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.
North Carolina has had a Certificate of Need (CON) Program for nursing homes since 1981. Consequently, compared to other states, they have a lower number of nursing home beds per person age 65+ than the national average: 3.8 percent compared to 4.2 percent. The current occupancy rate is 87.9 percent compared to the national average of 82.9 percent.1
Three groups are financially eligible for nursing home services:
Group A includes individuals eligible for SSI whose monthly federal benefit is $552 per month. This group is automatically eligible for Medicaid.
Group B includes individuals with incomes up to100 percent of the Federal Poverty Level (FPL), which is $749 in 2003.
Group C includes medically needy individuals whose nursing home costs exceed their countable monthly income. Income that is not countable includes: a personal needs allowance; health insurance premiums and medical expenses not covered by insurance or government benefits; certain spousal or dependent family members' allowance; and a home maintenance allowance if the if the nursing home stay is less than six months and there is no spouse living in the home.3
Asset limits for both groups are $2000 for an individual and $3000 for a couple.
The monthly personal needs allowance is $30 for individuals and $60 for couples.
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.
The state protects one half of the couple's assets subject to a minimum of $18,132 and a maximum of $90,660. For example, if the couple's assets are $30,000, one half is $15,000, but the state will protect $18,132 for the spouse at home. If the couple's assets are $250,000, one half is $125,000, but the state will protect only $90,660 for the spouse at home.
In nursing homes, families can pay the difference in cost between a semi-private and private room for a Medicaid beneficiary only if the beneficiary has been a private pay resident of the nursing home and has spent down to Medicaid eligibility.
To receive Medicaid coverage of nursing home care, a physician must certify that an individual needs eight hours of licensed nursing care (RN or LPN) per day, either direct care or oversight.
The state's waiver program for elderly persons is called the Community Alternatives Program for Disabled Adults (CAP/DA). Only persons residing in their own or another's home can receive waiver services because North Carolina licensing rules do not permit any residential care settings to serve persons who need a nursing home level of care. Due to a nursing home bed shortage and other factors, some people who meet the state's nursing home level of care criteria do in fact reside in adult care homes. They are not eligible for waiver services but can receive some nursing care through Medicare or Medicaid Home Health services".
Three groups are financially eligible for waiver services:
Group A includes individuals eligible for SSI, who are automatically eligible for Medicaid with no separate application.
Group B includes individuals with incomes up to100 percent of the Federal Poverty Level, which is $749 in 2003. No cost sharing is required.
Group C includes medically needy individuals who must spend down to $242, the amount they may keep to pay for community living expenses such as housing, food, and transportation. Any expenditure that the IRS considers to be a medical expenditure for purposes of tax deductions can be counted as a medical expense
Asset limits for both groups are $2000 for an individual and $3000 for a couple.
Waiver clients do not have the same spousal impoverishment protections as nursing home residents. Spouses of waiver clients may keep any income in their own name, but the state does not allow the waiver client to provide a monthly needs allowance to a spouse with an income under $2267 per month (the maximum allowed under federal law.) The state protects one half of the couple's assets subject to a minimum of $18,132 and a maximum of $90,660. For example, if the couple's assets are $30,000, one half is $15,000, but the state will protect $18,132 for the spouse. If the couple's assets are $250,000, one half is $125,000, but the state will protect only $90,660 for the spouse.
Any monetary resources provided to a waiver client are considered income and are counted in determining Medicaid eligibility. Medicaid waiver clients can not be served in residential care settings, so family supplementation to pay the cost of a private room is not an issue in the waiver program.
Waiver applicants have to meet the same level of care criteria as nursing home applicants. To receive Medicaid coverage of nursing home care, a physician must certify that an individual needs 8 hours of licensed nursing care (RN or LPN) per day, either direct care or oversight.
In the 1980's, the state added personal care services to the Medicaid State Plan. At that time, only Medicaid-eligible persons residing in their own homes could be eligible for personal care services. Personal care in people's homes includes assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs), and is capped at 80 hours a month. Between July 2000 and June 2001, 23,661 people received Medicaid personal care in their own homes.
In 1995, the state expanded the settings in which care could be provided to adult care homes. In adult care homes, personal assistance includes assistance with ADLs and medications. Assistance with meal preparation, housekeeping, laundry, and money management is covered under the room and board payment. To be eligible for Medicaid covered personal care services, individuals must first meet Medicaid's financial eligibility criteria. However, these criteria differ for individuals in their own home and individuals in adult care homes.
Three groups are financially eligible for Medicaid:
Group A includes individuals eligible for SSI, who are automatically eligible for Medicaid with no separate application.
Group B includes individuals with incomes up to100 percent of the Federal Poverty Level of $749. (Effective April 1 2003)
Group C includes medically needy individuals who must spend down to $242, the protected monthly income amount.
Asset limits for all three groups are $2000 for an individual and $3000 for a couple.
No income and asset protections are provided for the spouses of persons receiving personal care services in their own homes. When spouses live together in a home, a spouse's income is counted in determining whether a person meets the income eligibility standard, according to SSI policy.
Since 1974, North Carolina has provided a state income supplement called Special Assistance (SA) to aged, blind, and disabled persons who reside in Adult Care Homes.4 Special Assistance is funded jointly by the state and the counties, each contributing 50 percent. Effective October 1, 2003, the maximum monthly SSI/SA benefit for an individual is $1,112 and the personal needs allowance is $46 (the federal portion is $552 and the state portion is $560.) Couples are treated as individuals one month after entering an adult care home.5
To quality for Special Assistance, a person needs (1) to have a monthly income less than $1,112 and (2) to reside in an Adult Care Home. The amount of supplementation a person receives depends on their income. A person who is eligible for SSI would receive $560, whereas a person with an income of $850 would receive $262. The combined SSI/SA amount, minus a $46 personal needs allowance, is paid to the Adult Care Home for room and board and some services ($1,066).
Aged or disabled individuals whose income exceeds 100 percent of the federal poverty level ($749) but is less than the combined SSI/SA amount of $1,112 are not eligible for Special Assistance and Medicaid if they live in their own homes.6 The only way they can qualify for Medicaid--and thus for personal care services--is to either: (1) spend down the excess income on medical expenses to $242 (the protected monthly income amount), or (2) enter an Adult Care Home.
Once they enter the Adult Care Home, they are not only eligible for Special Assistance, to help them pay for room and board, but they are eligible for Medicaid, which will pay all their health care costs, including prescription drugs.
It is theoretically possible for an individual to spend down income and become eligible through the medically needy program while living in an adult care home. However, it is unlikely that this would occur because the medically needy income limit in an adult care home is the same as in a person's own home: $242. Because this amount would not be sufficient to pay for room and board, spending down in an adult care home is not practically possible.
The state currently has a demonstration project which is providing Special Assistance to up to 800 persons aged 18 through 64 with disabilities or aged 65 and older, who reside in their own homes but are at risk of placement in an adult care home.
