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.
Historically, nursing homes have been the predominant provider of long term care in Wisconsin. In 1981, the State instituted a moratorium for nursing facilities which remained in effect through 1998. The State no longer reviews the building of new facilities that are replacement beds; it has a Certificate of Need program for bed applications that would add to the total.
Over the past 20 years, the state has made an effort to reduce nursing home utilization by developing home and community service options. Between 1996 and 2001, the number of staffed licensed beds in Wisconsin nursing homes declined 12 percent from 47,200 to 41,500. However, even after a decade of decline, the nursing home bed rate in Wisconsin is still higher than the national average.1
Currently, about 10 percent of Wisconsin's nursing homes are in bankruptcy. The state does not know the current distribution of nursing home beds and whether it matches need. Nursing home closures have created several transition issues, for example, finding alternative housing for residents required to move.
There are three groups financially eligible for Medicaid covered nursing home care.
Mandatory Categorically Needy includes individuals who are receiving Supplemental Security Income (SSI), those receiving SSI and the State Supplemental Payment (SSP), those who have incomes no higher than the SSI/SSP level, and those who are eligible for full Medicaid benefits through any other eligibility option.
Optional Categorically Needy includes persons with incomes up to the special income standard of 300 percent of the SSI Federal Benefit Rate, which is $1,656 in 2003. This group must spend all of their income (minus a personal needs allowance) on nursing home care before Medicaid will begin to pay, unless spousal impoverishment provisions apply.
Medically Needy includes individuals whose nursing home costs exceed their income.
Asset limits for all three groups are $2,000 for an individual in a nursing home. When only one member of a couple applies and there is a community spouse, spousal impoverishment protections apply.
The monthly individual personal needs allowance is $45.
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 spouse of a nursing home resident may keep the larger of $50,000 or one-half of the couple's assets, up to a maximum of $90,660.2 All assets over this maximum must be spent on nursing home care before Medicaid will begin to pay.
Families may pay the difference in cost between a semi-private and private room directly to the nursing home without jeopardizing Medicaid eligibility. In Wisconsin, these payments are called voluntary family contributions.
To receive Medicaid coverage of nursing home care, individuals must meet all of the following eligibility criteria:
Wisconsin has several waiver programs. The Aged and Disabled waiver program provides services to persons residing in their homes, supported apartments, and all types of residential care facilities: Adult Family Homes, Community Based Residential Facilities, and Residential Care Apartment Complexes.
Three groups are financially eligible for waiver services:
Group A includes individuals who are receiving SSI, those receiving SSI/SSP, those who have incomes no higher than the SSI/SSP level, and those who are eligible for full Medicaid benefits through any other eligibility option.
Group B includes persons with incomes up to the special income standard of 300 percent of SSI, which is $1,656.
Group C includes medically needy individuals who spend down to the medically needy income level. There is no upper limit on income, but income can be no greater than $591.67 after deducting medical and remedial expenses.3 There is a hierarchy of spend down categories starting with out-of-pocket expenditures for medical expenses not paid by Medicaid (e.g., over-the-counter medications), followed by expenditures on long term care and other services not covered by the waiver program, then waiver-covered services, and finally Medicaid state plan services, such as prescription drugs.
Asset limits for all three groups are $2,000 for an individual and $4,000 for a couple when both members of the couple are eligible for the waiver and have been receiving waiver services for one year or longer. When only one spouse applies, spousal impoverishment protections apply.
Waiver clients have the same spousal impoverishment protections as nursing home residents. Spouses of waiver clients may keep any income in their own name. The minimum monthly protected income for the spouse of a waiver client, including residents of residential care facilities, is $1,935, and the maximum amount is $2,267, as allowable under federal law.
The spouse of a waiver recipient may keep the larger of $50,000 or one-half of the couple's assets, up to a maximum of $90, 660. All assets over this maximum must be spent before Medicaid will begin to pay.4
Persons in Group B who are receiving waiver services must share the cost of services if income remains after certain deductions. These deductions are:
A Personal Maintenance Allowance, which is a combination of three items:
A Family Maintenance Allowance.
Exempt income (e.g., to pay court ordered expenses such as child support).
Health insurance premiums.
Out-of-pocket medical remedial expenses.
Allowable deductions cannot exceed $1,114. Income over this amount is the cost sharing obligation.
Individuals residing in Community Based Residential Facilities or Residential Care Apartment Complexes are permitted to keep a discretionary allowance to cover incidental personal expenses.5 The counties determine the amount they are allowed to keep. The minimum and typical amount is $65 per month, the maximum permitted is $240 per month.
Anyone who is eligible for SSI is automatically eligible for Medicaid. If the family of a resident in a Community Based Residential Facility makes a payment directly to the facility for a private room, the SSI payment will be reduced by one third, and the family must make up this difference as well as paying the additional cost for the private room.
If someone is not eligible for SSI, the Medicaid program does not consider money paid to a Community Based Residential Facility for a private room to be in-kind income to the Medicaid beneficiary because the payment is not made in return for a service. Medicaid only considers in-kind payments to be income to the beneficiary if they are "regular, predictable, and in return for a service."
In Wisconsin, family members often make voluntary contributions to cover room and board, or the cost of a private room in residential care facilities, or to provide service enhancements, i.e., to pay for something individuals would not be getting under Medicaid, such as monthly hairdressing services.
There is some disagreement at the county level about allowing voluntary family contributions. Some counties fear that it can set a precedent and an expectation, and that some Community Based Residential Facilities and Residential Care Apartment Complexes might start to require it. Even though federal law prohibits such requirements, there is no way for the counties to monitor facility practices. If a family chooses to contribute, some counties require documentation in writing that if the contribution stops, it will not be picked up by any other public funding source.
Waiver applicants have to meet the same level of care criteria as nursing home applicants.
In 1988, personal care was added to the Medicaid state plan. Medicaid personal care services may be provided in a person's home or in a residential care facility--including Community Based Residential Facilities and Residential Care Apartment Complexes and Adult Family Homes. However, services may not be provided in a Community Based Residential Facility that has more than 20 beds.
To be reimbursed for the provision of personal care services, Community Based Residential Facilities and Residential Care Apartment Complexes may employ people to provide the care that is then billed by a Medicaid certified provider (i.e., independent living centers, county or home health agencies). Alternatively, the county may secure services through an agency that provides personal care. Even if the facilities directly employ people to provide personal care, the county, home health agencies or independent living centers still has to bill for the pre-authorized hours provided because Medicaid does not allow Community Based Residential Facilities or Residential Care Apartment Complexes to be certified providers. If a residential care facility wants to be reimbursed for Medicaid personal care, it must have a billing partner, typically a county. The rationale for this restriction is that it ensures county oversight of the care recipient's entire care plan and assures that duplication of services does not occur.
In FY 2002 Medicaid provided personal care through the state plan to 10,408 individuals at a cost of $105.6 million. The FY 2003 personal care budget is $115.4 million. Data on the number of persons receiving personal care in residential care settings are not available.
To be eligible for services through the personal care option, individuals must meet Medicaid's community income standard, which limits eligibility to those with incomes equal to the combined SSI/SSP benefit of $635.78 per month for an individual, of which $552 is the federal SSI benefit and $83.78 is the SSP. For couples, the income limit is $961.05. To be eligible for SSP an individual must be eligible for either SSI or some other federal benefit.6
Individuals may have no more than $2000 in assets; couples no more than $3,000.
