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



Nursing Homes
Waiver Program
Personal Care Option--Primary Home Care Program
Community Attendant Services Program
Long Term Care Programs Funded with State Revenues Only
Adult Foster Care Homes
Assisted Living Facilities
General Comments About the State's Residential Care System
General Comments on Medicaid's Role in Residential Care Settings
Licensing and Regulatory Requirements
Admission and Retention Requirements and Aging in Place
Barriers to Serving Medicaid Clients in Residential Care Settings
Suggested Changes to Improve the Medicaid-Funded Residential Care System
Future Plans
Recommendations for Other States
Formal and Informal Interviews

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

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

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


Nursing Homes

The state has a process for determining where new nursing home beds will be allowed based on the nursing home occupancy rate in a given county. The statewide occupancy rate is approximately 72 to 74 percent.1 The state also has a process for determining the proportion of nursing home beds allocated for Medicaid.

Financial Criteria

Spousal Protections

Family Supplementation

Family members may pay a nursing home facility the difference in cost between a semi-private and private room.

Level of Care Criteria

Applicants for Medicaid coverage of nursing home care must meet one of the following criteria:

  1. Must require licensed nursing care (RN or LVN);

  2. Must meet two or more of the criteria for nursing home risk, as specified in the Resident Assessment Instrument-Home Care Assessment for Nursing Home Risk as revised in April 1996 and summarized as follows:

  3. Must have been living for 30 consecutive days in a medical facility that has a contract to accept Medicaid patients. Persons in this category must still be screened for medical necessity.

Waiver Program


The Community Based Alternatives (CBA) waiver program provides home and community services to persons age 21 and older who qualify for nursing facility care. The goal of the CBA waiver program is to provide individuals with meaningful choices regarding long term care services. Waiver funds are used to allow individuals to avoid premature nursing facility placement and to provide current nursing facility residents an opportunity to return to a home or community living arrangement.

The CBA waiver program currently serves 32,793 persons and has more than 39,000 on an interest list. Placement on an interest list means potential clients have declared an interest in a program for which funding is limited, but have not yet been assessed for financial or service eligibility. The list has an attrition rate of a few thousand per month. The waiting period from the time people get on the interest list to receiving services is approximately 10 months. Eligible individuals are enrolled from the CBA waiver interest list on a "first come, first served" basis.

Within the constraints imposed by the cost ceiling on a participant's Individual Service Plan, the waiver program promotes the participant's active involvement and choices regarding the services provided. Participants may choose to live in their own homes or in a residential care setting covered under the waiver: Adult Foster Care homes or Assisted Living/Residential Care facilities. A waiver participant needing nursing care may choose to have that care delivered by a licensed nurse or, in those situations where delegation is appropriate, by an unlicensed person providing services under the direction of a registered nurse.

The majority of services offered under the CBA waiver program are provided by licensed home and community support services agencies. These agencies provide services to participants living in their own homes, adult foster homes, assisted living/residential care facilities (formerly known as personal care facilities), and other locations where services are needed.

Rider 28 of the General Appropriations Act, 76th Legislative Session3

As part of its Olmsted initiative, the State has tried to increase the ability of individuals in nursing facilities who could transition into the community to do so through the CBA waiver program. Because there are too few slots in the waiver program relative to demand, the State is using a money follows the person initiative to fund home and community care.

Under Rider 37, when there are insufficient slots or funding in the CBA waiver program, funding follows the individual from the nursing home into the community. The cost of services comes from the nursing home budget instead of the CBA waiver budget. Thus, individuals in nursing homes who are Medicaid eligible can move to the community and receive home or community residential care even when CBA waiver funding is not available.

During a recent twelve-month period, 952 individuals have taken advantage of Rider 37, with about 45 percent transitioning to residential care. Many of those who transitioned were between the ages of age 21 and 64.

The lack of CBA waiver slots can result in a person who spends down in the community having to enter a nursing home for a month in order to apply for funding under Rider 37. The state is grappling with the question of what to do with funds when persons funded through Rider 37 are no longer served. Currently, the money that funded their care is being returned to the nursing home budget.