Special Assistance is also available in some counties for "certain disabled." These are adults between the ages of 19 and 65 who are living in their own homes, are unemployable because of an impairment, but have not been able to meet the Supplemental Security Income (SSI) disability requirement.
No income and asset protections are provided for the spouses of persons receiving personal care services in residential care settings. The income of spouses of adult care home residents is not counted in determining eligibility for Special Assistance.
To be eligible for residence in an adult care home, a physician must certify that an individual needs the supervision and personal care provided by the Adult Care Home.
Family supplementation to pay for private rooms is currently not permitted in adult care homes or other residential care settings, but the state is considering allowing it. State provider associations are working with the North Carolina General Assembly to develop a bill.
North Carolina combines some state funds with Older Americans Act funds into a program called the Home and Community Care Block grant that is distributed to the counties based on an intrastate formula.
For the past several decades, North Carolina has depended heavily on domiciliary care to meet the long term care needs of its population.7 Domiciliary care was a term North Carolina used to define three types of residential care settings: Homes for the Aged (also called Adult Care Homes), Family Care Homes, and Group Homes for Adults with Developmental Disabilities. These homes are licensed by the Department of Human Resources' Division of Facility Services and monitored by county Departments of Social Services staff.
Domiciliary homes were defined in statute as any facility, by whatever name it is called, that provides residential care for aged or under 65 disabled persons whose principal need is a home that provides the supervision and personal care appropriate to their age or disability.
Personal care is defined as including bathing, dressing, and feeding and instrumental activities of daily living such as shopping and laundering clothes.
These homes are not permitted to provide medical care, except on an occasional or incidental basis, but they are expected to administer medications.
These homes are to be distinguished from nursing homes. Their license does not permit them to serve persons who meet the state's nursing home level of care criteria, and so the residents of these homes, even if they meet the state's HCBS waiver eligibility criteria, cannot receive waiver services in this setting. The homes provide custodial care, and if residents needed nursing care or skilled therapies, the state covers them through the Medicaid Home Health benefit.
Prior to 1995 when the state began paying for some personal care in these homes through the Medicaid program, domiciliary care was solely privately purchased. However a significant amount of the payments to residential care settings was publicly subsidized through the federal SSI program and the state's SSI supplement, called Special Assistance.
Persons eligible for SSI who live in domiciliary care homes are eligible for Special Assistance. Each month they receive a check, which is paid to the home. Monthly benefits for the combined SSI and Special Assistance benefit are established by the North Carolina General Assembly as the "rate" for domiciliary home care. Prior to the use of Medicaid to pay for some personal care in these homes, this rate covered room and board and custodial care provided by the home.
In the late 1980's to mid-1990's advocates for elderly persons urged the state to address perceived quality of care problems in adult care homes. In particular, their concerns focused on the retention of persons requiring a nursing home level of care in these homes, who not receiving appropriate or adequate services. During the same period, the development of a new model of residential care--market-rate assisted living--had become widespread throughout the state. Advocates also urged the state to provide this new care model to elderly persons who needed services in a residential care setting.
The state convened a domiciliary care team that met for 18 months and consulted with a number of experts to assist in the development of new residential care policy. In 1994, the state commissioned a study of North Carolina Domiciliary Care Home Residents.8 The study found that residents in domiciliary care homes in North Carolina had significant levels of impairment, with nearly two-thirds having moderate to severe cognitive impairment. Comparisons to domiciliary care home residents in ten other states showed that the North Carolina domiciliary home residents had much higher levels of ADL impairment, cognitive impairment, and incontinence.
These findings were a major impetus for the policy decision to use Medicaid to pay for additional personal care in domiciliary homes. Other important factors included pressure from advocates to increase the amount of care provided in these homes, pressure from providers for higher payments, and U.S. Congressional discussions about block granting the Medicaid program. In response to the latter, many in the state felt it would be advantageous to draw as much Medicaid money as possible before the program was block granted.
By using Medicaid to pay for these services, the state's domiciliary care team developed a budget neutral strategy that would increase the amount of personal care provided in adult care homes and provide case management to oversee residents with heavy care needs. The state reduced the Special Assistance payment and used the savings as the state match for the new federal funding.
Because the State was concerned about the cost of the new benefit, it established three fixed reimbursement levels for personal care in domiciliary care homes--basic and two enhanced levels--to be determined by a case manager.
In 1995, considerable debate occurred in the North Carolina General Assembly about the definition of the term "assisted living." On one side were those who believed the term should only be used by facilities that provided the new model of assisted living, which offered private rooms and individualized service packages. On the other side were those concerned that a segment of the domiciliary care industry would be negatively affected if it could not also call itself assisted living. The latter group convinced the North Carolina General Assembly to define an assisted living residence to mean:
"any group housing and services program for two or more unrelated adults, by whatever name it is called, that makes available, at a minimum, one meal a day and housekeeping services, and provides personal care services directly or through a formal written agreement with one or more licensed home care or hospice agencies. The Department of Human Resources may allow nursing service exceptions on a case-by-case basis. Settings may include self-contained apartment units or single or shared room units with private or common baths."
The legislature specifically recognized three types of assisted living residences: Adult Care Homes, group homes for persons with developmental disabilities, and Multi-Unit Assisted Housing with Services. Because the new law defined assisted living to include group housing for two or more individuals, Family Care Homes that serve two to six individuals were also included in the new definition of assisted living, and must meet the same licensing and regulatory requirements.
In response to nursing home industry concerns that adult care homes would be turned into intermediate care facilities and would admit the light care residents that were served in nursing homes, the regulations covering assisted living specify that persons with certain medical conditions, such as ventilator dependency, or individuals requiring continuous licensed nursing care, can never be served in these facilities, except when a physician certifies that appropriate care can be provided on a temporary basis to meet the resident's needs and prevent unnecessary relocation.
One commonality in two types of assisted living--adult care homes and group homes for persons with developmental disabilities--is the ability to provide protective oversight and services to meet unscheduled needs on a 24 hour basis. In contrast, Multi-Unit Housing with Services facilities are not permitted to serve residents who require assistance at night. Multi-Unit Housing with Services facilities may call themselves assisted living, but they are not required to be licensed under the assisted living rules; they only have to register with the state.
In 1997, a moratorium was placed on assisted living facilities for three years, and in 2001, a Certificate of Need program was enacted. Continuing Care Retirement Communities are exempt because they are contractually required to provide whatever level of care is needed.
Multi-Unit Housing with Services is a new type of residential care setting named by the 1995 legislation. However, it is more a housing model than a service model. The model was included in the legislation at the request of developers who were interested in a limited service model that did not have to be licensed or highly regulated, but could, nonetheless, be marketed as assisted living.
