have some double rooms, but the recent trend has been to develop private rooms with a private bath.
Non-certified boarding care homes are licensed as health care facilities by the Minnesota Department of Health, but they are often quite homelike. These homes are not certified to participate in the Medicaid waiver program, although qualifying residents may receive Medicaid waiver services provided under a home care license from an outside provider. They may also register as a Housing with Services establishment provided they obtain a home care license.
These settings may not accept or retain residents for whom care cannot be provided in keeping with their physical, mental, or behavioral condition.
At least five percent of the rooms in these settings must be designed for single-person occupancy (one bed) and have private toilets. At least 75 percent of the beds must be located in rooms designed for one or two beds. No room may have more than four beds.
In existing facilities, the usable floor area per bed shall not be less than 100 square feet for single rooms; 80 square feet for two-bed rooms; and 70 square feet for three- or four-bed rooms. In new construction the usable floor area per bed shall not be less than100 square feet for single rooms, and 80 square feet for two-, three-, or four-bed rooms.
Residential centers are another type of setting in which Medicaid waiver services can be provided. The state defines a residential center as a building, or a complex of contiguous or adjacent buildings with 3 or more separate and distinct living units in each building, which residents rent or own. With such a broad definition, there are many types of residential centers.
Some are market-rate apartment buildings designed specifically to serve frail seniors, and some are either market rate or HUD subsidized apartment buildings that are arranging services for residents who are aging-in-place. Some HUD buildings arrange for services using the HUD service coordinator model, which is paid for by public housing funds.
The Class E home care provider license was created specifically for residential centers that were providing fairly light services, such as individualized personal care services or home management services (also called Assisted Living waiver services), and therefore does not allow the provision of Assisted Living Plus waiver services. In order to provide the higher level of care, the residential center would need to be licensed as a Class A provider or contract with a Class A agency to provide the services. If the residential center is registered as a housing-with-services establishment, it would also have the option of providing services under the Assisted Living Home Care Provider license.
Since the new licensure category of assisted living home care provider came into effect, at the same time as the assisted living plus service package, there are now fewer residential centers using the Class E license.
Residential centers do not have to register as a housing-with-services establishment unless they provide sleeping accommodations to one or more adult residents, at least 80 percent of whom are 55 years of age or older, and offer or provide, for a fee, one or more regularly scheduled health-related services or two or more regularly scheduled supportive services.
Each type of residential care setting must meet its own licensing and regulatory requirements, which can include physical plant requirements. For example, adult foster care and boarding care establishments have physical plant requirements and rules regarding shared rooms. Minnesota does not require residential care settings registered as housing-with-services establishments to meet any additional specific physical plant requirements.
Regarding the provision of private rooms for low-income, publicly supported individuals, their availability depends on the residential care setting and its location. Some market-rate projects--whether apartments or board and lodges--can provide private rooms or apartments for Medicaid waiver clients, particularly where the state's Group Residential Housing (GRH) supplement (see Room and Board Payment below) is adequate or where the private pay rental revenue from other residents can help subsidize the costs of the low-income resident.
The Medicaid waiver program strongly supports the provision of private rooms and counties will negotiate placements with residential care settings in order to provide Medicaid clients with privacy. A few settings have private foundations that can help low-income residents pay the shortfall between what they (or the GRH supplement) can pay and the actual costs.
However, in many board and lodging or adult foster care settings, Medicaid wavier clients may share a room with another resident, while private pay residents may have the option of paying higher rents for a private room. A GRH client living in a shared room could move to a more expensive private room if the family was willing and able to pay the difference between the GRH rate and the rent.
Residents who receive services through the Elderly Waiver program, the Personal Care option, or the state's Alternative Care program must pay rent and raw food costs from their income. Room and board or rental rates are not defined or controlled directly by Medicaid or the Alternative Care program. However, Medicaid's financial eligibility rules do limit the amount of income that Elderly Waiver or Personal Care clients will have available to pay rent or room and board. If the client has inadequate income for room and board, the client may be eligible for the state's Group Residential Housing program.
Group Residential Housing (GRH) is a state-funded income supplement program that pays for room-and-board costs for low-income adults in a licensed or registered setting with which a county human service agency has negotiated a monthly rate. In FY 2002, the state spent approximately $75 million serving a monthly average of 12,425 disabled and elderly people. Approximately 9 percent of GRH recipients are seniors receiving Elderly Waiver services.
Aged, blind or disabled adult individuals with incomes no higher than the maximum GRH payment and assets no higher than $2,000 are eligible for the GRH program.24 If a person is eligible for the GRH program, he or she is eligible for Medicaid. To be eligible for the program, individuals must also be at risk of institutional placement or homelessness.
The amount of the GRH payment is based on a federal/state standard of what an individual would need, at a minimum, to live in the community. The maximum GRH room and board payment limit in 2003 is $680.25 A person eligible for SSI and receiving $552 would get the full state supplement of $81, retain a personal needs allowance of $72, and then the GRH payment would make up the difference of $119. If income is from a source other than SSI, there would be the same $20 SSI disregard applied, and then the personal needs allowance deduction of $72, and the GRH program would pay the balance up to $680. The GRH payment is made directly to the provider of housing on behalf of the eligible person.
The GRH rate is automatically adjusted each year based on changes made in the SSI benefit rate, changes in the value of Food Stamps for an individual, and change in the personal needs allowance.
Residential care settings eligible for GRH supplements include Adult Foster Care Homes, Board and Lodging Establishments, non-certified Boarding Care Homes and various residential settings registered under the Housing with Services Act. A county human service agency must approve placement in the GRH setting. There are over 4,800 GRH settings in the state.
Although three meals per day are provided by many assisted living programs, other assisted living programs in apartment buildings where residents have their own kitchens may offer only one or two congregate meals per day. These latter settings would not qualify for a GRH payment because it includes a full board component of three meals a day.