Financial Criteria

Cost Sharing Requirements

The state does not require persons in Group B who are receiving waiver services in their own home to share the cost of services.

For people in Group B who are living in residential care settings, the cost sharing amount is equal to the client's remaining income after all allowable expenses have been deducted. These deductions include:

  1. the cost of the client's maintenance needs allowance, which is equal to the SSI federal benefit rate of $552 per month. The client keeps $85 as a personal needs allowance and the remainder is used to pay for room and board costs;

  2. the cost of the maintenance needs of a spouse if the spouse is the only dependent of the recipient. This amount is equal to the monthly SSI federal benefit rate less the spouse's income;

  3. the cost of the maintenance needs of the client's dependent children. This amount is equivalent to the Aid to Families with Dependent Children (AFDC) basic monthly grant for children or a spouse with children, using the recognizable needs amounts in the AFDC Budgetary Allowances Chart;4 and

  4. the costs incurred for necessary medical or remedial care, which are not covered by Medicare, Medicaid or any other third party insurance, including the cost of health insurance premiums, deductibles and co-insurance.

If any income remains after all these deductions, the cost sharing amount is applied only to the cost of services covered by the waiver program and specified on the client's individual service plan and must not exceed the actual cost of services delivered. Clients must pay the cost sharing amount to the provider contracted to deliver authorized waiver services.

Spousal Protections

Family Supplementation

Family payments for an individual's food, clothing, and shelter are considered support and maintenance for waiver clients and a value is assigned. Because support and maintenance are not considered for clients in institutional settings, and institutional and waiver financial eligibility rules are the same, support and maintenance is not considered for waiver clients.5

Level of Care Criteria

To be eligible for waiver services, a person must meet the nursing home level-of-care criteria and several CBA waiver specific criteria. They must:

Personal Care Option--Primary Home Care Program


In 1979, Texas added personal care to its Medicaid State Plan. The personal care program is called the Primary Home Care Program, and it serves the aged and disabled. The program provides non-technical, medically related personal care services prescribed by a physician as part of a client's plan of care. Primary Home Care is available to eligible Medicaid clients whose health problems cause them to be functionally limited in performing activities of daily living. It is available statewide, and there is no waiting list.

Services are provided by a primary home care attendant employed by a licensed home and community support services agency. The agency's license must cover the provision of home health services, personal assistance services, or both.

Each eligible client may receive up to 50 hours of primary home care per month (42 hours per week for a client with priority status). The Primary Home Care Program provides three services:

Excluded services that must be provided by a person with professional or technical training, include:

Medicaid Financial Criteria--SSI

To be eligible for the Primary Home Care program an applicant must be eligible for SSI or have income no higher than the SSI level, or meet 1929(b) income and resource limits (see Community Attendant Services Program described below).

Spousal Protections

There are no spousal income and asset protections for community spouses of persons receiving personal care services.

Family Supplementation

Family payments made for support and maintenance may be counted when determining Medicaid eligibility, in accordance with SSI policy.

Level of Care Criteria

A client's degree of functional impairment is measured on a 60-point functional needs assessment to determine if the impairment is severe enough to qualify for services. Applicants for primary home care services must meet functional needs criteria as follows:

To receive services the applicant/client must reside in a place other than a hospital, a skilled nursing facility, an intermediate care facility, or any other environment where family members or sources outside the primary home care program are available to provide personal care. Services cannot be authorized if the client lives in a home licensed as an assisted living facility (ALF). If the home is not a licensed ALF, services may be authorized under the following two circumstances:

Community Attendant Services Program

In the 1980s, Texas implemented a demonstration waiver program called the Frail Elderly Program, which provided only attendant services. Texas was the only state that participated in the demonstration and in the early 1990s when the program ended, federal law permitted Texas to retain the program as a personal care option under 1929(b) regulations, which essentially allow higher income eligibility criteria (300 percent of SSI) than is used for other Medicaid state plan services. However, clients served under the program are not eligible for any other Medicaid services, e.g., primary and acute medical care, prescription drugs, and home health services.