Because Multi-Unit Housing with Services facilities cannot have in-house personal assistance staff, they do not have to be licensed; they have only to register with the state. Although North Carolina statute defines assisted living as group housing with services that, at a minimum, include one meal a day, housekeeping, and personal care services, Multi-Unit Housing with Services facilities are required to provide protective oversight and social services only. They may choose to provide additional services such as meals and housekeeping, and they may arrange for hands-on personal care and nursing services provided by an outside agency.
Multi-Unit Housing with Services provide private residences--studios and one or two bedroom apartments with private baths and full kitchens or kitchenettes. Persons who live in Multi-Unit Housing with Services are considered to be legal tenants who live in their own rented units.
Persons living in Multi-Unit Housing with Services facilities could theoretically become eligible to receive Medicaid personal care or waiver services in this setting. However, persons who meet Medicaid's financial eligibility rules (those with incomes no higher than 100 percent of the federal poverty level or who spend down to eligibility) are unlikely to be able to afford the rent in these facilities. While some Multi-Unit Housing with Services facilities may set rents on a sliding scale, some facilities charge as much as $1500 a month as their base rate, which does not include any personal care services.
There are three types of Adult Care Homes, all of which are licensed as assisted living facilities:
Family Care Homes, which are licensed to serve two to six residents. In most other states, these homes are licensed as adult foster care homes. Many are private homes in residential areas. They are required to provide room and board, personal care, supervision, housekeeping and laundry, and "meaningful" activities.
Adult Care Homes, which are licensed to serve seven or more residents over the age of 18. They provide room and board, personal care, supervision, housekeeping and laundry, and social activities.
Group Homes for Developmentally Disabled Adults, which are licensed to serve two to nine unrelated adults.
The remainder of this section will focus solely on the adult care homes licensed to serve seven or more residents.
There is no limit on the number of beds in adult care homes. The current licensed capacity ranges from 7 beds to 200 or more. Most have a capacity of 40 to 60 beds.9
Facilities may serve up to four residents per bedroom. Bedrooms must be 100 square feet, excluding vestibule and closet, for single rooms and 80 square feet per bed for multiple occupancy rooms. One bathroom must be provided for every five residents and a shower for every 10 residents.
Facilities vary in the availability of private and shared rooms. Some facilities, mostly older ones, do not have private rooms unless they are too small for two residents. Others have a mix of private and shared rooms. The newer facilities have all private rooms and some with private baths, to meet the preferences of the private pay market. Because private rooms typically cost more than shared rooms, they are generally occupied by private pay residents.10
The state limits the amount of room and board charges only for SSI/SA recipients, an amount determined annually by the North Carolina General Assembly. Facilities are free to charge private pay residents a market rate.
The services that are provided in assisted living facilities are defined in statute and regulations and include personal care, protective oversight, meals, and housekeeping.
The eligibility standard for adult care homes requires residents to need assistance with ADLs but not licensed nursing. Medication management is handled by medication technicians, or by RNs in facilities that have them on staff. The administrator must assure the provision of appropriate training for medication technicians.
Persons with nursing needs can choose to stay in an adult care home and receive nursing services through either Medicare or Medicaid Home Health. Persons with certain medical conditions can not be cared for. Private pay residents may pay for additional nursing care not covered by Medicare.
The state has several reimbursement levels for personal care provided in adult care homes:
Basic level--one hour of personal care per day.
Enhanced level I--assistance with eating
Enhanced level II--assistance with eating and toileting
The rates are based on the size of facility. In facilities with 1 to 30 residents, the basic daily rate is $14.71, which pays for one hour of personal care. In facilities with 31 or more residents, the basic rate is $16.11 per day. The enhanced rates are per diem add-ons to the basic rate and are the same for both sizes of facilities. Enhanced daily rates are provided when a resident needs assistance with: ambulation (+ $2.64); toileting (+ $3.69); eating (+ $10.33); eating and toileting (+ $13.18).
There are provisions to protect residents from premature involuntary discharge including a mandatory bed hold policy of sixty days per year.
A study of the state's system conducted in 1991 found that there was considerable concern about the inappropriate placement in adult care homes of persons who needed a nursing home level of care.11 The report cited a number of reasons for inappropriate placement, including,
Residents wanting to age in place,
Private pay residents wanting to avoid paying higher nursing home rates,
Lack of nursing home beds, and
Lack of nursing homes willing to admit "heavy care" residents, i.e., those needing tube feeding, oxygen, or decubiti care.
Several respondents believe that the same reasons for inappropriate placement apply in 2003.
In addition to consulting with 9 state staff and policy makers regarding the technical details of the state's programs, we also interviewed four of them. In addition, we interviewed 9 stakeholders, including representatives of assisted living provider associations, consumer advocates, a former county service administrator, and two university-based policy analysts, one of whom previously worked for the NC Department on Aging.
The interviews focused on respondents' views about several key areas and issues. This section summarizes their views and provides illustrative examples of their responses. These comments are not verbatim quotes, but have been paraphrased to protect the respondents' anonymity and edited for brevity. A list of information sources for the state description and the individuals interviewed can be found at the end of this summary.
Because many of the same residential care facilities serve both private pay and Medicaid residents, most respondents expressed views about the industry as a whole.
A few stated that the state's residential care system provides options for those with the money to pay privately and for the very poor but not for elderly persons with low to moderate incomes.
There is a huge middle group of people who can't pay for the expensive places. There is a big unmet need for places between the high end and the low end. The new Multi-Unit Housing with Services model is for those who can't afford high end assisted living and it works well for people who can direct their own care or who have someone to provide oversight, and who can afford to pay extra for overnight unscheduled needs.
Assisted living for the private pay market responded to people's desire for options and control. If public funds are paying for the majority of long term care--we need to fund the system people want.
Two respondents expressed views about the state's Certificate of Need program for assisted living facilities, one noting that it needed to be better targeted.
The Certificate of Need program does not distinguish between different models of assisted living, or between non-profits and for-profits. There is a cap on beds by county, but there is a shortage of beds for people who are difficult to place, such as people with HIV AIDS or behavioral problems.
The industry supports the Certificate of Need program because it reduces competition; over-bedding is considered a problem by some in the industry because it costs a great deal of money to maintain unoccupied beds.
When the state established the moratorium on assisted living facilities, industry lobbyists supported it saying they didn't want competition, and it would save the state money. They got the moratorium, but a number of developers came in under the wire--with 14,000 beds. There is probably some overbuilding and bankruptcy--some facilities are struggling to find residents.
The Certificate of Need program does not distinguish between different types of beds. There could be a county that has only two very old facilities in which no one wants to live. If someone wanted to build a better adult care home in that county, as long as the existing facilities had vacancies, the permit would be denied.
One expressed concern about the lack of oversight of Multi-Unit Housing with Services facilities
No one in North Carolina knows how many Multi-Unit Housing with Services units there are and how many people are being cared for in them. They are required to be registered, but there is no oversight of these facilities.
Others criticized the state's moratorium and Certificate of Need program for nursing homes.