SSI recipients who need at least 40 hours a month of assistance with activities of daily living are eligible for a larger state supplement of $179.77, for a total of $731.77. This amount can be used to pay for room and board in Community Based Residential Facilities. Prior to July 2000, this supplement--called the Exceptional Expense Supplement or SSI-E--was available only to individuals who lived in their own or another's home. Since that date, individuals who reside in (1) certified Residential Care Apartment Complexes, (2) Community Based Residential Facilities certified as consisting entirely of independent apartments, and (3) licensed or certified Adult Family Homes are also eligible for the enhanced supplement.
The state has a medically needy program for the aged, blind and disabled. The medically needy income standard is $591.67, with asset limits of $2000 for individuals and $3,000 for couples. The budget period for medical need is six months. The state provides the same medical coverage and services for the medically needy as it does for the categorically needy.7
There are no spousal income and asset protections for community spouses of persons receiving personal care services in their home or in Community Based Residential Facilities, Residential Care Apartment Complexes, and Adult Family Homes. Only the spouses of nursing home residents and waiver participants receive income and asset protections.
Covered personal care services include assistance with activities of daily living (e.g., bathing, dressing, grooming, toileting), assistance with housekeeping, shopping and meal preparation, accompanying the recipient to medical appointments, and providing assistance with medically oriented tasks that are assigned to a trained personal care worker supervised by an RN.
To be eligible for personal care, an individual's physician must provide a written order that such services are medically necessary. Services must also be based on a plan of care and supervised by a Registered Nurse. Amounts over 50 hours per year must be pre-authorized.
The policy regarding voluntary family contributions is the same as for the waiver program.
Services are provided through the state's Community Options Program (COP) only if they cannot be provided through the waiver program or the Medicaid state plan. The purpose of the state COP program is to divert or relocate persons of all ages and target groups from nursing homes. The COP program is funded through state and county revenues. The state also has a program that provides help for caregivers of persons with Alzheimer's disease or other causes of dementia.
In some instances, COP funding may be used to pay for room and board in Community Based Residential Facilities. Policies regarding room and board payment vary by county and depend, in part, on whether the county has state-only funds available at the time they are needed for this purpose. One study found that the average COP payment for room and board for a waiver client in a CBRF was $147 per month.
COP funding may not be used to pay for room and board in RCACs per state law because these costs are perceived as too high and paying for them would disproportionately reduce the amount of money available for home care services.
Eligibility for the program is restricted to those who are financially eligible for Medicaid or are expected to be eligible within six months of spend-down in a nursing home. Individuals who would be eligible under this latter criterion can receive COP services if they pay part of the cost of those services. COP recipients are permitted to retain $29,193 in assets, an amount equal to six months of nursing home care plus $2,000.
People with incomes over the allowed amounts can become eligible by sharing the cost of their services. Those with incomes over the cost of their services are generally not eligible, because they are assumed able to pay for services themselves.
The community spouse of a COP recipient has the same income and asset protections as the spouse of a waiver client.
Eligibility for the program is restricted to those who meet the state's nursing home level of care criteria.
The Family Care Program is a pilot managed long term care program currently operating in five counties. It is based on the philosophy that service dollars should follow the client. People enrolled in Family Care who meet the nursing home level of care criteria have a choice of home care, Residential Care Apartment Complexes, Community Based Residential Facilities, Adult Family Homes, and nursing homes.
The Family Care program replaces/combines waiver programs and other sources of funding for long term care. It provides greater flexibility in the use of funds and improved access through shorter waiting periods.
Wisconsin has three types of residential care settings (RCS) and separate licensing and regulatory requirements for each of them: Adult Family Homes (AFHs), Community Based Residential Facilities (CBRFs), and Residential Care Apartment Complexes (RCACs). The state has never had a moratorium on, or a certificate of need program for, RCS.
The state's primary goal in using the Medicaid waiver to pay for services in residential care settings is to provide an alternative to nursing homes for people who cannot live in their own homes. The state also provides Medicaid state plan personal care services in residential care settings, but relatively few people in these settings receive these services compared to the number who receive Medicaid personal care services in their own homes.8
Residents in all settings may be able to receive waiver services or personal care state plan services, as long as the facilities meet the regulatory requirements for providing these services and applicable COP and Waiver policies are met. Residents of CBRFs and AFHs may also receive COP state funded services.
In 2001, 76.8 percent of people receiving waiver & COP services received them in their own homes, 13.6 percent in CBRFs, 5.2 percent in AFHs, and .7 percent in RCACs. The remainder are served in other types of facilities such as supervised apartment living. There are no data on how many personal care clients receive services in these settings.
Adult Family Homes (AFHs) serve up to 4 residents. Those serving up to 2 residents need to be certified by county certifying agencies and those serving 3 or 4 residents need to be licensed by the state to be reimbursed for waiver services.
Community Based Residential Facilities (CBRFs) are group living arrangements that serve five or more residents and provide room, board, supervision and other supportive services. Residents have private or shared rooms and most have shared bathrooms.
CBRFs were first licensed in the late seventies. CBRF is an umbrella category that includes single family homes used for group living, group homes, dormitories, and apartment buildings with separate apartments. CBRFs vary in size from 5 to over 100 beds. Whatever their size or setting, they are all licensed under the same provisions and subject to the same regulations. Facilities with over 20 beds are subject to additional requirements for fire protection, sanitation, construction and maintenance, and other aspects of the physical environment.
The licensing term CBRF is an umbrella category that covers facilities that may provide care to people of all ages with all types of physical and mental impairments. CBRFs are intended for people who are neither acutely ill nor need extensive amounts of nursing care, yet cannot live independently. Some CBRFs serve a specific population, e.g., the frail elderly, working age adults with disabilities, elderly with dementia, while others serve a heterogeneous population, e.g., people of all ages with a range of physical or mental impairments.
The CBRF regulations state that it is desirable to provide services to a specialized target group, but the state does not require it, in part because the state has many rural areas and there may not be a large enough population in each target group to guarantee full occupancy. Whatever the population served, the CBRF regulations require that the facility be able to meet the residents' needs. Most residents of CBRFs are elderly persons who pay privately, so generally, public policy does not drive the industry.
Newly constructed CBRFs must have at least 100 sq. ft. of floor area in each single and 160 sq. ft. in each double occupancy bedroom. Minimum bedroom floor area for existing buildings is 60 sq. ft. per resident for multiple occupancies and 80 sq. ft. for single occupancies in facilities serving ambulatory residents only, and 80 and 100 sq. feet for single and multiple occupancies respectively in facilities serving semi-ambulatory and non-ambulatory residents.
The proportion of CBRF beds in single rooms depend on the county and the population served. There are many small facilities with eight beds and dual occupancy rooms. Larger facilities tend to offer private rooms and baths, generally to meet the preferences of private pay residents. The newer, larger facilities generally have only private rooms, but there is considerable variability regarding private baths.
Whether or not Medicaid clients have private rooms depends on the availability of these rooms in a given county, and the county's willingness to pay for private rooms using state Community Options Program funds. Facilities enrolled in the Family Care pilot program vary in the number of private units available from 20 percent to 75 percent of total units. The percent of Medicaid clients in private rooms varies considerably by county, most likely reflecting the availability and cost of private rooms in each county.