Although the program was called Frail Elderly, the statute allowed the program to serve persons of all ages. In 2003, the State changed the name of the program to the Community Attendant Services Program. The program's eligibility criteria and services are the same as for the Primary Home Care program. It currently serves 30,000 persons.


There are two types of Medicaid in Texas: traditional and STAR. People in both programs get the same benefits. Under the traditional program, individuals get medical care from any doctor or provider who accepts Medicaid. Under the STAR program, the enrollee has one provider who coordinates and manages their care.

The STAR+Plus pilot program is a Medicaid pilot project operating since 1998. It is designed to integrate delivery of acute and long term care services through a managed care system. The project requires two Medicaid waivers--1915(b) and 1915 (c)--in order to mandate participation and to provide home and community services.

The project serves approximately 55,000 SSI aged and disabled Medicaid recipients in Harris County (Houston). STAR+PLUS provides a continuum of care with a wide range of options and increased flexibility to meet individual needs. The program has increased the number and types of providers available to Medicaid clients.

Participants may choose from two health maintenance organizations. Certain participants have a primary care case management option in addition to the two HMO choices. The HMO provides both acute and long term care services. STAR+PLUS Medicaid Only clients are required to choose an HMO and a Primary Care Provider (PCP) in the HMO's network. These clients receive all services--both acute and long term care--from the HMO.

Those also eligible for Medicare choose an HMO but not a PCP because they receive acute care from their fee-for-service Medicare providers. The STAR+PLUS HMO provides only Medicaid long term care services to dual eligible clients. Of the approximately 55,000 STAR+PLUS eligibles in Harris County, about half are "dually eligible" for both Medicaid and Medicare. The program has demonstrated significant savings, but there are no plans currently to expand it.

STAR+PLUS Long Term Care Services

All clients receiving long term care services under STAR+PLUS receive care coordination for acute and long term services from the HMO. Care Coordination services include the development of an individual plan of care with the client, family members and provider, and authorization of long term care services for the client.

Long term care services provided by the HMOs include day activity and health services, personal attendant services, and short-term (up to 4 months) nursing facility care. Additional services provided to CBA waiver clients are adaptive aids, adult foster home services, assisted living/residential care services, emergency response services, medical supplies, minor home modifications, nursing services, respite care and therapies (occupational, physical and speech-language). Approximately 200 clients are receiving services in assisted living facilities.7

In 1998, the State amended the CBA waiver program to create a new waiver program specifically for Harris County (in effect, there are now two 1915(c) waiver programs in Texas). The providers contract with the HMOs and, as much as possible, deliver the same services as the CBA waiver program, by way of a capitated payment from the CBA waiver budget for Harris County. There is no waiting list. The HMOs may also provide additional "value-added" services, such as CBA waiver services to clients living in the community but not in a CBA waiver slot.

Long Term Care Programs Funded with State Revenues Only

Community Care for Aged and Disabled (CCAD) is a state program that provides services in a person's own home or community for aged or disabled persons who are not able to take care of themselves, and who might otherwise be subject to unnecessary institutionalization or to abuse, neglect, or exploitation.

In addition to services provided through the waiver program and the personal care option, CCAD includes a number of home and community service programs funded by state general revenue funds and Title XX funds. Two of these programs cover services in residential care settings: Adult Foster Care (AFC) and Residential Care(RC). The state program serves approximately 200 people in AFC and 800 in RC each year. Reimbursement rates for services are less than those paid for waiver clients.

To be eligible for the Adult Foster Care and Residential Care programs through CCAD, individuals must be financially eligible for Title XX services or must meet the income criteria for Medicaid waiver services (300 percent SSI), and not have assets exceeding $5,000 for an individual and $6,000 for a couple. In calculating financial eligibility, a number of exclusions from income and resources are permitted. Clients keep a monthly allowance for room and board and personal and medical expenses, and the remainder of their income is contributed to the total cost of care. Applicants/clients must also score at least 18 on the Clients Needs Assessment Questionnaire and have the approval of the CCAD led unit supervisor. The applicant's needs may not exceed the facility's capability under its licensed authority.