The nursing home Certificate of Need program has had a negative impact on consumers. There are not enough nursing home beds and people who should be in nursing homes wind up in adult care homes.
When North Carolina had the moratorium, for the better part of a decade there were no new nursing home beds in North Carolina. During that time there was a large increase in domiciliary care home beds. In effect, these beds substituted for nursing homes. Then in the early 1990's there was a large rush to build assisted living facilities that would cater to the private pay market. This was disconcerting to the traditional homes who depended on some private pay residents.
One mentioned that the overbuilding of market rate assisted living facilities could result in a larger number of Medicaid clients being served in these newer and "nicer' settings.
Very few market rate facilities take Medicaid clients. In one county, the developers had to pay such a steep price for land that their debt service is very high. They overbuilt the market--in one year over 20 facilities went up--now there are too many beds, which could lead to their taking Medicaid residents.
Many respondents were very pleased that the state is using Medicaid funds to provide personal care to residents of adult care homes and felt it improved the quality of care. However, while there is a general sense that Medicaid coverage resulted in some quality improvement, some believe that the adult care home population is becoming more and more impaired, and that the homes are not able to provide the level of care residents need.
The introduction of Medicaid in 1995 did change things because more people are paying attention to people in these facilities. The residents are now seen by social workers and advocates--more people are in and out of the facilities--so the spotlight on these places has led to some improvement. The more people paying attention to very isolated residents with no family the better.
Introducing Medicaid personal care services into adult care homes was a cost- savings measure. It had very little to do with expanding services, options, or choice.
The primary purpose was to shift costs to the feds. It had the added benefit of increasing training and staffing requirements.
The advantage of having Medicaid in adult care homes is that is provides a dedicated revenue stream for the direct care part of adult care home costs. It allows the state to see if Medicaid dollars are being fairly utilized and if the rates are reasonable for the workload.
Bringing Medicaid into adult care homes was viewed as a means to keep people in domiciliary care safer, and some hoped, to bring more federal oversight of these homes, based on the Medicaid funding.
The state did the best it could at the time--putting more money into the homes to take care of the residents. Some in the state see it as only a temporary solution, and that the state needs to continue looking for better ways to serve the population in adult care homes.
Others are concerned that the state is using limited resources inefficiently by providing nursing care to this population through the Medicaid Home Health program.
Providing nursing care to assisted living residents through Medicare or Medicaid Home Health programs is an extremely inefficient way to provide nursing services to people in residential care facilities when large numbers of people need nursing services. This approach also does not meet all of the residents' nursing needs.
One respondent mentioned that the state had at one time looked into using the private pay model of assisted living for waiver clients.
The state's Housing Finance Agency received a grant under the Robert Wood Johnson's Coming Home Program. The purpose of the Coming Home Program is to encourage the development of affordable assisted living in rural areas. At that time, the Agency was interested in developing an affordable version of private pay assisted living with private rooms and baths and locked doors for persons eligible for SSI and Medicaid. To make this model financially feasible requires both housing subsidies to finance construction and Medicaid coverage to finance services for all the residents.
The plans were dropped when the state could not guarantee that everyone residing in the facility would be able to receive services, even if they met Medicaid eligibility criteria, due to waiting lists for services and the freeze at the time on North Carolina's waiver program.
One stated that she had opposed allowing waiver clients to receive care in assisted living.
If you use the waiver, then the residents must meet a nursing home level-of-care criteria. This would encourage the industry to operate unlicensed nursing homes.
One noted that not all facilities accept Medicaid residents and discussed some of the reasons for this.
There are three types of assisted living facilities (1) those that will take Medicaid if the person has spent down in the facility. A very small percentage will take folks who've spent down after 18 months in the facility; (2) those that have no interest in taking Medicaid and take private pay and once you can't afford it you're out; and (3) those that accept both spend down folks and Medicaid admissions--but the available beds are limited.
A disincentive to taking Medicaid residents is that the facilities have to provide cost reports to the state even if they have only one Medicaid resident in a 100 bed facility. Some providers have a huge number of buildings, but there is little movement to accept Medicaid to fill the beds. They are targeting a specific population--elderly folks with the means to pay. Facilities that take Medicaid generally set a percentage of Medicaid beds for their facility. About 35 percent is all you can have on Medicaid. Some facilities are 100 percent Medicaid but they can't provide anything above the bare minimum.
Many respondents--both providers and consumer advocates--expressed concerns that the licensing category of assisted living was too broad and created problems, both for consumers and for facilities that provide the new model of assisted living.
The state's licensure category is too broad. In the battle that occurred before the new law put all types of adult care homes under one term, I was on the side that assisted living in its purest sense should have been for the frail elderly. If the state is going to use it for all adult care homes, then at least we need separate classifications for homes that serve different populations: the frail elderly, the seriously mentally ill (SMI), and the developmentally disabled (DD).
There was a push by some providers to call everything assisted living--now we have the same regulations for facilities that have 35 year old seriously mentally ill folks and for frail elderly playing bridge all day. Very generic rules; they don't work. It's a disservice to the general public who don't know what's going on. We get lots of inquiries asking about homes and they are given a list and not told that it's a mixed facility. Providers should be given the choice for different licensure requirements and marketing. Combining everyone into one category is a big disservice. I get calls from families who are looking for assisted living for their mothers, and they go to facilities with SMI and DD folks, and call me crying, saying I can't put my Mom there. Then we have to explain that there are some assisted living facilities that serve only the frail elderly.
The public is confused about long term care options. They don't understand the difference between residential care facilities, nursing homes, and assisted living. They also do not understand the difference between skilled and intermediate care, particularly the difference between eligibility requirements and staffing requirements.
In North Carolina, assisted living is nothing but a marketing term; a lot of so-called assisted living is just like institutional care. Many adult care homes look just like nursing homes. Most of the rooms are dual occupancy, few have private baths, and none have locked doors, but they can call themselves assisted living just like the $4000 a month Sunrise assisted living facility in Raleigh.
Assisted living in North Carolina does not necessarily mean a studio or apartment with a lock on the door. The domiciliary care industry decided that the words assisted living made them more marketable so they repainted their signs. There may be exceptions, but on the whole it's just a new name for an old program.
Assisted living should mean privacy plus a la carte service options plus the ability to stay and receive additional services as your care needs increase. You don't get that in adult care homes. The private pay folks get it in high end assisted living.
Some people in the state are interested in developing affordable models of assisted living that have private rooms and baths, but it can't be done without the assurance of Medicaid funding for services. With the freeze on the waiver program, it's simply not feasible at this time. If the time comes when we can do, given that North Carolina now uses the term assisted living generically to cover a wide range of facilities of varying levels of care and quality, we would not call it assisted living.
A few respondents raised serious concerns about quality and safety.