Room and board is paid for with either private funds or public funding through SSI. There are no data indicating what percentage of people in CBRFs are private pay and what percentage are SSI eligible. Wisconsin does not set room and board rates for Medicaid waiver clients in CBRFs because the waiver program is administered at the local level by the counties. Consequently, many people who are eligible for the waiver cannot afford to pay market rate room and board costs in CBRFs, or any other residential care setting. In some instances, a waiver client may be able to receive state COP funds to help them pay for room and board costs.
Some CBRFs will accept the SSI benefit as payment for room and board costs for people who are eligible for Medicaid through SSI eligibility or through the Medically Needy program.
CBRFs serve people who do not require care above an intermediate level of nursing care and need no more than 3 hours of nursing services per week. Nursing care includes anything that is covered by the state's nurse practice act, including tasks that can be delegated, e.g., dressing changes. Assistance with ADLs is not considered a nursing task. Nurses do not have to be on site to supervise delegated tasks. Nurses can be paid hourly or on retainer for a certain number of hours per week. Exceptions to the hourly limits are made for temporary conditions lasting no more than 90 days or longer with department approval.
General Revenue Funded Community Options Program
The Community Options Program (COP) was originally designed as a home care program in 1982 and there was no separate funding source for individuals in residential care who required long term care services. Once the state approved funding of services in CBRFs through COP and the waiver program (in the mid-eighties) and established new regulatory requirements for receipt of this funding (see below), the industry responded with a growth in new facilities that met the regulatory requirements.
Consequently, greater and greater amounts of COP and waiver funding went for residential care--80 to 90 percent in some counties. In response, the state set a statewide maximum amount of COP and waiver funding that could be spent in CBRFs. This maximum was set at 25 percent of a county's COP and waiver allocation. Because it was recognized that a statewide cap did not accommodate local needs, the policy was changed. Counties now set their own maximum amount of COP and waiver allocations that will be used for CBRF care.
All Medicaid state plan services--e.g., personal care, medications, and skilled nursing and therapies through home health care--are provided in CBRFs. Both waiver funds and state plan funds can be used to pay for services in CBRFs. The primary reason for introducing Medicaid waiver payments for care in CBRFs was that it was a more cost-effective way of delivering services than the nursing home for people who, for whatever reason, could not live at home. In the nursing home, the state pays for everything--room and board and services, whereas in CBRFs, they pay only for services.
In 1988, personal care was added to the state plan. The date when personal care was first covered in Community Based Residential Facilities varies by county. The rationale for adding personal care to the state plan was that existing programs providing personal care were not sufficient to meet the demand, and many persons with disabilities did not qualify for these programs. Prior to coverage under the state plan, personal care provided in Community Based Residential Facilities was paid for through the waiver program, the state's Community Options Program, county funding, and federal block grant funding, e.g., Title XX dollars.
Whereas people eligible for waiver services often face long waiting lists, there is no waiting list for personal care under the state plan because the services are an entitlement for Medicaid eligibles when medically necessary. Once personal care was a Medicaid state plan service, counties, home health agencies and Independent Living Centers could apply for a provider number, which allowed them to provide services.
In 2001, 2,473 residents in CBRFs were receiving services funded by COP, the Medicaid waiver or the state plan. Together these public pay residents occupy 11.5 percent of the state's total CBRF capacity of 21,468 beds. Only a very small proportion of these residents were receiving personal care services through the state plan.9
State plan personal care services and waiver services used to be limited to persons in CBRFs no larger than eight beds.10 The reason for this policy was that the state did not want to encourage the payment of public money intended to serve individuals in home-like settings, to quasi-institutional residential care facilities. Historically, the state has used small bed size as a proxy for "home-like." Consequently, residents who spent down to Medicaid eligibility in a facility that was larger than eight beds would have to move to a different facility to receive Medicaid, waiver, or COP covered services.
In 2002, the state revised the policy that limited Medicaid funding to CBRFs with eight beds or fewer. The state now allows waiver funding to be used in CBRFs with up to 20 beds, and more than 20 beds with Department approval. Residents receiving personal care through the state plan may not be served in CBRFs with more than 20 beds.
Medicaid waiver coverage in CBRFs with more than 20 beds may be allowed when one of the following applies:
The facility consists entirely of independent apartments. Independent apartment CBRFs have a separate kitchen, full bathroom, sleeping and living area within each unit.
The Department has approved a variance, requested by the county, to provide COP and/or waiver funding for a specific facility. The variance request has documented how the facility design, environment and programming mitigate the effects of living in a large congregate setting.
This change occurred because many providers, residents, and counties wanted to expand residential options for county clients and no longer felt that size was an appropriate way to define "institutional."
Wisconsin's pilot program to redesign long term care financing pays for CBRF services provided to enrollees in the five participating counties. Family Care pays for services in RCACs only in pilot counties where there is a care management organization (CMO) and when the facility is included in the CMO's provider network.
Persons who live in group community living arrangements, such as RCACs that house no more than 16 persons, can receive food stamps if they are either blind or disabled and meet the program's financial eligibility criteria.
Effective March 1997, the state carved out a portion of the residential care market that was most suitable for deregulation and created a new category of residential care setting (RCS), called assisted living, with its own specific regulations. The state's intent was to reduce regulatory burden, give providers the flexibility to be creative in developing quality residential environments, and permit residents to have maximum control over their daily lives. Residential Care Apartment Complexes (RCACs) were intended to be a less regulated type of RCS than CBRFs and to increase residential care choices for older persons.
This new category of RCS required that each unit be a separate lockable apartment with a private bath and kitchenette. The statute clearly defines RCACs in accordance with the assisted living philosophy, with specific provisions to assure privacy, autonomy, and the ability to age in place. The statute says that RCAC residents retain control over their personal space, care decisions, and daily routines, and that services are individually tailored to each resident's capacities and preferences.
Because the new assisted living regulatory category required private rooms, other RCSs were prohibited from using the term assisted living. Because many AFHs and CBRFs called themselves assisted living or used the term in marketing, they lobbied the state to allow them to use the term. The state agreed but wanted to distinguish the new model from other CBRFs and AFHs. Consequently, in March 1997, the state issued a new rule changing the name of the new model from assisted living to residential care apartment complex.
RCACs are frequently described as "nice assisted living facilities," but they vary with regard to the availability of amenities, e.g., some have washers and dryers in each unit while others have laundry rooms; some have more common space, such as private dining rooms for family parties, libraries, and computer rooms.
RCACs that do not serve Medicaid waiver clients need only to register with the state. Those that wish to receive Medicaid waiver funding must be certified. Standards for both are the same, but certified facilities are subject to a higher level of regulatory oversight and enforcement, including yearly site visits, and a full range of enforcement actions. One respondent noted that the state's policy is to visit certified facilities once a year, but in actual practice, there are not enough regulatory staff to do so. Registered facilities are reviewed only in response to complaints and the state cannot levy fines or impose other "intermediate sanctions."
Wisconsin has 129 RCACs. Forty six percent are registered because they do not plan to admit Medicaid waiver clients. Sixteen registered facilities have become certified, generally because residents have spent down to Medicaid eligibility.
Over 5000 units have been built in the last 5 years. The newer ones are real apartments with separate bedrooms and living areas; the older ones are more like a large studio apartment.