If the base room and board rate pays for a bed in a double room, a resident's family may pay extra for a private room, but settings with GRH agreements must be able to accommodate clients whose income limits them to the GRH rate. To contract with a county to be a GRH setting, a provider has to have at least one unit available for the GRH room and board rate. Family supplementation of the GRH rate may only occur if the other unit is "substantially better" such as being larger, better view, better amenities etc.
GRH does allow payment within limits for room and board costs if a person is temporarily absent from the establishment and is expected to return. GRH can pay up to 18 days per episode of absence, not to exceed 60 days in a calendar year, for a GRH recipient who is temporarily absent.
Residential care settings may have specific service requirements and limitations based on their particular licensing category. Beyond those requirements, they may choose from an array of possible "supportive" and "health-related" services to develop their own service packages based on the needs of their community and their target market.
Services furnished or arranged for by a provider may include supervision, supportive services, individualized home care aide tasks, individualized home health aide-like tasks, and individualized home management tasks (see description below). Individualized means services are chosen and designed specifically for each resident's needs, rather than provided or offered to all residents regardless of their illnesses, disabilities, or physical conditions.
Supervision is defined as a service which includes an ongoing awareness of the residents' needs and activities. It is provided by an employee of the assisted living provider whose primary job responsibility is to supervise residents of the congregate living setting, and who is capable of communicating with residents, recognizing the need for assistance, providing the assistance required or summoning appropriate assistance, and following directions.26
The setting must provide the resident with a means to summon assistance, for example, with a pull cord near the toilet, and the employee must be able to respond, in person, to the request for assistance within a reasonable amount of time, not to exceed 10 minutes, depending upon the physical plant.
Supportive services includes assisting clients in setting up medical and social services, assisting clients with funds, arranging for or providing transportation, and socialization (when socialization is part of the plan of care, has specific goals and outcomes established and is not diversional or recreational in nature),
Home care aide services include:
Home health aide-like services include:
Home management tasks include housekeeping, laundry, preparation of regular snacks and meals, and shopping.
Home care provider regulations cover the service agreement, which includes a description of the service to be provided and the frequency of each service, the persons or category of persons who will provide the service, the schedule or frequency of sessions of supervision or monitoring, fees for each service, and a plan for contingency action if scheduled services cannot be provided.
Providers may not accept anyone whose service needs they cannot meet. Orientation and training are required based on the tasks performed by the worker.
Providers of any service must hold all required license(s) and/or registration(s). The county is responsible to take all necessary steps to ensure that such license(s) and/or registration(s) are current, and that providers meet applicable provider standards as stated in state or federal statute or rule.
Counties must develop a contract for Elderly Waiver or Alternative Care services with providers before any services can be approved. Each setting must be licensed to provide a distinct set of services and each provider may choose to provide some or all of those services they are licensed to deliver, depending upon their mission and their targeted market.
Minnesota began covering services for aged and disabled beneficiaries under the Elderly Waiver program in 1988. Waiver services are provided both in people's homes and in residential care settings. In FY 2001, the Elderly Waiver program served 2,895 beneficiaries in 291 residential settings.
Although the Elderly Waiver program has provided services (and some service packages of bundled Medicaid services) for many years to elderly persons in residential care settings, the development of the Assisted Living and the Assisted Living Plus service packages for the Elderly Waiver program (and the state's Alternative Care program) helped facilitate the provision of a more comprehensive set of services, particularly under the Assisted Living Plus program, in Housing-With-Services Establishments. With "packaged" or bundled services, Medicaid can reimburse for "generalized" services such as supervision, that could not easily be billed on a fee-for-service or hourly basis.
The state's Medicaid waiver program defines Assisted Living Services as "up to 24-hour oversight and supervision, supportive services, home care aide tasks and individualized home management tasks…" Under the Elderly Waiver program (and Alternative Care), residents may also receive home health and skilled nursing services, which are reimbursed separately from the payment for assisted living services.
The provider requirements for offering the Assisted Living and Assisted Living Plus packages are as follows:
Assisted Living Providers must be either:
registered as a Housing with Services Establishment AND licensed as a Class A Home Care Agency or a Class E Home Care Agency or an Assisted Living Home Care Provider, OR
be a Class A Home Care Agency contracting directly with the county to provide the Assisted Living package of services to persons in a congregate living setting, OR
be a Class A Home Care Agency or a Class E Home Care Agency delivering services in a residential center which is exempt from registration as a Housing with Services Establishment.
Assisted Living Plus providers must meet more rigorous standards. They must be both:
Registered as a Housing with Services Establishment, AND
Licensed as either a Class A Home Care Agency or an Assisted Living Home Care Provider, AND
The Assisted Living Plus service package they provide must include 24 hour supervision.
Both Assisted Living and Assisted Living Plus service packages can be provided in the following settings:
As a general rule, services provided in all settings that are registered as Housing with Services Establishments are called Assisted Living or Assisted Living Plus. If the provider is not so registered, the name of the services will be different, e.g., Corporate Foster Care in Corporate Adult Foster Care Homes or Residential Care Services in Board and Lodge establishments, and they will carry different payment codes.
In the last legislative session, the Housing with Services Act was modified to allow residential care settings that don't have at least 80 percent elderly persons to voluntarily register as Housing with Services Establishments, thus enabling their residents to be served with the Assisted Living Plus package. However, they were specifically prohibited from receiving new Group Residential Housing payments unless they already had a GRH contract with the county. The GRH budget is a state forecast-spending amount based on demographics, and under the Governor's budget proposal at the time, could not be increased to accommodate any increase in utilization.