Regulations are always minimum health and safety. In the county where I worked, there was a home chronically doing terrible things--violating rights--didn't have food. We documented everything--breakfast--no one there--cook gone to get eggs and milk--nothing in larder--they are supposed to have several days supply of food. Even with media attention--change doesn't happen. People who care get burned out.
When the state authorized the use of the Medicaid Personal Care option in adult care homes, there were concerns about how the extra money was going to be used. The industry had gotten a 10 percent increase. Advocates felt that the extra money should be used to increase staffing (the regulations at the time only required one staff person per 20 residents and 1 to 50 at night).
Shortly after, there was a fire in a rest home and 7 men died of smoke inhalation (the staff were in the women's wing). There was no sprinkler system. A Governor's Committee was established to look at the issue. The media found out that the people who died were not ambulatory, and that the regulations really applied to a less impaired population. Consequently, there was an increased focus on this issue. Some members of the Governor's Committee insisted that there be a performance standard that if people couldn't evacuate, the facility had to have a sprinkler system, but it was not enacted. There was also a motion to reduce the number of high level needs folks in these homes, but it wasn't allowed to come up for a vote. A positive result of the Committee's works was that the staffing ratio was reduced from one to 50 to one to 30. But how can one person help 30 people to evacuate in the case of a fire? The new facilities have sprinklers, but a lot of older facilities without them were grandfathered.
Several expressed concerns about inadequate staffing.
Insufficient staff is the key quality issue. We were involved in the effort to change the requirements for staffing ratios for the 11-7 night shift, effective in 2000. Prior to the change, it was only one personal care aide per 50 residents. Now it's one to 30 on the night shift, and one to 20 on the other two shifts.
We need more staff in adult care homes but I don't know if putting more Medicaid money in is the answer. We are just starting to learn about the actual costs of these homes. We've had so many studies, but I'm not sure that we have a sense of what the actual costs are.
Staffing needs to be based on care needs, not a ratio of 1 to 20. If people are heavy care then 1:20 is totally insufficient. We need an assessment form and a point system to determine what people need.
One respondent noted that it is difficult to recruit and retain good staff.
Workers in adult care homes do not receive a living wage and less than 25 percent of workers get any kind of benefits. They spend a lot of time applying for government benefits: health insurance and food stamps. If the industry doesn't pay enough so that their staff are not eligible for food stamps, then the federal government is subsidizing these businesses.
Others expressed concern about inadequate enforcement of new training requirements.
New regulatory requirements for increased staff training have not been enforced. Adult care homes are not held accountable for the additional funding they received to provide this training.
Several raised concerns about quality issues relate to medication administration.
There is a lot of concern about the administration of psychotic medications and medication errors. Some homes have nurse and pharmacy consultants; others don't. Daily supervision of medication administration is not there.
A facility I visited, which had mental health clients, put the residents' medications in the spoons on the dining room table that was set for lunch. There were no names by the spoons. When I asked about this, the staff told me that the residents knew which pills were theirs.
Many residents are cognitively impaired and the complexity of medication regimens has led to the need for medication management. The statute defining domiciliary care homes states that one of their responsibilities is to administer medications. But assisted living settings are exempt from the North Carolina controlled substances act based on the assumption that persons in domiciliary care homes are self-medicating.
There are lots of medication problems in North Carolina. Until a few years ago you didn't even need a competency test to do medications. One found medication error rates in the 20 to 40 percent range.
A few felt that national standards could be useful as long as they are put forth as a model and not mandated.
National standards can be used as a platform to build on. We do not want national regulations. With regard to disclosure requirements, a model would be helpful, but it should not be required.
We can handle regulations at the state level. Model regulations could be helpful. But until North Carolina separates our adult home populations--stops mixing types of residents--I guarantee that model regulations won't help.
It would be very helpful to consumers to have a rating system for adult care homes because it's so hard for them to evaluate what's available. It's much easier in the nursing home. A model of quality would be a good thing, and a system to measure how individual providers stack up against the model.
A few respondents stated that the regulations are too rigid and need to be more person-centered and outcome based.
The regulations are too prescriptive. They look at pieces of paper rather than outcomes. It is easier to check off a chart than visit the residents. The surveyors ask, did they have a bath? They don't have a person-centered process. We need to look at outcomes. For example, with regard to diet, we should ask is the person gaining or losing weight, are they happy with the meals? We can serve them a nutritious meal, but if they don't like the food they won't eat much and they will lose weight. Same thing with hypertension. We can't have salt and pepper on the table because one resident may have hypertension, so everyone walks around with their own salt shakers. We need to spend more time taking care of residents and less time taking care of paper.
The rules are not flexible, which is especially important when caring for people with dementia. There is a regulation that says there must be a minimum of ten hours between breakfast and dinner. But this doesn't account for people who like to sleep late. If someone wants to eat at 9, then technically we can't give them dinner until 7 PM. But a lot of people want to eat between 5:30 and 6:30. A building was cited last week for this--a dementia unit. One of the residents sleeps late, eats a late breakfast and nibbles all day and wants dinner at 5:30 PM because that's the time they have always eaten dinner. They were cited for not meeting the 10 hour rule.
One noted that when looking at regulations, consumer advocates need to distinguish between the majority of providers who are doing a good job, and the few providers who are not.
Consumer advocates would like to see regulators walking around with a stick. They paint all providers with the same brush. It doesn't help when they come to the rules review committee and say we need a new rule to address one issue at one home.
One noted that the aging in place philosophy is not so easy to implement.
Aging in place policy is a conundrum. There will always be people who need to be in a nursing home and so we need a different model of care at the nursing home level--that's the ultimate goal to work towards: resident-centered models of care that can provide skilled care without the institutional and warehousing look and feel.
Some felt that while retention requirements needed fine-tuning, it was not a good idea to have rigid requirements as in nursing homes.
Discharge and transfer policy needs more work. I believe discharge regulations need to be more flexible than in nursing homes where they have rigid distinctions between an ICF and a SNF level of care. Some homes want only the frail and some market to those with more acute needs. It's important to remember that some facilities with a specific area of expertise want to market to a particular group. It's a private business. The advocacy groups and ombudsman want to rigidly define discharge requirements but I will oppose this. The variety and ability to be creative has made our assisted living good.
Many facilities have not bought into aging in place. To protect the public and families--we need to move away from the idea that everyone can age in place. You need full disclosure when someone enters a facility so there are no surprises down the road. There are limitations on tenancy. People have to choose a facility knowing that they many not be able to stay there forever. They just have to enjoy it as long as they can.
One felt that while flexibility is desirable, parameters are needed.
The assisted living umbrella is too big. The state needs to tighten up admission and retention requirements but not so much that consumers don't have choices. You need different types of licensing. The public is not served well--they have no idea what the umbrella term of assisted living covers. You want flexibility so people have choices, but you need parameters.