RCACs serve 5 or more residents in single occupancy apartment units and there is no limit on the number of units in RCACs; 69 percent of facilities offer one bedroom apartments and 51 percent have studios; 37 percent have 2-bedroom units, though generally only a few.
Facilities can include a mix of independent living units and RCAC units, and approximately one third do so. About a third are freestanding facilities and two thirds are in a campus setting.
RCACs are generally full, with an average occupancy rate of 87 percent. Fifty-five percent of RCACs have waiting lists, with an average of 17 people on the waiting list.
RCACs serve a predominantly private pay clientele. Only 189 people in RCACs are receiving waiver services--four percent of all RCAC residents.
Apartment units must have at least 250 square feet excluding closets, with a full private bath and kitchen and a separate sleeping and living area. The average unit size is larger than the national average and larger than required by Wisconsin administrative rules.
Wisconsin does not set room and board rates for RCACs. This policy is based on a philosophy of local control and a belief that the state does not have the information needed to set accurate rates. Counties negotiate the room and board rates for publicly funded clients. As part of a Robert Wood Johnson funded project, the state is developing rate setting methods for counties and facilities to use.
Facilities are free to charge both private pay residents and Medicaid waiver clients whatever they want. In January 2000, monthly RCAC charges ranged from $625 to $3,700 per month. The average total charge was $1,881 per month, allocated as follows: rent $841, meals $259, services $781.
Based on the special income standard for waiver clients (300 percent of SSI) and required cost sharing for services, the typical amount of income that Medicaid waiver clients have available to spend on room and board is $667 a month (the minimum amount is $312 and the maximum is $1,591). Those eligible for Medicaid through the community financial eligibility standard have no more than this amount. Thus, the great majority of persons eligible for Medicaid waiver services and state plan personal care services will not have sufficient income to pay for room and board in an RCAC without a subsidy. Some may be eligible for Food Stamps, which could make the RCAC more affordable.
If people spend down to Medicaid eligibility in RCACs, some providers (e.g., mission driven non-profits, or religious orders) have an endowment fund to subsidize the cost of care for a limited number of residents.
Service requirements in RCACs are non-prescriptive, stating only that facilities must provide services that are sufficient to meet the care needs identified in the service agreement, both scheduled and unscheduled, and to have emergency assistance available 24 hours a day. Minimum services that must be provided include: meals, housekeeping and medical transportation; assistance with all ADLs; and nursing services such as health monitoring, medication management and administration.
However, while the regulations require that an RCAC have the ability to meet the needs of residents, which may include a need for three meals a day, only about half of RCACs offer three meals a day in their meal packages. The state does not dictate how many meals need to be provided, only that 3 meals be provided if a resident needs them. If the basic package includes only two meals, the facility can charge an additional amount for the third meal, and if they don't want a lot of residents who need three meals a day, they can charge a very high rate for a third meal.
Both registered and certified facilities may provide up to 28 hours of supportive, personal or nursing services per resident per week, with no additional restriction on the type or amount of nursing care provided. They may choose to provide fewer than 28 hours a week if they wish. RCACs can discourage the entry of residents with high needs by including only a limited amount of care per week in the basic package (e.g., ten hours) and charging a very high rate for any additional hours.
One respondent noted that when the RCAC regulations were being developed, the nursing home lobby expressed concern that RCACs not become a substitute for nursing homes. In response, the state limited all supportive, personal, and nursing services that can be provided in an RCAC to 28 hours of supportive, personal, or nursing services per week, with no additional restriction on the type or amount of nursing care provided. Private pay residents may pay for additional services they need or want above the 28 hour limit, as long as the service are provided by an outside vendor.
Among the respondents interviewed there was agreement that 28 hours enables a significant amount of physical care, in fact, more than many nursing home residents get. In contrast, CBRFs are permitted to provide only up to 3 hours of nursing care per week with no restriction on the amount of personal care. For temporary conditions lasting no more than 90 days or longer, RCACs may bring in home health services. They may choose whether or not to keep waiver clients under hospice care.
RCACs may provide all services directly with their own staff or through contracts with outside entities. The waiver program pays the facility for the care provided. Residents may contract for additional services not included in the service agreement, as long as they comply with applicable facility policies and procedures. Facility policies may limit the total amount of services purchased from the RCAC and outside providers to no more than 28 hours. They may not put an hour limit on services up to 28 hours. Facility policies may require that services be provided by licensed personnel, that providers check in when they enter or leave the property, or comply with other requirements they may set.
As in CBRFs, to be reimbursed for the provision of personal care services, RCACs have to either employ people to provide the care or have the county secure services through an agency that provides personal care. Even if the facilities directly employ people to provide personal care, the county still has to bill for the pre-authorized hours provided, because the state allows only certain types of providers to bill for personal care: Medicaid certified home health agencies, counties, and Independent Living Centers. If an RCAC wants to be reimbursed for Medicaid personal care, it must have a billing partner, typically a county. The rationale for this restriction is that it ensures county oversight of the care recipient's entire care plan, and assures that duplication of services does not occur.
Staff must be trained and staffing levels must be sufficient to meet resident needs. The state does not set minimum staffing levels or required training hours. Staff at an adjacent care facility can provide coverage, as long as they are available to provide care on short notice. The average staffing ratio in RCACs is one caregiving staff for 12 residents. Sixty-two percent of staff are certified nursing assistants, and employee turnover is 31 percent per year.
Wisconsin does not set RCAC service rates for Medicaid waiver clients. Reimbursement is based on cost consistent with the maximum Medicaid waiver reimbursement for RCACs, which is capped at 85 percent of the average cost of nursing home care to the Medicaid program--$73.50/day or $2,263/month. However, counties are budgeted for only $41.86/client/day or $1,280/month and must keep spending for their entire waiver caseload within this average amount.
Because the waiver reimbursement cap is double what is actually available under the waiver program, the result is that few waiver clients are served in RCACs. One respondent expressed concern about people who spend down in RCACs having to move because the waiver program will not cover the cost of services, assuming that a waiver slot is even available.
Service rates are negotiated between the county and the facility, consistent with guidelines set by the state. If the negotiated rate turns out to be higher than allowable costs,11 the facility must give back the difference at the end of the year. Some counties also negotiate room and board rates on behalf of their waiver clients. Many counties lack the expertise to contract effectively and to enforce the profit limit, and counties often feel pressured to pay the maximum rate, which includes a high profit margin. The state is working to develop a more effective contracting process wherein the service rate will be tied to the care plan and will vary according to the services provided rather than a flat rate.
The average age of RCAC residents is 83.6 years. The average length of stay is 1.6 years, significantly below the national average of just under 3 years. The average turnover rate is 30 percent, consistent with the national average of 29 percent. About half leave because of increasing care needs (53 percent), one in four die, 12 percent spend down and move elsewhere to receive Medicaid services, and 14 percent move to another assisted living setting.
RCACs cannot admit someone who is incompetent or who has dementia. Individuals who are subject to guardianship through a court determination of incompetence, people who have an activated POA for health care, and those who have been found by a physician or psychologist to be incapable of recognizing danger, summoning assistance, expressing need or making care decision cannot be served in RCACs. Facilities are required to do a thorough assessment, but there is no standardized method for determining competence.