The state uses a case-mix classification system to reimburse Assisted Living and Assisted Living Plus services. Individuals must fit into one of eleven case-mix categories, four of which include people with behavior problems. The lowest category is for people with few or no Activity of Daily Living (ADL) dependencies. Someone with cognitive and other mental impairments without ADL dependencies could fit in this category.27
The Elderly Waiver program and the state's Alternative Care program set a maximum rate for providers for a package of services. Each county determines what services are included in its "base service package" and negotiates a rate for those services, which may not be the maximum allowed under the programs. Currently, service providers do not have information to determine which services should be included in a basic assisted living service package in order to receive the maximum allowable rate.
Half of the Elderly Waiver and Alternative Care budgets is spent on Assisted Living services. To assure appropriate payment levels, the state has been developing a rate negotiating tool for counties to use for the Assisted Living and Assisted Living Plus packages. The tool is intended to ensure the provision of only those services actually needed by residents. Oversight and supervision will be specifically addressed as the majority of residents do not need 24 hour oversight, or supervision beyond what is needed for ADLs. The tool will help to specify exactly how much supervision is required, which is particularly important for persons with cognitive impairment.
Clients' service needs are unique to each person in each setting and must be addressed individually in the contract language. However, there are certain principles involved in developing and negotiating a contract for packaged services, including:
Counties have the option of creating a "base rate" that defines payment to the provider for certain services all residents of the setting receive, such as supervision or meal preparation. The law says that each client is to receive an individualized service plan and that the county only pays for those services in that service plan. However, if all the clients referred to a particular provider always need a particular set of services, the county may have a "base rate" set for those services and, in addition to that rate, pay for the other individualized service needs of each person. Thus, the base rate may or may not include personal care services. When the contract is renewed, the county has the option to re-negotiate rates, based on of increases or decreases in the amount of funding available from the state.
Service package payments are limited to services that meet chronic needs. Services that meet episodic or acute needs should not be included in the package, but should be billed on a fee-for-service basis to the appropriate payer. These payers include fee-for-service Medicaid, Pre-paid Medicaid, Medicare or private insurance.
Personal care services (which meet chronic client needs) and incidental nursing services (which are limited to medication set-ups and the drawing up of insulin) may be included as an Assisted Living service, payable by the Elderly Waiver or Alternative Care programs. Those that are not included in the Assisted Living or Assisted Living Plus group of services (e.g., those for episodic or acute needs) must be delivered by a Medicare certified Class A Home Care agency or by the client's Prepaid Medical Assistance Plan provider (the state's managed care program.)
Individualized service rates negotiated within a payment package should not exceed the fee-for-service rate limits for similar services delivered outside of an Assisted Living or Assisted Living Plus group of services.28
Per state and federal regulation, payment shall not be made for homemaking service in addition to the Assisted Living service payment package; it is expected that any homemaking service needed is always included within the payment package.
Contracts for Assisted Living or Assisted Living Plus services must enumerate which appropriately licensed services are offered by the provider and the service payment methodology the county will use to pay for each needed service.
Although county contracts with Residential Care, Family Foster Care or Corporate Foster Care providers may not detail the service rate payments for each service provided to Alternative Care or Elderly Waiver clients to the same level that Assisted Living or Assisted Living Plus contracts do, the service(s) these providers are responsible for delivering to Alternative Care or Elderly Waiver clients must be detailed in the client's care plan.
The Assisted Living Plus package, which can only be provided to residents of a Housing with Services Establishment, permits counties to approve monthly packages under the maximum rate available to the client.
The Elderly Waiver monthly service plan limit is the statewide average monthly Medicaid payment rate to nursing facilities for the 11 case mix categories to which the person would be assigned under the Medicaid case mix reimbursement system.29 Around 90 percent of Elderly Waiver participants fall into the first five of the eleven categories, the monthly rates for which range from $1,963 to $2,985.30
For Elderly Waiver clients who do not participate in a Pre-Paid Medical Assistance Plan (PMAP), a state managed care program, the cost of all state plan home care and Elderly Waiver services including extended medical supplies and equipment, skilled nursing, home health aide, and personal care services reimbursable by Medicaid are included when determining the cost effectiveness of Elderly Waiver community support plans. For PMAP clients, some of these services are services provided under the PMAP contract and premium.
Additional services, which do not duplicate any of the services provided by the Residential Care or Assisted Living service package, may be added to the person's community support plan and authorized for payment if the total cost of services does not exceed the person's monthly service cap.
The Group Residential Housing program also makes service payments for disabled and elderly adults in foster care and other settings if the person is not eligible for service payment from another source. The GRH limit for services is $461.36 per person per month. The services, called "supplemental services", must be necessary for an individual to remain independent, and are typically provided to an individual who has not been able to get Alternative Care or Elderly Waiver services due to their not meeting nursing home level of care criteria.
In addition to consulting with eleven state staff and policy makers regarding the technical details of the state's programs, we also conducted more in-depth interviews with four of them. In addition, we interviewed seven stakeholders, including representatives of residential care provider associations, consumer advocates, the state ombudsman program, and an academic expert.
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.
Respondents raised a number of issues that they believed constituted existing or potential problems with the residential care systems generally.
The system is confusing for the typical consumer. There is a perception by residents and families that the assisted living services constitute 'nursing home lite'--or getting all the services of nursing homes, but a la carte. However, that is not the case. Twenty four-hour supervision cannot be assumed, although family members and residents are surprised to learn that it is not available when they are receiving assisted living services and not the assisted living plus package. Many families are surprised to hear that although a residence is licensed it is not regulated. They don't understand the system. Some refer to a residence as an "assisted living nursing home" and are surprised to learn that the assisted living model is licensed as a home care provider. We need education, education, and more education for consumers, their families and physicians.