At the assisted living level, there is considerably more variation than at the nursing home level. There are very tight definitions of services at the independent living level and in nursing homes with most of the variation in the level of care at the assisted living level. They are given so much leeway. Some homes say they can do much more than they deliver. Some don't want residents to be too dependent, some will accept people with multiple needs, yet they are all licensed under the same standard. Mental health issues are major.
Many of the respondents expressed a wide range of concerns about the ability of adult care homes to meet the needs of its residents. Most concerns related to homes keeping people beyond the point where they should be discharged.
As the requirements for SNFs and ICFs have become more stringent, and nursing homes have become more focused on subacute residents, a lot of people wind up staying in lower levels of care far beyond the capability of those levels to provide the care that is needed. These places don't provide adequate staff training and don't have required coverage ratios. But they keep the residents in order to keep the beds filled and because it's difficult to find a nursing home bed for a Medicaid beneficiary. Nursing homes are under a Certificate of Need program--so nursing home growth has been constrained. So the situation is affected by two things--lack of beds and higher acuity hospital discharges.
The State does not have a good system in place to assess residents of Adult Care Homes to be sure their needs continue to be met as they age.
Adult care homes tend not to take people with certain disabilities. They want people they can manage with limited assistance and oversight. But as they age, their needs increase, and some homes do try to accommodate them to the best of their ability. But others take whoever they can get--and the residents get minimal custodial care.
I am particularly concerned about inappropriate placement of persons with SMI. Residents with serious psychiatric problems are retained because it is very difficult to get people into the geriatric wards in the state psychiatric hospitals. The state needs to conduct a study to determine the extent of inappropriate placement of people with SMI, particularly in response to Olmstead.
In some states the nursing home occupancy rate has been dramatically reduced but not here--we still don't have enough beds. The easiest way to get into a nursing home is from a hospital--paperwork is done--Medicare will pay. When we tried to place folks from home, like an Adult Protective Services case, it was very difficult--even if they had a bed--too difficult to admit. Coming from the hospital, they know what medications the person is on and whether they have a catheter. Nursing homes don't want to accept the unknown--maybe because they have had very difficult residents or very heavy care folks placed by county folks with no forewarning. It could have made them reluctant to trust the information provided on cases seeking admission from the community.
The adult care home client is basically the old ICF nursing home client. We have people in adult care homes in North Carolina that would be in nursing homes in other states.
Prior to 2000, assisted living residents did not have some of the same rights and protections that nursing home residents have. If you were a resident of assisted living, you could be discharged with no notice for no reason. A bill enacted in 2000 gave assisted living residents the same rights as nursing home residents: they can't be discharged without 30 days notice. Basically, the bill applied existing North Carolina law regarding nursing homes to assisted living residents. However, implementation has been problematic. The regulatory body has issued regulations and there has been a lot of discussion about changes in the level of care. Facilities are saying that when there is a change in the level of care designation by the MD on the eligibility assessment form, then it's immediate jeopardy and the 30 day notice doesn't apply.
Residents may desire to stay because it's a familiar setting. Most homes are for-profit businesses so occupancy rates play into this. If they have 100 percent then they look to skim the cream.
One made a distinction between the need for protections for residents with and without families.
Many discount the intelligence of family and residents but they are better regulators than the state. But residents without families who live in adult care homes need different standards.
Some expressed concerns about the level of nursing care needed by residents in adult care homes.
If Catherine Hawes' 1991 study was repeated today, it would find that people need two hours of care a day not one hour.
There are people in adult care homes who need nursing care and it is provided either through the Medicare or Medicaid Home Health benefit. However, providing nursing care through these benefits one-on-one is very expensive. But if you allow these homes to provide health care, then you will have unlicensed, substandard nursing homes. There is a lot of money in the system but it is not focused on getting needs met in the right way.
Many of the current residents of adult care homes in the past would have been in ICF nursing facilities. The old ICF nursing homes had LPNs and there was LPN supervision of aides, and nursing care was provided. Although Adult Care Homes are not licensed to provide nursing care, there is probably no difference in the type of residents they serve. People in private pay assisted living facilities may also be inappropriately placed from the perspective that they meet the nursing home level of care criteria. However, people in these places can pay for as much care as they can afford.
Most respondents had not heard of these agreements or any issues related to them. One felt that the state needed to provide more guidance to providers regarding their use, predominantly in private pay assisted living.
Some facilities are using them. They get forms from their national associations and get their attorneys to review them. They deal with things like wanting rugs in their rooms that could pose a fall hazard, and diabetics who want to eat apple pie. The state can cite you for not enforcing special diets. If would be helpful if the regulatory agency identified areas that are not appropriate for shared risk agreements. The state should help to define parameters for shared risk agreement. The county monitors also need to understand them.
A few mentioned the need for a different rate system than the current one.
A case mix system would be preferable over what we have now: a fixed Special Assistance and Medicaid rate. The basic service rate is too low and the enhanced rate is minimal. There has been no increase this year and increases in the past year have not equaled what the cost reports said it should pay. With a case mix system, you could track expenditures to determine whether a resident did in fact get the service that the provider is reimbursed for.
We must assure that the public system supports and demands quality from providers. Medicaid payment is totally inadequate for the level of care required. It pays for one hour a day and the rate for that hour is too low. $270 per month for one hour a day, plus a little more if enhanced care. There is no direct requirement that all Medicaid money for direct care staffing be actually paid for direct staffing.
Rates are inadequate. Since 1995, the state has used a cost reimbursement method based on cost reports--averaging, a state wide average. Using one rate for the whole state has its plusses and minuses. There are no incentives for those who aspire to a higher level of quality care. We need a case mix system. Then you are paying for the amount of care someone needs. Under the current system, there is no incentive in the reimbursement system to take heavy care residents.
The biggest quality issue is staffing and the Medicaid rate for direct care workers is not adequate. We give the staff too heavy a workload, too many residents to care for in a limited amount of time. Is it fair to the workers and the residents? Medicaid should require that you have to pay staff adequately, using a case mix model to assure that residents' needs are met.
One mentioned that the Medicaid rates in adult care homes are not sufficient to provide care to persons with dementia.
The state does not pay a sufficient rate to take care of people with dementia in special care units. Special care residents don't qualify for the enhanced personal care rate--because Medicaid only pays for hands-on physical assistance. Cueing and set up takes more time than doing something for the resident. So we encourage dependence. Without a case system, we will not get designated funding for dementia and this population gets ignored.
Respondents had numerous suggestions for improving the state's residential care system generally, and Medicaid specifically.
We need adequate reimbursement for dementia care, more outcome oriented regulations, and providers need to give full disclosure about what is and is not provided.
We need more congregate housing with private rooms. We're looking how to convert existing bricks and mortar--we need specialized housing for persons with disabilities and those with cognitive impairment that is a notch above what's available in our adult care homes for persons on public assistance. We would like to provide private rooms with a bath and kitchenette and round the clock support.
We do not need more residential care beds in North Carolina. We need to upgrade the beds we have. There are a number of old facilities that are substandard.