The rationale for the prohibition is that RCACs are minimally regulated. There are no surveyors for registered facilities. To enable some degree of aging in place, a facility may choose to retain residents who develop cognitive impairment or dementia, but if they do, they are required to provide appropriate services. Because the developmentally disabled and many people with serious mental illness cannot meet the competency test, in effect, RCACs serve only elderly persons.
There are provisions to protect residents from premature involuntary discharge. There is no bed hold policy, but RCACs have to give 30 days notice for discharges.
Private pay residents have the option to buy services from somewhere else but they still have to pay the facility base rate. Thus, private pay residents have the ability to age in place if they have the resources to bring in additional help. However, people can't necessarily age in place better in an RCAC than in a CBRF because RCACs can choose to provide a minimum amount of care or a maximum amount.
For example, RCACs can provide minimal nursing services, such as health monitoring and medication administration. They can select their own discharge criteria as long as they do not conflict with regulatory minimum requirements. One of these minimum requirements is that residents can not be discharged based on hours of services purchased until the total number of hours of service purchased from all sources reaches 28 hours per week.
RCACs cannot limit the amount of care provided to Medicaid waiver clients by setting limits on hours of care. They have to provide whatever is needed up to 28 hours. They can discourage a high level of care for private pay clients through pricing. Most RCAC residents on the waiver have spent down. RCACs are willing to accept them as Medicaid clients because the overwhelming majority of their residents are private pay.
Personal, supportive and nursing services provided in RCACs are reimbursable through Wisconsin's HCBS waiver program. Waiver funds pay for services appropriate for the individual participant. However, most counties have long waiting lists for their waiver program and in some cases the wait can be from one to three years or more. There are approximately 9,000 people on waiting lists for waiver services in Wisconsin. No waiver slots are dedicated for use in RCACs or any other facilities.
All counties administer the Medicaid HCBS waiver program but they are not required to use waiver funds for RCAC services.
Although the maximum waiver reimbursement is 85 percent of Medicaid nursing home costs, the Wisconsin HCBS waiver program provides counties with a budget and counties generally do not reimburse to the maximum, because doing so enables them to provide services to more people.
RCAC residents eligible for Medicaid may be eligible for personal care, home health, therapies, and disposable medical supplies and any other benefit under the state plan.12
Wisconsin's pilot program to redesign long term care financing pays for RCAC services provided to enrollees in the five participating counties. Family Care pays for services in RCACs only in pilot counties where there is a care management organization (CMO) and when the facility is included in the CMO's provider network.
Persons who live in group community living arrangements such as RCACs, which house no more than 16 persons can receive food stamps if they are either blind or disabled and meet the program's financial eligibility criteria.
|Requirements and Funding Sources for Residential Care Facilities in Wisconsin|
|Facility Type||Who Regulates||Size and Care Limits||Available Funding Sources|
|Adult Family Home (AFH)||
|Community Based Residential Facility (CBRF)||
|Residential Care Apartment Complex (RCAC)||
In addition to consulting with eleven state staff and policy makers regarding the technical details of the state's programs, we also interviewed four of them. In addition, we interviewed eleven stakeholders, including representatives of residential care provider associations, residential care providers, consumer advocates, the state ombudsman program, aging service providers, and a county agency that administers the state's home and community services programs.
The interviews focused on respondents' views about several key areas and issues. This section summarizes their views and provides illustrative examples of their responses. These comments are not verbatim quotes, but have been paraphrased to protect the respondents' anonymity and edited for brevity. A list of information sources for the state description and the individuals interviewed can be found at the end of this summary.
Because many of the same residential care facilities serve both private pay and Medicaid residents, most respondents expressed views about the industry as a whole.
When it created RCACs the state had an idea of a clientele that never materialized -- younger and healthier. If Wisconsin did it over again -- I doubt they would do RCACs.
The assisted living industry has been overbuilt because the industry thought they'd attract younger, healthier clientele. But people do not want to leave their homes unless they absolutely have to. When you go to a CBRF or RCAC, you give up your home, all or some of your furniture, your support system. People do this only when they feel they don't have another alternative.
People don't go to RCACs unless they really need to and they usually don't plan to go there. Typically the decision is precipitated by a health care crisis. The average age for new entrants is the mid-eighties.
There is considerable over bedding in nursing homes, CBRFs, and RCACs. It's not to the industry's advantage, yet they keep building them. They say they want to develop affordable assisted living but when we sit down to talk about it, their ideas and ours are worlds apart.
There are very few private rooms in CBRFs and most do not have a private bath. The Family Care Program is supposed to look for private rooms and move in that direction. But the industry didn't build that way. It's an outrage that the residential industry has been allowed to treat people as marginal and put two people in a room.
The residential care industry does not understand that most people do not want to move to assisted living. They never bothered to look at what older people actually want. They want to eat what they want, when they want, with whom they want. They want privacy. They want to be able to watch a movie on TV at 3 AM and sleep late and have breakfast whenever they wake up.
The entire industry was developed around a medical model -- it was supposed to be an alternative to the nursing home, but it looks too much like a nursing home. They can't think outside the box. There are other ways to structure assisted living. All you have to ask is how would you like to live your life when you are old and figure out how to structure services around those preferences, even if a person needs protective oversight.
Several expressed concerns that the residential care system was very confusing for the public.
Consistency in terms would help because the current situation is very confusing to people who can't figure out the difference among all the options: CBRFs, RCACs, assisted living.
In Wisconsin, "Consumer Beware" is the operative condition because a person with three cots in their basement can call themselves assisted living.
Currently, "buyer beware" prevails. The public does not understand the distinction between Community Based Residential Facilities and Residential Care Apartment Complexes and how they differ from assisted living. I don't understand the distinction. The Wisconsin web site that has information about these facilities is outstanding -- but the ability to utilize the web is an issue. Some older persons and their families don't have computers, and some don't know how to use them to find information.
Because CBRFs and RCACs have considerable latitude in what services they offer, the situation is very confusing for the public; it is very difficult for consumers to find what they are looking for.
Most people haven't a clue what an assisted living facility is and don't know the difference between CBRFs and RCACs. They all call themselves assisted living. I pulled up all the assisted living sites on the web and the list included both CBRFs and RCACs. There is some helpful information from the state on the web, but in Wisconsin, the average age of assisted living entrants is 82 or 83 -- they are not likely to have computers and the families don't really understand what they need and which facility can best provide it.
Because of the competition, CBRFs are blurring the distinction between the two types of facilities with regard to how they look. There are more new CBRFs with apartments and private rooms and baths. This is good as long as it does not exclude Medicaid eligibles. In fact, Medicaid eligibles will probably wind up in the crummier CBRFs with lower room and board rates.
AARP did a survey last year and asked our members and the general public about who paid for assisted living and most believed that Medicare paid for it.
There was a consensus among the respondents that the state's home and community services program -- both the state funded portion and the Medicaid portion -- were exceptionally good. Most felt that the state's goal in using Medicaid to cover services in residential care settings is to provide an alternative to nursing homes for people who can not live at home, and that CBRFs are fulfilling this goal.
The most important feature of Medicaid paying for services in residential care facilities is the ability to be flexible and to provide services based on people's needs.
It's important that the state is involved in residential care -- it's trying meet the needs of residents and operators.
Wisconsin has done especially good work with CBRFs because Medicaid funding has driven the expansion of the pool of facilities. It has no effect on RCACs -- the private pay market is driving the development of RCACs.