We have more folks taking advantage of these services and avoiding a nursing home--and that's good--but we have some egregious situations and they will increase if we don't respond in a responsible manner. The Department of Health has been upfront about the fact that many of these places have not had onsite inspections and they are frustrated about the lack of staff to conduct these inspections. The tools in place to address poor providers are not adequate. There are discussions within the long term care task force to assure quality--there is recognition that a problem exists. But the state lacks adequate oversight of residential settings.
We don't have assisted living that focuses on dementia, but do have some foster homes that provide a high level of care.
Some respondents expressed concerns about lack of funds to build housing, and the impact of converting senior housing to assisted living.
On the housing side--we are flat broke. We cannot afford to build assisted living for low income seniors. We already have a large stock of housing that serves seniors--so there is no point in putting money into purpose built assisted living. We need to look at what we have and enhance it when needed; provide services in the existing housing stock and remain solvent.
I'm concerned about the impact of providing the assisted living service package on the character of low income public housing and congregate housing. This is an issue that is likely to be somewhat unique to Minnesota, however, it is worth noting. People are struggling with how far the state should go with the level of support before adversely affecting the living climate or environment for the other residents. Or, how far can services go in providing coverage for increasing levels of acuity and support, and where should the line be drawn? When should people move to other settings that can better meet their needs? This is a work in progress--we are implementing a philosophy.
It is complex when trying to turn subsidized senior housing into assisted living; it has not panned out. Many seniors in these settings are doing fine and not signing up for services. When there are vacancies and you bring in people who need services and supervision it changes the mix and character of the setting, although in some small towns it works out fine. You then change your stock of low and moderate income housing and turn it into assisted living. So for those who are poor and need housing you've limited their choice--an unintended consequence.
We have buildings where people who are being served don't need a lot of the services but they get the entire package.
Overall satisfaction was expressed with the program; there was pride in the lack of a waiting list and in the fact that many people have been served in settings outside the nursing home.
It's worked pretty well--providers have been happy.
We're really happy with our program--it provides flexibility for the community to build a program that is right for them.
On the housing side, because Minnesota did not have the resources to build assisted living for low income seniors, the waiver assisted living program was built on the idea that assisted living services would be mobile. There was already a large stock of housing where low income seniors resided so that the Minnesota approach to assisted living was viewed as a successful way to deal with the housing piece of residential care.
Originally we thought housing with services establishments would be for people headed to nursing homes--to provide another option for people who didn't feel that they could stay in their own home or when services could not be delivered in their home settings. We do find that nursing home admissions have decreased and people are staying in their homes longer. Assisted living is another option for people whose needs cannot be met in their own homes.
Minnesota generally has pretty good delivery--many of the providers are religious organizations--church related entities are major real-estate holders and provider entities. A climate where the care is good--many are nursing home managers trying to avoid the over regulation, but they are concerned about assuring quality in these looser entities.
Minnesota has senior housing stock that has been subsidized--now they are attempting to introduce varying levels of services to enable aging in place--through Assisted Living Plus. Adding assisted living waiver services to these settings mean that buildings stay occupied, the state does not have to subsidize purpose built facilities, and the people served are able to remain in their apartments.
The cooperation between housing and services is due to the fact that human services is all under one big umbrella. An individual who was hired to straddle housing and services sits on joint committees and understands both perspectives. I believe this makes a difference in terms of coordination.
The most successful part is that we are not creating senior Medicaid ghettos. In an assisted living place, if the residents aren't talking to each other about who's paying--you don't know who is private and who is Medicaid. Of course, rich seniors will live in nicer places. Medicaid coverage provides more options for seniors. One of the goals of covering assisted living services through the waiver program is to allow seniors who have spent down in assisted living to stay there as long as their needs can be met.
Minnesota is one of the few states that does not have a licensing category for assisted living. There were differing points of view regarding this. While those representing the providers voiced that from their perspective there is an adequate regulatory structure and they did not see anything that needs to be added, this sentiment was not consistently shared by others.
We need to license administrators of assisted living to assure a minimum skill set or knowledge base for dealing with this vulnerable population.
Licensing the services but not the property or building is not sufficient.
Many providers of assisted living are former nursing home managers that are trying to avoid what they perceive as the-over regulation that is found in the nursing home industry. They understand that to avoid this type of over-regulation they need to self-impose quality standards.
We think there is an adequate regulatory structure--we don't see that anything needs to be added. Home care entities can be surveyed, and anyone receiving waiver or alternative care services has to go through the counties, so that's another vehicle for oversight.
Quality assurance--the people who do the surveying of the home care agencies are very concerned about the frail elders who are not getting adequate care. There is concern that licensure of the services--but not the building--is not sufficient. The owner can obtain a home care provider license, which is not a big deal, but an outside home care agency needs to have a home care Medicaid license, which is a big deal.
Housing with services registration has been in place since '95 or '97. It was promoted by long term care trade associations because state regulations to set up assisted living were not available and the industry wanted some regulations. Over time, this has worked fairly well and is supported by private and public entities. One of the non-profit long term care associations has a quality initiative. They want to keep what Minnesota has: flexibility without extensive regulation.
Right now, assisted living is primarily private pay--80 percent or more. The way it works in Minnesota is that there is a presumption in the Housing with Services Act that two competent parties enter an agreement: the provider and the resident. We think this creates the best opportunity to create maximum choices. We fear that as more and more waiver dollars flow into assisted living, there will be pressure to create a regulatory scheme that will look like nursing homes. We do not regulate assisted living to the worst case scenario like nursing homes do and don't think we should have to.
Minnesota doesn't have very specific regulations, e.g., about how and when meals are to be provided. We operate under the assumption--whether it's private pay or Medicaid--that you have two competent parties entering an agreement. There is a 17 point contract that must be signed by both parties. This eliminates the need for lots of regulations. Alterra had a problem at one of their places and the state attorney general had them in court over a contract violation and it was in the paper. This is a faster way to address quality problems than lots of regulations.