We have plenty of beds and facilities, what we need now is better living conditions.
What North Carolina needs is a better mechanism for managing the long term care needs of all the populations we serve. Currently, our system is very fragmented. Too many agencies have responsibility for different pieces of the system: the Division of Facilities Services, the Division of Social Services, the Division on Aging. The state has been looking into ways to consolidate--trying different approaches--to manage funds on a need basis rather than program category, but it constantly faces opposition. There are too many players. No one argues with what needs to happen--they argue about who will do what and who will have control. Each department needs to be better consolidated. It will happen eventually, but not for at least five years.
The state needs a designated funding stream for dementia special care. There are very few Medicaid clients in these units because there is just not enough money. About three years ago there were new dementia regulations, which providers fully supported, and the state said that money would be available but it didn't happen. The model is so cost prohibitive that Medicaid folks can't be in it--so they get transferred to a nursing home because they can't afford a special care unit, which provides extensive cueing and supervision.
A few mentioned that adult care homes should serve homogeneous populations, and that the state needed different regulations to assure the quality of care for the different populations.
I don't believe in mixing diagnoses in one building. We need to separate the populations. Have separate licensing categories by type of population served.
The market should call for more specialization of clients in adult care homes, and hopefully the industry and policy makers will push it--create rules to not mix types of clients (e.g., putting the young SMI with the elderly.)
There should be separate licensing standards for adults with serious mental illness than for the frail elderly. These populations have very different needs.
Some homes serve a heterogeneous population: Younger SMI and DD and the elderly all together. There are still stories in the media about the non-vulnerable preying on the vulnerable--rapes and even murder.
A number stated that the state needed better assessment procedures and data for a number of purposes.
It is very difficult for the state to figure out exactly what it should be doing because they do not have sufficient data to make decisions. The state does not have a good assessment procedure. The form currently used is only two pages and is not appropriate for care planning. The state needs an appropriate assessment instrument to better understand the needs of those being served.
The State's Department of Social Services has been working to develop and automate an assessment form for three years. It is costing millions and it is still not completed, but the General Assembly will be cutting funding for this project.
There are two questions in North Carolina--are adult care homes being paid enough and what are they doing with the payments they receive? Getting data from the homes after they started getting Medicaid money was like pulling teeth.
The Department of Human Services has consultants who are looking at reimbursement for all long term care facilities. They're having no problem making recommendations for nursing homes and ICF-MRs because they have the data for these facilities. But they don't know what to recommend for residential care because they do not have adequate data. The state hopes to have the data from adult care homes computerized by 2004.
Two respondents said the that the state needed to better utilize Medicaid funding, noting that North Carolina has a 64 percent match, and the Special Assistance payment is all state and county money.
The state should use Medicaid to broaden coverage, specifically for the MRDD, SMI and dementia folks.
If the type of care that could be provided in assisted living facilities were increased, then they could fund more of the care costs under Medicaid.
Another expressed concern about cuts in the state's Medicaid budget.
The most important issue we are dealing with now is opposing proposed cuts in the Medicaid program, specifically, a proposed across the board decrease in the service rates for all providers.
A number said that the state needed to better support home care.
People shouldn't have to go into an adult care home to get Special Assistance and Medicaid.
North Carolina has rules allowing spousal separation of income that make it relatively easy for a moderate income household to qualify one member for nursing home benefits without impoverishing the community spouse. Similar generosity is not provided for those applying for waiver services.
Several noted that the state should permit family supplementation in assisted living settings to pay for private rooms.
It would be great if families were permitted to pay the difference in cost between a semi-private and private room in assisted living for folks on Medicaid. But there are concerns about equity. Providers may give priority in admissions to those whose families can supplement.
There are an increasing number of requests for information about SSI/Medicaid and family supplementation from market rate assisted living facilities who have residents who have spent down and they want to see if they can figure out some way to keep them.
Provider associations are getting more calls about this issue than ever before. People have spent down in market rate assisted living and they have to move to an adult care home and the family wants to supplement their income to pay for a private room.
When private pay folks with dementia are in special care units and their resources run out--families often pay the difference in cost between the regular rate and the special unit rate, which is about $600 a month.
One noted that even continuing care retirement communities (CCRC) have requested information on how to keep private pay residents who have spent down.
A CCRC called the other day and wanted to know how to deal with spend downs. We told them that they have to become a Medicaid Provider and be licensed by DSS, then their residents will be eligible for a state supplement if they meet asset and income tests.
The state is planning to move from a tired rate for Medicaid personal care in adult care homes to a case mix reimbursement system that will be based on assessed needs. The state wants an assessment to determine what someone needs and how much the state should be paying for services. The state thinks it is paying too much for some and not enough for others. The state is waiting to get the assessments of Medicaid enhanced care (required since 1996) computerized to do the data analysis needed to support a case mix reimbursement methodology.
A number of stakeholders are working with the General Assembly on a bill to allow family supplementation in assisted living facilities.
The boundaries between the new model of assisted living and old forms of residential care are very squishy. How do you regulate a philosophy? What Keren Brown Wilson did in Oregon when she was a hands-on manager is one thing. But when it goes beyond mission driven entrepreneurs into the market place it turns into something else. North Carolina has played it out and we haven't done it well. The Keyes amendment is the only way the feds can weigh in.
North Carolina provides a good example of what not to do. Don't put people who should be in nursing homes into assisted living settings that can't meet their needs.
The big issue states have to think about is that we don't' know how to care for very impaired people without a professional component. We don't know how to regulate the settings that provide this care. We don't know what to replace the current regulations with.
In looking at what the states are doing in residential care with Medicaid you have to realize that states are starting from very different places. Oregon was very serious about deinstitutionalization, but its very important to remember that because of the nursing home moratorium, North Carolina had a very low nursing home supply--maybe 35 beds per 1000 people age 65 and older. When Oregon started, they had more than the average--approximately 50 per 1000. When Oregon started to change their system, they had less than 5000 domiciliary care beds; at the same time, North Carolina had 30,000.
North Carolina had already bifurcated the population--the people in nursing homes were very impaired, and the ones in rest homes--while they may have started out less impaired--were getting more and more impaired. So in effect, North Carolina already had the situation that Oregon was aiming for. North Carolina had difficulty discharging folks from hospitals due to lack of nursing home beds. But people in North Carolina and consumers--older people with family looking for nursing home care--they have not been in favor of decreasing nursing home beds--so consumers said: give us something besides nursing homes--if the occupancy rates are so low--how low can you go and still give consumers a choice. We had virtually 100 percent occupancy. No consumer choice. The nursing homes were going to take some heavy needs patients but not that many. So for a heavy needs person to get placed, someone else had to expire or be transferred. The only place where there was movement was on the adult care home side.