Just having the option of residential care other than nursing homes is a good thing. Better than having just a choice of a nursing home if you can't live at home. Some people do choose to live in CBRFs. It's also a safety net for people who wind up there because they have no other choice.
I think the use of Medicaid funds to support older persons with dementia in CBRFs has been highly successful. A good CBRF environment is highly preferable to a nursing home.
However, some thought that the state has not done a good job of developing facilities that are alternatives to nursing homes for the Medicaid population.
People shouldn't have a choice only of CBRFs and nursing homes -- they should also be able to choose home care and adult family homes (Wisconsin does not have a lot of them.) We need more alternatives to nursing homes for the Medicaid population -- like Oregon has -- we're getting there.
With regards to RCACs, there was agreement that the state had met its objective for facilitating the development of apartment style assisted living, given that 5000 RCAC units were built since 1997. This model, however, was not developed specifically to serve Medicaid clients; only 189 RCAC residents are receiving waiver funded services.
The state wanted to encourage the development of an apartment style of assisted living modeled after the Oregon model, which it believed was a good model. At the time, the state was also committed to deregulation, and the idea was to create a model of assisted living that was less regulated than the existing model at the time -- CBRFs. Coverage of the Medicaid population was not a driving factor. The state knew it would have to find a way to pay for the Medicaid population in these settings and to get providers interested in accepting Medicaid eligibles.
The state never intended to cover room and board or to limit it to an affordable amount for Medicaid eligibles. There were insufficient powerful people in the housing and social services field to take on the industry. They couldn't even enforce the exclusive use of the term assisted living for RCACs.
No one felt that regulations posed a major obstacle to affordable assisted living in Wisconsin.
The RCAC regulations have strong support from assisted living providers and, judging by the rapid growth of the industry in the state, they have not been an obstacle to development. Most facilities exceed the minimum physical plant and staffing requirements included in the regulations.
Several respondents had concerns about too much regulation in the CBRFs and too little in the RCACs, particularly given that RCACs certified to serve waiver clients are less regulated than CBRFs, even though they are permitted to provide up to 28 hours of care per week, including nursing care. One provider felt that the CBRF regulations were more stringent than nursing home regulations, and another expressed concern that the state will adopt a nursing home enforcement approach in assisted living settings, noting that this approach is not working in nursing homes.
One respondent expressed concerns that the state regulates facilities that serve very different types of people under the same rules.
CBRFs range from 5 to 203 residents -- there are even CBRFs for unwed mothers and veterans and TBI and DD and corrections clients -- all under the same regulations (there are a few changes in the regulations for correctional clients -- some of the residents' rights provisions don't apply.) The state needs to regulate differently for different populations in different settings. Some standard nomenclature is needed. Assisted living is a generic term -- it can be applied to any setting. I have no answer to the question of what to call the different facilities and why.
The majority felt that the regulatory requirements for oversight in both CBRFs and RCACs were inadequate, and as a result the state was not enforcing regulatory standards.
I don't have a good answer to how you keep the bad providers out. More regulations in nursing homes have not solved the problem. The quality of care in Wisconsin is good compared to what we hear about in other states. We need more enforcement of existing regulations. There are very few license revocations.
The CBRF licensing guarantees only minimum oversight -- with an annual visit. RCACs don't even get that.
Severe under-funding (and more to come with the budget crisis) has led to inadequate oversight of RCACs by the state agencies. At least CBRF residents have the ombudsman program. RCAC residents have nothing. Anecdotally, I hear as many horror stories about bad care in RCACs as in CBRFs, but they have no recourse except the legal system.
In an RCAC, which has much less oversight than a CBRF, you can get 28 hours of nursing care compared to a three hour limit in CBRFs. There is a lot less supervision in RCACs. Most CBRFs have a two staff to eight resident ratio. In RCACs -- it's all contracted services -- they have one staff person on duty for 100 folks.
In general, the regulatory process needed to be overhauled. But we are concerned about the cost of the licensing process. There are no facilities that would argue against the necessity for regulations as long as the cost is not exorbitant, particularly for small facilities with 4 to 8 beds who can't afford the training costs on top of recruitment costs. We're spending $1200 to get folks into jobs and then they leave in six months.
RCACs were created based on a philosophy of de-regulation. The state now realizes that there are enough problems that it needs to visit these facilities more frequently than required in regulation. The state had only one staff person to deal with the oversight of 5000 units. The industry was basically off the hook and got used to this, but then the state got additional staff and started issuing citations.
The requirements are excellent and the oversight to assure the requirements are met is abysmal.
There should be oversight and regulations should be enforced. There is a system for fining providers, but it's not implemented well. Providers are not fined the full amount. There is inadequate enforcement of existing rules.
The state's top regulatory initiative is to shift from a consultation to an enforcement mode in RCAC regulation. The state has identified the need to develop a consistent policy framework for interpreting the RCAC rules as the initial enforcement actions are taken.
Another state goal is to seek increased program revenue to support a more substantial level of enforcement activity -- increasing the certification fee (currently $350 +$6 per bed per year), extending fees to registered as well as certified facilities, and pursuing Medicaid administration funding for regulatory staff costs.
More enforcement of existing regulations is needed. The CBRF industry is a good example of how regulations by themselves don't equate to quality. We don't want to over-regulate. The Ombudsman program is not regulatory. The providers should see this as an advantage. It's better than having crises lead to heavy regulation.
A number of respondents mentioned that when the RCAC regulations were being developed, the industry opposed oversight by the ombudsman program.
In some ways Wisconsin is progressive in their standards and some ways not. For example, the Ombudsman Program is not allowed into RCAC's. The rationale was that the state did not want to burden the providers. The law specifically states that the Ombudsman is not permitted to advocate for people in RCACs. Even if an RCAC resident calls the Ombudsman's office, the program is not legally allowed to respond. We are promoting the involvement of the Ombudsman Program in RCACs. However, with the budget crunch, it may not be a priority issue this year.
Several noted that the way in which RCACs are regulated reflects a compromise among the industry, state staff and consumer advocates; but some felt that the industry had the upper hand.
We didn't get what we wanted, e.g., like a requirement that all RCACs provide three meals a day. We had to fight for every thing. It was very hard. We did the best we could but the decision not to license RCACs is questionable as is the decision to not allow the ombudsman program in RCACs. Not having enough staff at state level at the outset of the program was a problem -- one person statewide for a new industry. There was little opportunity for adequate consultation.
One respondent noted that after four and a half years of a consultative approach to RCAC regulation, Wisconsin is now citing and fining violators for the first time: three citations have been issued in the last 6 months, and 11 complaints are currently under investigation.
Many felt that insufficient regulations inevitably lead to problems and if the media picks up on it and reports the problems, then the pendulum swings the other way with a demand for regulation to address the problems, such as a need to assure a higher quality of staff in CBRFs and RCACs.
We have a lot of concerns. We have a list of homes in the community and social workers give information about what's available. We get feedback from families about quality and some issues are pretty serious. For example, a resident left the facility and the staff did not know they were missing for eight hours; families go to the facility and can't find the staff; the staff are not trained properly; and the staff did not know who to call in an emergency.
With regards to quality the major problem faced by all states is staffing. There is a lack of trained staff to work in both nursing homes and assisted living. There are major problems recruiting and retaining which leads to poor quality. The turnover rate is phenomenal - about 100 percent. Pay is low and benefits are non-existent. The State has to do more regarding the pay scale and the quality of the work environment. There have been some promising quality initiatives in nursing homes to improve the work environment. McDonalds and Lands End are competitors for staff - they pay $8-10 an hour plus benefits.