The state should not have approved Assisted Living Plus in the Elderly Waiver program without additional standards.
With few exceptions there was agreement that national model standards for assisted living would not be helpful. There was a sense that Minnesota has developed a unique approach to providing services in residential care settings and would not adopt national standards if it required abandoning their approach.
Our approach provides freedom of choice but we want to make sure that quality issues don't arise--both because of their human cost and because they can lead to over-regulation with its attendant costs. It's in everyone's best interest to assure quality.
The industry has carved out something unique and is fighting hard so it won't be changed. Even a little tweaking is seen as threatening.
The Assisted Living Workgroup (in DC) has 110 recommendations--they've said they don't want the feds to regulate, so they've sent recommendations to the states. In August we're having a town hall meeting to discuss the recommendations and the current state regulations. The meeting is for providers and the state Attorney General will attend, because in Minnesota, the attorney general enforces the regulations against Medicaid fraud and regulations regarding landlord / tenant relations.
Because Medicaid's assisted living program is not tied to a particular type of housing, admission and discharge decisions are left up to the housing owner or manager. Respondents had conflicting views about this approach.
The county case manager determines eligibility for assisted living services under the waiver and the hours of service needed, however, it is the property owner that decides whether the resident's needs can be met in their property. If a resident's condition deteriorates and more care is needed, then the property owner can claim that the increased need for services cannot be met, requiring the resident to leave that setting.
Currently, there is no bill of rights that enables the resident or family to appeal this decision. Once the decision to terminate is made the resident is given a ten day termination notice and a list of other providers.
We need a resident bill of rights to give a right of appeal when discharged.
Giving the property owner discretion over discharge is not a problem because typically a lease addendum gets executed at the time the property is leased. This addendum informs the resident what services are available with the rent, services that are available a la carte and who can provide these, as well as information about when the resident would need to move on to a different residence.
Families are often unaware that a setting does not have the capability to provide 24 hour a day coverage. There needs to be a resident bill of rights that would support an appeal process. The resident in these settings is under a home care bill of rights which is much more limited than a nursing home bill of rights. This bill of rights was written when it was assumed that the individual receiving services was in their own home so that privacy and termination issues were not applicable.
When retention issues arise they are more typically due to an inability to pay the rent portion of the housing because the services can always be provided under the waiver.
To be honest it is an open question whether assisted living serves those headed for a nursing home. For some it does, but it tends to be for those who are not as disabled. When you have people who are very disabled or have a lot of incontinence, or get to the point that they can't be sustained in the assisted living setting, then they tend to end up in a nursing home.
Termination of lease requires only a 10 day notice, not a 30 day notice, and there is no appeal, the provider just gives you a list of other providers. This is not an eviction, it never gets to that point because once the services are stopped the person has to move to a nursing home. There are no appeal rights for service termination--even if you are a public assistance client and the case manager authorizes the services. But the home care provider can determine that they cannot meet your needs in that setting and the consumer is stuck.
If a provider accepts a Medicaid client and is providing services, and the resident begins to have other needs that the provider can't meet, the provider should not be required to use his or her capital and money to bring the services in for one person at the expense of other residents. The providers who keep people because they don't want to give up the money are the ones that will get into trouble.
Providers have to fully disclose up front what they do and do not provide. Anyone moving in has to do so with the knowledge that at some point they may not be able to stay. If someone is receiving home health services but can no longer be served safely at home, he has to move. Someone living in a housing with services establishment is still considered to be living in his own home.
The biggest complaint in Minnesota is "they're making me move" not "they're not taking care of me."
There was consensus that consumers should have the option of assuming risk, but uncertainty about the correct process for doing so, particularly for persons with cognitive impairment.
Negotiated risk is not specifically identified as such; it is addressed indirectly. Providers are using negotiated risk--but mainly as a communication tool.
The state has begun to talk about negotiated risk but there are no regulations in place. There is a move to introduce this into pre-admission screening, which is done on the county level by a social worker or public health nurse. The emphasis in current thinking is not so much about insuring health and safety but whether the individual is willing to take the risk of remaining in the community and what the state is able to do to make the home more conducive to their staying in that setting. Negotiated risk is a piece of that but the state is not there yet.
This is a hot button issue in the state and we have not yet come to a consensus because I think we have not had sufficient consumer agreement. Younger consumers want negotiated risk, but another large group--families of the cognitively impaired--question whether people are capable of making the decisions about the risk. We are looking for a way to provide enough of a safety net in these settings to provide for the cognitively impaired. We want cognitively intact people to have the ability to accept risk, but we haven't found the right mechanism for the cognitively impaired.
Currently, insufficient capacity is not an issue in Minnesota. But due to the potential for budget cuts, several respondents expressed concerns about sufficient funding for the waiver program in the future.
There is no waiting list and everyone who needs assisted living services under the waiver receives them. But more and more people are getting the Assisted Living Plus service package, which includes the requirement for 24 hour supervision, and this is the more expensive option for waiver services. If costs continue to increase for this service package, the waiver may be capped.
At this point in time the governor's budget does not cut the funds too severely for the elderly in assisted living--but younger disabled clients have been capped. If our costs continue to grow we may see that happening for the elderly as well. The costs have shot up in the Assisted Living Plus program--our numbers looked really good prior to the inclusion of the Assisted Living Plus option. Assisted Living Plus has been in place a couple of years and that has made program costs look similar to nursing home cost, but overall they can do an average cost per client that is less.
A few respondents noted that private pay residents may spend down to Medicaid eligibility and not be able to afford room and board. However, they noted that there were no data to know to what extent this was or could be a problem.