Adult Foster Care Program

Adult Foster Care is provided in homes enrolled with the Department of Human Services. This service provides 24-hour living arrangements and may include meal preparation, housekeeping, minimal personal care to help with activities of daily living, and provision of, or arrangement for, transportation.

Residential Care Program

The Residential Care program provides services to eligible adults who require 24-hour access to care, do not require daily nursing interventions, and do not meet waiver level-of-care criteria. Services include, but are not limited to personal care, home management, 24-hour supervision, social and recreational activities, and transportation. Services provided under this program are delivered through one of two arrangements:



Historically, personal care facilities (sometimes called personal care homes) and adult foster care were the primary residential care options in Texas. In 1999, personal care facilities were renamed assisted living facilities, which are defined as any facility that serves four or more adults who are unrelated to the proprietor. Adult Foster Care homes that serve four or more persons are also required to be licensed as an assisted living facility.

In the mid-1990's, the state became interested in supporting residential care alternatives to nursing homes for individuals who met a nursing home level of care but could not be safely cared for at home. The Department of Human Services worked with providers and advocates to develop a 1915(c) waiver program to provide services in both private homes and residential care settings. The new waiver program, called Community Based Alternatives (CBA), was implemented in 1994. Initially, the cost of CBA waiver services was capped at 90 percent of nursing home cost, but the state has now raised the cap to 100 percent.

The primary goal of the CBA waiver program is to offer home and community alternatives to institutional care and to provide the opportunity for those in institutions to transition to the community. In keeping with this goal, the state made efforts to bring about a "culture change" among hospital discharge planners, doctors and families regarding the appropriateness of home and community care alternatives to nursing homes. One respondent noted that these efforts appear to have been successful, given that 95 percent of those receiving CBA waiver services have never been in a nursing facility.

When the CBA waiver program was developed, it was anticipated that 50 percent of waiver clients would be served in personal care facilities, particularly elderly persons who did not need a high level of care. This expectation fueled the development--and some respondents said--the over-development of personal care facilities and other types of residential care settings.

In 1987, Texas had 4,200 beds in personal care facilities. In 2002 there were over 40,000 licensed assisted living beds (including adult foster care homes licensed as Type C assisted living facilities), of which only 67 percent (26,000) were occupied, primarily by private pay residents. The main reason for the low occupancy is that the majority of waiver clients choose to live in their own homes. In 2002, approximately 2,500 CBA waiver clients received services in assisted living facilities through 320 contracts with providers across the state--less than seven percent of the 32,000 clients receiving CBA waiver services.

Adult Foster Care Homes

Assisted Living Facilities

In Texas, assisted living is a service delivery model not an architectural model. It is defined as a housing plus services arrangement for persons who, because of a physical or mental limitation, are unable to live their own homes. Assisted living settings provide food, shelter and personal care services to four or more persons who are unrelated to the proprietor of the establishment.

There are five types of licensed ALFs, but there are two primary licensing designations, which are based on residents' physical and mental ability to evacuate the facility in an emergency, and whether nighttime attendance is necessary.8 They are:

Only licensed facilities may use the term assisted living, and the statute requires careful monitoring to detect and report unlicensed facilities. An assisted living facility must be licensed to participate in the CBA waiver program.

Medicaid Waiver Contracts

The Department of Human Services (DHS) contracts directly with qualified providers on an open enrollment basis. Any provider agency that meets the enrollment or licensing criteria for the service it proposes to provide under the waiver is eligible to apply for a contract with DHS. Providers are required to maintain current certifications or licenses for the applicable services throughout the time period during which waiver services are delivered.

The Medicaid CBA waiver program contracts with six categories of assisted living providers to cover Assisted Living/Residential Care (AL/RC) services:

In addition to meeting all relevant licensing and regulatory requirements, providers must agree to contractual rules for accepting CBA waiver clients.