On respondent stated that there were major concerns about quality, based on a six-month investigative report by a major newspaper, which reviewed 460 assisted living facilities (CBRFs and RCACs) and found numerous citations for violations over the past 4 years relating to untrained staff, medication errors, not calling the doctor when a resident got sick, leaving residents alone, and abuse. Other respondents felt that there are always a few bad providers, which get the media's attention, but that most providers do their best to provide good care.
In my 21 years experience in the field, I can say that those providers who are in the business to provide good services do wonderful things. Those doing a lousy job are always complaining about too little money. I always tell the industry, this is not a place to expect to make huge amounts of money.
A number felt that the major causes of poor quality were inadequately trained staff, a lack of training requirements and competency testing, and lack of enforcement of existing training requirements.
One provider related the inadequacies of staff, in part, to the increased needs of the typical resident.
The original concept for RCACs was good -- folks who were pretty independent and needed protective oversight and less care than CBRFs -- could be cared for in a supervised apartment setting. But what's happened is that once the first layer of higher functioning people are placed then you get people with higher and higher needs, the same as in CBRFs.
And I agree with the state that the industry is taking care of people who are too highly impaired. But there is also a push to get people out of nursing homes. The original concept of CBRFs was also to take care of the mildly impaired. But if they are caring for some very impaired residents, obviously more training is needed. I understand the state's perspective. But the state needs to understand that the extra training costs more.
Some respondents, both providers and those representing consumer interests, felt that the industry needs more outcome-based regulations.
We're concerned that the legislature will be pushed to apply nursing home type regulations to assisted living and we do not want this. There are always stories in the newspaper about someone being hurt in assisted living and so there is pressure to "do something."
While many expressed dissatisfaction and at times conflicting views about the state's regulations, there was a consensus that the nursing home regulatory model is not appropriate for residential care settings.
A number of respondents felt that the state needed better standards for dementia care. One stated that the industry opposes regulation in this area, but another disagreed:
We need regulations for dementia care but the industry is not opposed. They just don't want nursing home style regulations. The better providers are not against regulation. They don't want rotten apples to spoil the barrel.
Dementia standards would be a good thing. But the state needs need to figure out its capacity to regulate because there is no point in enacting regulations that can't be enforced. Model standards for dementia would help. The state could encourage the adoption of these standards through incentives. Facilities that operate according to the model standards could advertise that they were certified as meeting the standards. Regulations just set a floor -- they don't get you to a desirable level of care -- they just set a minimum.
One respondent noted that cognitive impairment is a real problem in RCACs, because while the regulations prohibit the admission of people who are incompetent, it's possible to be competent but be incompetent at managing medications.
With few exceptions, respondents agreed that national or model standards for assisted living would not be helpful. One respondent felt that model standards are intended to be minimum standards, but in many instances become maximum standards. Most felt that each state's long term care system is unique and what is appropriate for one state is not appropriate for another.
We've picked our poison -- we know what we're dealing with. The model standards I've seen from the DC based assisted living advisory group would destroy the small provider, and most of our CBRFs are under 8 beds.
No one interviewed raised issues about admission requirements, but many had concerns about retention requirements. Some were concerned about their affect on the ability to age in place.
A key complaint about RCACs is premature and/or involuntary discharge. The average time spent in RCACs is fairly short -- approximately 18 months -- and fifty three percent of those leaving RCACs do so because they need more care.
The CBRF limit of three hours of nursing care is unrealistic -- there is some confusion as well about the definition of nursing care.
The hourly limits are ridiculous. People should have to move from their homes only once and they should get the care they need in the new setting. What difference should the setting make? The nursing homes pushed this -- they want people to think nursing homes are the only place to get skilled nursing care. We have paid for people that nursing homes won't admit -- those needing tube feeding and on ventilators. We pay more than $42 a day on some folks. You spend what it takes to support the care plan.
I advocated for the hour restrictions, but I feel that if CBRFs and RCACs can demonstrate their ability to care for people then they should be able to keep them, even if they need a half hour more care than is permitted by regulation. This would promote the notion of aging in place.
The concept of aging in place in place is one thing. The reality is a disappointment. But I think it's doable to a greater extent than it is currently being done. We still try to fit people into facilities rather than get the facility to match the person's needs. We say, here's a package of service -- if it meets your needs OK. If not, you have to go somewhere else.
Several raised the issue of inadequate guidance in the RCAC regulations regarding the retention of people who develop cognitive impairment and dementia while in an RCAC. One commented that the state needs to expand the options for people with dementia, and noted that the general public does not know what to do about family members with dementia.
One provider stated that the hours of care needed is not the only indicator of the amount of care needed.
Even if a person needs only three hours of care a day, if they need a two-person transfer or one-on-one feeding, we can not serve them because we do not have the staff. Transfer and feeding issues cause people to leave long before they need 28 hours of care. The average number of hours of care people get is about 16 per week. Dementia is also not an hours issue, but a safety issue. Is the person safe behind a locked door? If a family can pay for a one-on-one companion, then they can stay. We don't have the staff to be with someone every moment.
Respondents varied considerably in their views about these agreements. Some felt that such agreements can be useful for both providers and residents, enabling a less "paternalistic" approach to service delivery. Some felt they should not be mandated, while others that they should be required in all residential care settings.
I don't think negotiated risk agreements will stand up legally. Consumers pay us to use our professional judgment regarding their safety. We have to have risk agreements on certain things -- e.g. non-compliant diabetics. We do not use them for safety issues, e.g., people who can start a fire because they are unsafe with a stove.
We hear about individuals who are not given the opportunity to accept risk and are discharged long before they approach the 28 hours of care limit. The industry needs to grow into the modern concept of taking risks. Many RCAC operators come out of the nursing home industry, which is very paternalistic. Providers say we can't afford to take risks because of liability issues. But they can take steps to minimize risk. They need to treat RCACs as rental agreements not nursing homes. If a provider were sued for allowing a person to take risks, I would be on their side. The issue regarding competency to enter into negotiated risk agreements is a legitimate concern. I don't know why the RCAC industry isn't concerned about this.
I'm not as concerned about these agreements in CBRFs because they have a pretty standard package of services. Plus the ability to complain to the Ombudsman. You don't need them as much in CBRFs, because the consumer does not negotiate the services package, and many elderly residents are not competent to execute them. In RCACs, theoretically there is more negotiation about services, and a prohibition to admit incompetent people.
In a CBRF, a facility may not abrogate responsibility for providing medication monitoring. Now the state is telling us that RCACs cannot abrogate responsibility in this area as well, that you can't let go of certain responsibilities in a risk agreement.
One respondent felt strongly that the existence of such agreements were a sign of ageism in service delivery because they required older persons to negotiate the right to be autonomous rather than have it assumed.
I believe that until a person is adjudicated incompetent they should be able to do whatever they want -- eat what they want -- not exercise if they want, not socialize if they want.
Another noted that a major issue in risk agreements is the lack of an accepted method for determining the competency of individuals to enter into them. One respondent raised the issue of liability concerns and mentioned that liability insurance problems are starting in Wisconsin. Another noted that there has not yet been any litigation related to risk agreements, but there is a need for more individualized agreements, noting that there are too many "cookie cutter" agreements than is desirable.