The rent piece is the hardest to subsidize. Families can supplement what the resident can afford to pay for room and board when the resident is getting Alternative Care or Elderly Waiver services. If the state lodging supplement covers a shared room, the family can pay for a private room.
For people who go into purpose-built assisted living--if they spend down, the Elderly Waiver or Alternative Care can cover the services but it's typically the rent that becomes a problem. They may not be able to afford the rent and have to move to other subsidized housing where the rent is cheaper.
Many providers who don't take Medicaid payment are concerned about continuing to serve those who spend down.
There's a lot of discussion about spending down--but no data. There is a recognition that this is happening but we are not tracking it. We've had calls that rates are going up beyond the calculations of the elderly regarding what they thought they could afford.
People talk about it and worry about it but as for how often that happens we don't know. We will be doing an analysis of that by looking at the number of people applying for the waiver while in Assisted Living. We hear anecdotally that this is happening, but not a large enough number to cause major concern. Most people who leave purpose built assisted living go on to nursing homes but it's not clear whether that's due to increased frailty or spend down.
There is a geographic maldistribution in availability--we had a recent report on availability and there are some areas where there is 1 per 5,000 and another 1 per 10,000. Persons eligible for Medicaid of course, have fewer options than those with means. But that too varies by geography.
Most respondents felt that rates for assisted living services are generally adequate. Some, however, voiced concerns that the State set a maximum rate but allowed counties to negotiate lower rates. There is a desire to develop tools to help counties determine the number of hours of service needed by each individual, which would enable them to better match the reimbursement level to the services needed.
Sometimes working with individual counties can be a challenge. Funding is viewed generally as adequate; when it's not, it's a disagreement between the county and the provider. The state sets rate limits for each client--some counties go close to full rate--other counties try to come in under that rate.
Providers of market rate assisted living have taken in Medicaid at a little less than the going rate to fill beds.
Medicaid rates should be equal to the private pay market rates. By law the waiver rate has to be at or below what the private pay rate is. The State caps what the counties can pay for services but they have discretion in negotiating rates. You can have two places on the same street--one in one county and one in another--each getting a different rate.
Respondents views on needed changes focused on quality of care and rights issues, as well as the need to help counties determine appropriate service rates.
Two things are needed. One is a specific bill of rights for residents of assisted living and the second may be a requirement for a licensing of administrators of assisted living to have a minimum skill set or knowledge base for dealing with this vulnerable population.
Consumers living in their home, whether its their own home or a congregate residence considered as a home, have fewer rights than residents of nursing homes. There are substantial federal requirements for rights in nursing homes for non-discrimination. The home care bill of rights is much more limited.
There are specific problems with the landlord / tenant contract where we will need to plug holes--assisted living is in the gray area so that the rights of the resident are not clear. The rights of the resident versus the rights of the landlord. I would like to see a specific bill of rights for residents of assisted living facilities.
Because the regulatory scheme was built on a home care model we do need to do some thinking in three areas:
We need to come up with a universal bill of rights for long term care. The current one does not provide an appeal process or due process prior to termination.
The current assisted living regulations are poorly written in terms of supervision--consumers think that monitoring means 24 hour availability of a nurse. The state needs to 'clean up' supervision and to clarify communication with the consumer so individuals clearly understand what they are getting. Someone should be available 24 hours a day. The current requirement: they have to have someone in the building with no specificity as to ratio, sleep or awake, who this person is. This is the case under Assisted Living Plus as well--with no ratio required. "Present and aware" but no requirement to be awake.
The number and training of staff needs to be addressed. The little training that assistants receive is not directed toward the type of residents they will be taking care of. Resident assistants are not required to complete a nursing aide course.
We need to give county health departments tools with which to determine the hours of service needed for a particular level of care. To have better model procedures that the state can provide to the counties as to what they can do before a person can be placed in a particular setting. The state needs to give the county some model language and enforcement language if quality is not adequate. In addition to licensing, the county needs to have a greater role to ensure that waiver clients are actually getting their needs safely met over time.
In Minnesota we have folks on Medicaid who are elderly who need to be in a managed care situation--it is still being developed in some counties--the PMAP program--it's supposed to provide all benefits, but if someone is eligible for the waiver they refer them to the county. If you're at risk for institutionalization and meet income guidelines you get moved to the waiver--otherwise you get PMAP (and Medicaid state plan services).
This creates an incentive for PMAP to move people to the waiver but they should keep them and use Medicaid Home Health. Once they move to the waiver, care coordination is lost.
You have these perverse incentives and you have these two programs that go back and forth--we would get more bang for our bucks if we could coordinate both acute and long term care for this population. Minnesota's managed care program should be giving 90 days post acute care, but it's not working. There was a desire to move the waiver patients to PMAP but counties did not want that because they wanted to hold on to the case management dollars but can only do that if they manage Elderly Waiver. There are reasons to think about a more integrated model--if political and financial realities could be overcome then another more integrated model would be possible and would have a positive effect on assisted living services.
Most respondents agreed that the State is likely to continue the model of assisted living that is currently in place. While the budget is not having an impact on the availability of waiver services in the short term it is not clear what will happen in the long term, particularly if the Assisted Living Plus service continues to grow at its current rate.
We need to examine the Assisted Living Plus option carefully to understand its rapid rate of growth.
From the advocacy side, we need to advocate for a bill of rights and develop requirements for staffing and supervision.
We want to make affordable assisted living available as an option. We need to make sure that assisted living provides only the services that people need. To do this we are planning to help the counties to figure out how to set rates. Providers can't expect to be paid for a package of services, when some of them are not included in a person's plan of care. We're going to give the counties tools and training for setting rates in 2003.
We asked the respondents to make recommendations for other states interested in using Medicaid to fund services in residential care settings, based on their experience doing so in their own state. Most agreed that the regulatory model should not be based on a nursing home model.