The Medicaid contract rules specify three different types of housing options in which waiver clients may be served: assisted living apartments, residential care apartments, and residential care non-apartments. All are considered types of assisted living and all are licensed as assisted living facilities. The three types of housing options are described below.

Assisted Living Apartment

Residential Care Apartments

Residential Care Non-Apartment

These non-apartments tend to be the older personal care facilities (redefined as assisted living facilities in 1999). Most have dual occupancy rooms and some have rooms with up to four residents in a dormitory style. No more than 50 percent of the beds in a given facility can be shared by three or more persons. Bathrooms are required for every six residents.

Single Occupancy

A big hurdle in developing the waiver was obtaining consensus among the consumer advocates and providers regarding occupancy rules in assisted living facilities. The consumer advocates wanted single occupancy to be required for waiver clients, while the providers wanted double occupancy to be the standard because existing providers already had double occupancy rooms in many facilities.

CBA waiver provider participation standards require the assisted living facility to provide each client with a choice of a private or semi-private room. The Texas Waiver Handbook also states that the facility must provide each participant with a separate living unit. However, in practice, dual occupancy rooms and apartments are not excluded from the waiver program. Most assisted living facilities serve a predominantly private pay clientele and single occupancy units are not always available

There are no data indicating the percentage of CBA waiver participants typically served in dual occupancy or dormitory units, but respondents did not think that the percentage was that different from the percentage of private pay residents in dual occupancy or dormitory units. As of December 31, 2002, 1787 CBA clients were in single occupancy apartments, and 952 CBA clients were in double occupancy apartments.

The CBA waiver contracts specify which of the three housing options will be available for CBA waiver clients. Providers may not deliver CBA waiver services in a housing option which is not specified in the contract. If the AL/RC provider wishes to limit the types of apartments in a facility that are available to CBA waiver participants, this must be specified in the contract. Without this specification, all types of apartments in the facility must be available to CBA waiver participants.

If the facility limits the type of apartment available for CBA waiver clients and there is no apartment of that type available, they can refuse to accept any CBA waiver client, based on not having space available. This would apply both for a client wanting to move into the facility from the outside, or to a private pay client currently in the facility who has spent down to CBA waiver eligibility. The client would then have to move to another assisted living facility or to an adult foster care home.

Room and Board

Texas limits the amount that can be charged for room and board to Medicaid waiver clients in assisted living facilities. The amount is equal to the SSI federal benefit rate minus a personal needs allowance of $85.00, which equals $467. There are no restrictions on the amount that private pay residents can be charged.


Medication Administration

Service Rates

Admission, Retention, and Discharge Criteria, and Aging in Place

Texas believes that services provided in assisted living facilities should enhance a person's ability to age in place while receiving increasing or decreasing levels of service as the person's needs change.10 The key distinction between nursing homes and assisted living facilities is that the former provides regular nursing care. Licensing rules do not permit assisted living facilities to serve those who require more than intermittent, short-term acute, or terminal nursing services. If an assisted living resident--either private pay or CBA waiver--requires intermittent, short-term or terminal nursing services, the provider has to contract with an agency to provide them.

The regulations specify that assisted living facilities may admit residents who:

If residents have a change in health or conditions related to the amount and type of care required, the case manager, in conjunction with the other members of the Interdisciplinary Team, the provider and the resident or their legal representative, may explore other means to continue serving them in assisted living. CBA waiver participants (and private pay residents) may receive licensed nursing services in an assisted living facility if they are provided through contracts with certified home health agencies. Another option is to have the resident attend a day activity and health services program, which provides some nursing care. In either case, the cost of all services combined may not exceed the waiver cap.

Rules regarding retention criteria include:


In addition to consulting with ten state staff and policy makers regarding the technical details of the state's programs, we also interviewed four of them. In addition, we interviewed nine stakeholders, including representatives of residential care provider associations, consumer advocates, the state ombudsman program, aging services providers, the state agency that administers the home and community services program, the state office of a national advocacy association for seniors, and a former state administrator (now a long term care policy consultant.)