Theoretically, people who meet the nursing home level of care criteria should not be in domiciliary care. There are big issues to consider on the health care side. Moving to a lower level of care shouldn't mean abandonment of health care standards. You need to keep costs manageable, but you also need to assure that people receive the health care and medication management that they need. North Carolina provides a good example of what happens when you serve a lot of folks in a lower level of care than the nursing home. You might have a private room, but if you don't pay enough for services, then people will not get good quality care. Other states should understand all these things before they move forward.
Bolda, E., Initial report on North Carolina domiciliary care policy. The Long Term Care Resources Program, Duke University Center for the Study of Aging and Human Development (1991).
Gregory, S.R. and Gibson, M.J., Across the States: Profiles of Long Term Care. Public Policy Institute, AARP, November 2002.
Hawes, C., Lux, L., Wildfire, J., Green, R., Packer, L. E., Lannacchione, V., and Phillips, C., Study of North Carolina domiciliary care home residents. (February 15, 1995). Report submitted to the North Carolina Department of Human Resources.
Kassner, E. and Williams, L., Taking Care of their Own: State-funded Home and Community-based Care Programs for Older Persons, AARP, September 1997.
Kassner, E. and Shirley, L., Medicaid Financial Eligibility for Older People: State Variations in Access to Home and Community-Based Waiver and Nursing Home Services, AARP, April 2000.
Manard, B. et. al., Policy Synthesis on Assisted Living for the Frail Elderly: Final Report, submitted to Office of the Assistant Secretary for Planning and Evaluation, December 16, 1992. [Executive Summary]
Mollica, R.L., State Assisted Living Policy: 1998, Report (ASPE and RTI) June 1998. [Full Report]
Mollica, R.L., State Assisted Living Policy: 2000, National Academy for State Health Policy; funded by The Retirement Research Foundation (LTC13). August 2000.
Mollica, R.L., 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/
Department of Health and Human Services http://www.dhhs.state.nc.us/
DHHS Division of Aging http://www.dhhs.state.nc.us/aging/
DHHS Division of Facility Services http://facility-services.state.nc.us/gcpage.htm
DHHS Division of Medical Assistance http://www.dhhs.state.nc.us/dma/
DHSS Division of Social Services http://www.dhhs.state.nc.us/dss/cty_cnr/depts.htm#top
North Carolina Administrative Rules, Aging: Program Operations http://ncrules.state.nc.us/ncadministrativ_/title10ahealtha_/chapter06agingp_/default.htm
North Carolina Administrative Rules, Licensing of homes for the aged and infirm http://ncrules.state.nc.us/ncadministrativ_/title10healthan_/chapter42indivi_/subchapterdrule/subchapterdrule.doc
North Carolina Assisted Living Association http://www.ncassistedliving.org/
Elise Bolda, PhD, Research Assistant Professor
Institute for Health
Policy, Muskie School of Public Service
University of Southern Maine
Jerry Cooper, Executive Director
NC Assisted Living Association
Jackie Franklin, Special Assistance Program Manager
Adult Social
Services Section, Division of Aging
Bill Hottell, Manager
Adult Care Homes
Bill Lamb
UNC Institute on Aging
Sandra Crawford Leak, Associate Program Director
Long Term Care
Resources Program
Center for the Study of Aging and Human Development
Duke University
Mary Jo Littlewood, Manager
Community Alternative Program
Lou Morton, Program Consultant
Adult Care Homes
Beverly Patnaik
Long Term Care Resources Program
Center for
Study on Aging and Human Development
Duke Medical Center
Lynn Perrin, Section Chief
Medicaid Policy and Institutional
Services
Helen Savage
AARP--NC Chapter
Dennis Streets,
Division of Aging
Carol Teal, Executive Director
Friends of Residents in Long Term
Care
Mary Reca Todd, Supportive Housing Team Leader
North Carolina
Housing Finance Agency
Judy Walton, Administrator of Managed Care for Seniors
Division of
Medical Assistance
Office of the Director
NC Department of Health and
Human Services
Susan Williamson, President and CEO
North Carolina Association of
Nonprofit Homes for the Aging
Andy Wilson, Project Coordinator
Medicaid Eligibility Unit
N.C.
Division of Medical Assistance.
Lou Wilson, Executive Director / Facility Operator
North Carolina
Association Long Term Care Facilities
Gregory, S.R. and Gibson, M.J., Across the States: Profiles of Long Term Care. Public Policy Institute, AARP, November 2002.
Prior to 1995, North Carolina (North Carolina) was a 209(b) state and had the option of using more restrictive financial eligibility criteria than that of the Supplemental Security Income (SSI) program to determine financial eligibility for Medicaid. During this time, persons who were eligible for SSI, either because they were disabled or 65 years or older, were not automatically eligible for Medicaid, as they were in most states.
Individuals could become eligible for Medicaid by spending down to $242, or $317 for a couple. Resource limits were also more restrictive than SSI. The one exception to this income standard was linked to receipt of the SSI state supplement, called Special Assistance (SA), which was provided only to individuals residing in adult care homes.
In January 1995, the state began covering all SSI recipients under Medicaid, and in 1999 increased the income standard to 100 percent of the federal poverty standard. This standard is used to determine eligibility for all long term care services in the state, including nursing homes. The state also has a medically needy program.
As permitted under the §1902(r)(2) less restrictive income methodologies, the state excludes wages paid by the Census Bureau for temporary employment; it also does not count the following: personal effects & household goods; life estate interest and tenancy in common interest (except for optional state supplements); burial plots; cash value of life insurance if the total face value does not exceed a specified amount.
At a county's option, blind and disabled adults who are not eligible for SSI may also receive a supplement in a private living arrangement. They are covered under "certain disabled" provisions but receipt of the SA does not confer Medicaid eligibility as it does to individuals residing in Adult Care Homes.
In August 1995, the combined SSI/SA payment was lowered from $982 to $800. The savings were used to provide the state match for the new Medicaid personal care benefit. The reduction resulted in some people in adult care homes not meeting the Special Assistance income eligibility criteria, and thus losing Medicaid eligibility. However, the state grand-fathered them for continued coverage.
There are some exceptions, a discussion of which is beyond the scope of this report.
The information in this section draws heavily from Elise Bolda's report: Initial report on North Carolina domiciliary care policy. The Long Term Care Resources Program, Duke University Center for the Study of Aging and Human Development (1991).
Hawes, C., Lux, L., Wildfire, J., Green, R., Packer, L. E., Iannacchione, V., and Phillips, C. Study of North Carolina domiciliary care home residents. (February 15, 1995). Report submitted to the North Carolina Department of Human Resources.
One respondent noted that some owners believe a minimum of 60 beds are needed to make a profit.
One respondent stated that people on Medicaid could not afford private rooms because Medicaid only pays for services, not for lodging.
Elise Bolda's report: Initial report on North Carolina domiciliary care policy. The Long Term Care Resources Program, Duke University Center for the Study of Aging and Human Development (1991).
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