Think through the need for both regulation and flexibility. It is a challenge to design a regulatory system that provides safety and quality for the consumer but does not impose a nursing home like regulatory environment.
Consider the Minnesota approach and disaggregate housing from services, particularly if there is an existing stock of elderly low income housing.
The biggest challenge is to design a regulatory system that provides safety for residents without bringing in the entire nursing home regulatory system.
Defer to folks in human services. From the housing vantage point--people were looking for capital to build affordable assisted living but it simply was not there. Section 202 HUD projects that provide housing and services--we have a high number of these, have a resource already--from our vantage point it was not practical to use a site specific, purpose built assisted living program.
I'd advise them that whatever the system--it needs to be consumer driven--consumers making choices--deciding whether services are adequate--that they focus on the contract between the individual and provider and let that be the guiding regulatory principle. Require lots of disclosure and transparency of information.
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]
Minnesota House of Representatives Research Department, Information Brief, Medical Assistance Treatment of Assets and Income, September 2000.
Minnesota House of Representatives Research Department, Information Brief, Assisted Living/Housing with Services in Minnesota, February 2001.
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., State Assisted Living Policy: 2002, National Academy for State Health Policy, November 2002.
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.
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/
Aging Initiative: Group Residential Housing http://www.dhs.state.mn.us/Agingint/Services/grh.htm
Aging Initiative: Alternative Care Program: Services and Provider Standards http://www.dhs.state.mn.us/Agingint/ltc/ACServPS.htm#als
Aging Initiative: Community Resource Development: Affordable Housing and Service Options http://www.dhs.state.mn.us/Agingint/Services/housing.htm
Aging Initiative: Elderly Waiver Program Services Provider Definition and Standards http://www.dhs.state.mn.us/Agingint/ltc/EWServPS.htm.
Alternative Care Program helps seniors access programs. http://www.dhs.state.mn.us/Agingint/ltc/acfacts.htm
Bulletin #00-24-4, "Assisted Living Plus" service available for qualified Housing with Services Establishments and "Assisted Living" service name expands to additional settings, http://www.dhs.state.mn.us/FMO/LegalMgt/Bulletins/pdf/2000/00-25-04.pdf
Bulletin #02-25-07, Legislation Affects Rate Limits and Monthly Service Caps for Elderly Waiver (Elderly Waiver) and Alternative Care (AC) Programs, http://www.dhs.state.mn.us/fmo/LegalMgt/bulletins/pdf/2002/02-25-07.pdf
Children and Family Services: Minnesota Supplemental Aid http://www.dhs.state.mn.us/ecs/Program/msa.htm
Elderly Waiver helps low-income seniors access services and remain in their homes. http://www.dhs.state.mn.us/newsroom/Facts/EWfs.htm
Long term Care Task Force: Reshaping Long term Care in Minnesota. http://www.dhs.state.mn.us/agingint/ltctaskforce/reportsum.htm
Minnesota Department of Human Service Info Center: Services for Senior Citizens http://www.dhs.state.mn.us/infocenter/senior.htm
Minnesota Health and Housing Alliance, Assisted Living in Minnesota, May 2000 http://www.mhha.com/cons/al.html
Minnesota Rules, Chapters 9500 to 9585, Department of Human Services http://www.revisor.leg.state.mn.us/arule/9505/0290.html
Minnesota Senior Health Options (Minnesota DHS), February 2002 http://www.dhs.state.mn.us/agingint/Services/mshosumm.htm
Minnesota Statutes, Health, Chapters 144 to 159 http://www.revisor.leg.state.mn.us/stats/144.html
Pat Callaghan, Supervisor
Eligibility Policy
Minnesota
Department of Human Services
Suzana Cobic-Ivkovic, SSI Coordinator and Program Administrator
Department of Human Services
Minnesota Supplemental Aid and General
Assistance
Duane Elg, Program Consultant
Group Residential Housing,
Minnesota Department of Human Services
Maren Hayes, Project Officer
Demonstration Project on Affordable
Housing With Services for Older People,
Minnesota Department of Human
Services
Walter Eisner, Housing and Alternative Services Specialist
Care
Providers of Minnesota
Pat James, Elderly Waiver Program Administrator
Minnesota Department
of Human Services
Neil Johnson, Director of Marketing and Member Services
Minnesota
Home Care Association
Rosalie A. Kane, Professor
Division for Health Services Research
& Policy
School of Public Health
University of Minnesota
LaRhae Knatterud, Planning Director
Aging Initiative/Continuing Care
Minnesota Department of Human Services
Gayle Kvenvold, Executive Director
Minnesota Health and Housing
Alliance
Colleen Leach, Program Specialist
Program Assurance Unit
Minnesota Department of Health
Lisa Rotegard, Supervisor
Aging and Adult Services/Community Support
Minnesota Department of Human Services
Nancy Sailer, Director of Program Services
Minnesota and Dakotas
Regional Chapter of the Alzheimer's Association
Julie Skoy, Supervisor
Eligibility Policy
Minnesota Department
Of Human Services
Diane Sprague, Policy Analyst
Minnesota Housing Finance Agency
Darrell Shreve, Director of Research and Regulations
Minnesota
Health and Housing Alliance
Mary E. Youle, Director of Housing & Community Services
Minnesota Health & Housing Alliance
Sharon Zoesh, State Ombudsman
Office of Ombudsman for Older
Minnesotans
Minnesota Department of Human Services
Long term Care Task Force: Reshaping Long term Care in Minnesota.
The State applies the following §1902(r)(2) less restrictive resource methodologies for Group C: household/personal goods are excluded and a more liberal homestead exclusion is allowed for certain long term care residents.
Asset limits for the Minnesota Supplemental Aid program are lower, i.e., $2,000 for an individual and $3,000 for a couple.