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

General Comments About the State's Residential Care System

Because residential care facilities serve both private pay and Medicaid residents, a few respondents expressed views about the industry as a whole, and about particular issues the long term care system is facing, including a liability insurance crisis.

Several expressed satisfaction with the state's efforts to involve all stakeholders in the regulatory process and for keeping them informed.

One respondent expressed concerns about unlicensed assisted living facilities.

Another was very pleased with the state's approach to nurse delegation.

General Comments on Medicaid's Role in Residential Care Settings

There was a consensus among all those interviewed that the CBA waiver program was a very good program and that coverage of assisted living was a success for a variety of reasons.

Two respondents mentioned that the room and board payment for Medicaid waiver clients was not sufficient to cover the costs and needed to be addressed.

Licensing and Regulatory Requirements

There were some issues among those interviewed regarding the content of the state's licensing and regulatory requirements for ALFs, although no one felt that regulations posed a major obstacle to affordable assisted living in Texas.

National Standards

The consensus among those interviewed was that national standards were not warranted, although some advantages were noted.

Admission and Retention Requirements and Aging in Place

A number of respondents expressed concerns about admission practices and the need to assure that people can age in place.

With regard to discharge policy, one respondent reported that it was hard to discharge people from assisted living facilities, but noted that the state was getting better about supporting facilities who had really difficult cases.

Respondents felt that the issues related to aging in place were far from settled, with some providers liking the concept and others not. Most supported the concept but had concerns about its implementation.

Negotiated Risk Agreements

Few respondents were familiar with negotiated risk agreements. One noted that although the term "negotiated risk agreement" is not used, there are agreements that must be signed between the facility, the person and the person's attending physician to allow aging in place to occur. Several of those interviewed were aware of these agreements and supported the notion of negotiated risk.

Barriers to Serving Medicaid Clients in Residential Care Settings

Respondents noted a number of barriers, which are discussed in turn.

Insufficient Capacity in the Waiver Program

The unanimous opinion of all those interviewed was that the number one issue for the CBA waiver program is the lack of funding, and there is pressure from providers to fund more waiver slots.

One respondent felt that there was not much of a demand for assisted living in the waiver program.

Service Rates

Some stated that low rates were a barrier to the expansion of assisted living, and one respondent felt that Medicaid rates were low across all settings, not just in ALFs. Another said that Texas is limited in its funding for Medicaid programs, noting that the state ranked 47th in terms of its reimbursement rates. Another disagreed:

One respondent said that the state's bed hold policy was a major cost problem for providers.


Suggested Changes to Improve the Medicaid-Funded Residential Care System

A few respondents did not make specific suggestions about Medicaid, but instead noted that there were general areas that the state needed to pay more attention to.

Others had very specific recommendations.

Future Plans

A number of respondents mentioned ongoing activities related to the Olmstead decision.

A number of respondents mentioned regulatory issues that the state is planning to address.

Another mentioned the state's ongoing data monitoring activities.

Recommendations for Other States

Only one respondent had a specific recommendation for other states interested in using Medicaid to pay for services in residential care.



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.

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

Case Manager Community Based Alternatives Handbook

Community Care for the Aged and Disabled Handbook

Community Based Alternatives/Community Care for the Aged and Disabled Policy Clarifications

Department on Aging

Elder Options of Texas, Assisted Living Communities

Gaps in services for older Texans, a survey report

Home and Community Based Services network

Information Letter No.2000-17, Change in Reimbursement Methodology for Community Based Alternatives Assisted Living/Residential Care Providers

Spousal Impoverishment

Texas Administrative Code, Title 25, Health Services$ext.ViewTAC?tac_view=2&ti=25

Texas Administrative Code, Title 40, Social Services and Assistance: Chapter 92, Licensing Standards for Assisted Living Facilities$ext.ViewTAC?tac_view=4&ti=40&pt=1&ch=92

Texas Department of Human Services, Community Care Programs for Elderly and Disabled