"If the community or institutionalized spouse establishes that the community spouse needs income greater than the monthly maintenance needs allowance determined in this paragraph due to exceptional circumstances resulting in significant financial duress, the monthly maintenance needs allowance may be increased to an amount that provides needed additional income." (Minnesota Statutes 2003, Chapter 256B.058: Treatment of income of institutionalized spouse.)
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.
The 300 percent of SSI rule is for the aged only. CRS Report for Congress, Medicaid: Eligibility for the Aged and Disabled, updated July 5, 2002.
The State applies the following §1902(r)(2) less restrictive resource methodologies for Group C: household/personal goods are excluded and a more liberal homestead exclusion is allowed for certain long term care residents.
Asset limits for the Minnesota Supplemental Aid program are lower, i.e., $2,000 for an individual and $3,000 for a couple.
"The commissioner shall seek to amend the federal waiver and the medical assistance state plan to allow spousal impoverishment criteria as authorized under United States Code, title 42, section 1396r-5, and as implemented in sections 256B.0575, 256B.058, and 256B.059, except that the amendment shall seek to add to the personal needs allowance permitted in section 256B.0575, an amount equivalent to the group residential housing rate as set by section 256I.03, subdivision 5." (Minnesota Statutes 2003, Chapter 256B.0915, subdivision 2: Spousal impoverishment policies)
CRS Report for Congress, Medicaid: Eligibility for the Aged and Disabled, updated July 5, 2002.
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.
Asset limits for the Minnesota Supplemental Aid program are lower, i.e., $2,000 for an individual and $3,000 for a couple.
Minnesota Statute 144D.
Typically Board and Lodge with Special Services entities would not have a special care unit unless it registered as a Housing with Services Establishment to enable it to receive waiver payments. If it is not registered as a Housing with Services Establishment, it cannot serve waiver clients, but may be receiving GRH Supplemental Service payments for non-elderly clients who are ineligible for waiver services (usually dual diagnosed with mental illness and chemical dependency).
Minnesota Statues 2003, Chapter 144D.065, Establishments that serve persons with Alzheimer's disease or related disorders.
Under Minnesota law, most agencies or individuals regularly providing home care services to clients for a fee are required to have a Minnesota home care license. Some individuals do not need to be licensed or registered if they provide limited types of services for 14 or fewer hours a week to only one client. Family members and volunteers providing such services without charge generally do not need a license. When Minnesota's home care license requirements were implemented, only services provided in single-family homes and apartments were covered. Although the Housing with Services Contract Act created no new licensing program, it did extend the existing home care licensing requirements to additional types of residential settings--including, board and lodging establishments and corporate adult foster care homes, if they meet the Contract Act criteria.
The home care license requirements spell out the services the agency or individual is allowed to provide and other requirements such as those related to the training and supervision of unlicensed caregivers, assessment of client needs, and the development and implementation of clients' service plans. Some home care providers are also Medicare-certified and must meet federal Medicare requirements in addition to the state licensing requirements. Liability insurance is a requirement for licensure.
Certified Boarding Care Homes are considered nursing homes and are eligible to receive Medicaid payments. However, these homes may only provide "light" care and cannot provide skilled nursing home care.
When the Housing-with-Services Contract Act was passed in 1995, it was designed to apply to various types of buildings serving seniors, rather than settings serving other groups, such as persons with developmental disabilities. To distinguish which buildings served seniors, the state used the definition from the federal Fair Housing Act, which requires that 80 percent of the residents be age 55 or older.
The state purposely excluded housekeeping services, meal programs, routine van transportation to shopping or recreational activities from the definition of supportive services so that the providers of these services would not have to meet all the requirements of the Contract Act.
There is an erroneous belief that Minnesota's Medicaid waiver program only provides assisted living services to elderly persons living in private apartments with a full kitchen. It stems from the fact that when the Elderly Waiver service packages were first created, the package of services that were provided in apartment settings (where there were individual kitchens) was labeled "assisted living" while a very similar package covering essentially the same services could be provided in settings where residents did not have individual kitchens. The latter package was given a different name--residential care services. Both service packages covered the same types of personal care and health-related services, but they had two different labels. Consequently, many people made the assumption that because the service package labeled assisted living could only be provided in apartments with kitchens that these kinds of services could not be provided in other types of settings. (Personal communication)
A Rule 203 license for 5 people is only available if all residents are at least 60 years old and none have a serious and persistent mental illness or a developmental disability; otherwise the setting must be licensed as a board and lodge by the Minnesota Department of Health. (Source: DHS Bulletin #00-25-4.)
These settings were grandfathered in with the passing of the Housing with Services Contract Act. A moratorium was put into place so that no more settings of these types could be developed and there remain approximately 125 in the system. See section titled Background under Residential Care Facilities.
A personal needs allowance and any income allocated for a community spouse is disregarded.
The amount is based on the following formula: $552 (SSI payment) minus $20 disregard and $72 personal needs allowance + $81 (Minnesota Supplemental Aid (MSA) maximum) + $139 Food Stamps. The state does not get reimbursed from the Food Stamp program, but the state has a workgroup that is looking at how to get food stamps for persons in residential settings. The state uses the $139 figure to estimate what a person would need to live in the community, as that is the maximum Food Stamps benefit provided to a single person.
Supervision may not be provided by a resident who is receiving services.
Although this level receives the lowest reimbursement, the people in this category may in fact need extensive supervision. O'Keeffe, J. op.cit.
Rate equalization exists only in that the service payment rate for a "public-pay" client shall not exceed the service payment rate for a "private-pay" client.
The Alternative Care Program's monthly service cap is limited to 75 percent of the monthly service cap in effect for persons assigned the same case mix classification as persons receiving Elderly Waiver services.
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