Texas Health and Human Services Commission, STAR+PLUS Background Information

Texas Statutes, Health and Safety, Chapter 247, Assisted Living Facilities,

Texas Statutes, Health and Safety, Chapter 242, Convalescent And Nursing Homes And Related Institutions,

Formal and Informal Interviews

Kerry Adair, Provider Funding and Contracting
Pine Tree Lodge, a Veranda Living Assisted Living Facility

Gerardo Cantu, Director,
CBA Waiver Program
Texas Department of Human Services

Candice A. Carter
Texas AARP, State Affairs

Dee Church, Section Director for Client Eligibility,
Long Term Care Services
Texas Department of Human Services

Pam Coleman, Project Manager,
STAR+PLUS Managed Care Project

Skip Comsia, President
Veranda Living

Cheryl Cordell, Ombudsman
Texas Department on Aging

Frank Genco, Program Analyst
State Medicaid Office

Marc Gold, Director,
Long Term Care Policy
Texas Department of Human Services

Becky Grantham, Contract Manger
Assisted Living Concepts

Rose Ireland, Director of Clinical Services
Texas Association of Home and Services for the Aged

Bob Kafka, National Organizer

Richard Ladd, Long Term Care Policy Consultant
Ladd & Associates

George Linial, President
Texas Association of Home and Services for the Aged

Susan Moellinger, Executive Director
Covenant Place of Abilene

Mary Ann Ramirez, Supervisor
Unit 54, Long term Care Services
Texas Department of Human Services

Jeannie Williams, Benefits Counselor
West Texas Council of Governments Area Agency on Aging

John Willis, Ombudsman,
Texas Department on Aging

Jeanoyce Wilson, Unit Director
Long Term Care Regulatory Policy
Texas Department of Human Services


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

  2. When SSI recipients enter a nursing home, SSI provides only $30 for personal needs. For these individuals, the state provides a supplement of $30 per month.

  3. The provisions of Rider 28 were originally contained in Rider 37 in the 76th legislative session. The number was changed during the 78th legislative session.

  4. Although the AFDC program no longer exists, allowable maintenance costs are still tied to the basic monthly grant when it did exist.

  5. "Support and maintenance are not counted as income if eligibility is being tested for a waiver program; for example, Community Living Assistance and Support Services (CLASS), the Community Based Alternatives (CBA), Home and Community-Based Services (HCS), and Medically Dependent Children's Program (MDCP). The 1929(b) program is not a waiver program." Texas Administrative Code, Title 40, Part I, Chapter 15, Subchapter E, Rule 15.455.

  6. The TILE classification system was developed by the Department of Human Services to group nursing home residents on the basis of their clinical conditions and functional abilities.

  7. The respondent who provided this figure stated that it is a conservative estimate based on incomplete data, and that a larger number is probably being served in these settings.

  8. Type C facilities are Adult Foster Care Homes with four or more beds. In 1999, when personal care facilities were renamed assisted living facilities, the state required AFC homes with four or more beds to be licensed as an assisted living facility. Type D facilities are operated by the Department of Mental Health and Mental Retardation for persons with serious mental illness and developmental disabilities. Type E facility residents are the same as Type A except that they do not require assistance with ADLs, but only with medication administration.

  9. Use of advertising terms such as "medication reminders or assistance," "meal and activity reminders," "escort service," or "short-term memory loss, confusion, or forgetfulness" will not trigger a requirement for certification as an Alzheimer's facility. (Source: Texas Administrative Code, Title 40, Chapter 92)

  10. Texas Administrative Code, Title 40, Social Services and Assistance, Chapter 92, Licensing Standards for Assisted Living Facilities, Subchapter A, Rule 92.2,a.

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  • APPENDIX A. Methodology
  • APPENDIX B. Florida
  • APPENDIX C. Minnesota
  • APPENDIX D. North Carolina
  • APPENDIX E. Oregon
  • APPENDIX H. Factors for States to Consider When Choosing to Cover Medicaid Services in Residential Care Settings
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