Respondents noted a number of barriers, but overall, the consensus was that the costs are too high and that it is not possible to get assisted living costs low enough for people with low incomes to pay for themselves.
Providers think $2000 a fair price; $1600 a month is the minimum for good care. Most folks don't have this. They have $500 a month.
There was a consensus that the major barrier to providing affordable assisted living in Wisconsin is insufficient capacity in the statewide waiver program. Even though the Medicaid waiver program provides services in residential care settings, few people benefit because of the long waiting lists. There are over approximately 9000 elderly and working age disabled on waiting lists for state COP and waiver services.
Typically, people do not spend down by paying privately for home care; rather, they go to residential care as private pay. The problem for many is that it is very likely that there will be a waiting list for services once they spend down. Providers cannot count on residents being able to access funds when needed, so they wind up moving to a nursing home.
Many RCACs do not bother to become certified to serve waiver clients because they see no need to do so. Only about 20 percent of registered facilities have become certified, generally because residents have spent down.
On an individual basis, it would cost the state less to keep people who spend down in an RCAC than put them in a nursing home. But fear of induced demand and fear of having a state funding source drive what's available keeps the state from expanding the waiver to cover people in RCACs who have spent down. Doing so would make the waiver program an entitlement for people who spend down in RCACs. Another concern is that if the state kept everyone who spent down in an RCAC on the waiver, then it would wind up spending all of the waiver money in RCACs, and have very little left for home care.
The state pays lip service to the goal of providing alternatives to nursing homes. There are insufficient waiver services. It is a major disconnect for families when their relative can't stay in an RCAC or CBRF because there is no waiver slot, but the state will pay more money to put them in a nursing home.
There was general agreement that room and board costs in RCACs and many CBRFs were unaffordable for waiver clients.
If you're low income you will need assistance to be in a residential care facility. If you run out of money and there is no COP money available, you will have to go to a nursing home. If you don't meet the nursing home level of care criteria, then you're in trouble.
I don't' know of any CBRFs who accept SSI as full rate. The SSI payment does not cover the cost of room and board. Even facilities with high functioning elderly charge more than SSI. RCACs can't get by on the SSI rate either.
An industry survey in 2000 found that the average room charge without meals was $841 per month, but the typical waiver client's income is in the $545-$725 range.
We use CBRFs more than RCACs, primarily because the RCACs won't contract with us because we won't pay them what they charge the private pay. We will only pay the industry median.
One respondent noted that while room and board costs are a barrier, there is no way to supplement these costs without cost shifting to other public funding sources, such as COP (the state's general revenue funded HCBS program). Others felt that each facility should be able to afford to take a few Medicaid residents. Some counties opt to use COP funding to pay for room and board for a few waiver clients in smaller CBRFs.
The state should limit room and board charges. The average cost of an assisted living facility is $2500 -- how can a person on SSI afford this? It is best to have facilities cross subsidize -- have a small percentage of Medicaid residents, and a majority private pay. A mix of clients also helps to assure quality for the publicly-funded residents.
A number of respondents felt that using state dollars with no federal match to pay for room and board gives too large a proportion of the states HCBS funds to the residential care industry.
Several respondents discussed the need to develop a greater supply of affordable assisted living facilities and stated that state and federal policy needs to create incentives to build more affordable units.
There was disagreement about whether the state should cap the amount that can be charged to Medicaid clients for room and board. Some felt that without a cap, Medicaid clients would never have access to "real" assisted living, meaning a facility with private rooms and baths and sufficient services to age in place. One noted that the issue had been discussed but rejected by the state's legislators, who wanted the market alone to decide the rates.
A few respondents stated that many of the counties did not want to use public funding in residential care settings, because they subscribed to a philosophy that favored homecare. One stated that many counties thought some CBRFs, particularly larger ones, were more like institutions. Given that the COP and waiver program are intended to provide alternatives to institutions, they do not want to use limited funds in what they see as quasi-institutional settings.
The state gives counties tremendous power -- even when there is pressure for counties to fund assisted living, some won't fund it. Some of the resistance comes from the COP philosophy of providing services at home. But if someone lives in an assisted living facility, it is their home.
There has been a bias towards providing services to people in their homes and in small facilities (eight beds or smaller). It took years to get the state to allow waiver funds to be used in facilities with up to 20 beds. You need special authorization to provide waiver services in facilities with 20+ beds. But some places have 160 beds and they have waiting lists because that's where people want to be.
A few respondents commented that access can be limited due to maldistribution of assisted living facilities.
It's a big issue in Family Care where you're supposed to have a choice. In some of the counties, there may not be a facility within 100 miles. This is a major access issue. The RWJ project is supposed to address this. There is also a maldistribution of service providers, particularly in the northern part of the state.
I've heard that in certain areas they're overbuilt -- other areas have none or not enough. The same for nursing homes. The state does not have a planning process to determine where they should be built. The developers build wherever they want and they don't even do a market analysis -- they don't look at the demographics of the area. They also assume that lots of elderly people are going to move in. But clients still consider assisted living to be institutional (CBRFs primarily). Private pay clients going into assisted living are not thrilled, but it's less of a stigma than a nursing home -- more like a hotel.
There were major differences in views regarding service rates and whether they constituted a barrier to serving Medicaid clients. Some, but not all, providers felt the state's rates were too low or "wholly inadequate." Most other respondents felt that the RCAC and CBRF combined market rate (room, board, and services) was too high and that the variation in these charges did not appear to be correlated with the quality of care.
This is an area where I'm more sympathetic to the industry. Medicaid rates have been suppressed to hold down costs and need to be re-evaluated.
Providers always say they are too low, but I know Wisconsin pays a higher rate than other states.
I think we're paying too much. Someone puts up a ranch house with 4 bedrooms and 2 people per room and they charge $3800 a month for each person. That's outrageous. The DD rates are $6500 a month. Half of the rooms might be empty and then they come to us and want us to pay these rates.
The assisted living industry thinks there is this large private market of people who want to move to their facilities and that they will have enough money until they die. When the money runs out, they come to the counties and want us to pay their private pay charges of $4500 a month, but the counties won't. Under Family Care, the state negotiates rates.
One respondent said that a major barrier to serving waiver clients in RCACs is that the state's statutory limit on waiver rates, which is 85 percent of the state's average nursing home rate, is almost double the actual waiver rate of $43 a day. Another respondent strongly disagreed:
It's not true that counties limit waiver payments to $43 a day. It's exactly the opposite. The counties pay what they're asked to pay and they don't' have the expertise to figure out from the facility's cost report if they are overcharging.
Several respondents expressed concerns that people who spend down in RCACs will not be able to stay in their RCAC apartments because the facility will not accept the waiver rate, and a number of providers specifically cited the state's payment policies as a problem.
The profit on services provided to public pay residents is limited to 10 percent and a financial audit is required of all providers receiving $25,000/year or more in public reimbursement.
Others stated that counties do not have the expertise to enforce the limit, and that many facilities exceed the 10 percent profit limit.
We had to hire outside auditors to look through the CBRF contracts because they hire expensive accountants to hide stuff. We hired retired accountants who'd worked in big auditing firms -- we recouped a lot of money -- hundreds of thousands. But most counties can't do this, so the facilities have the upper hand.
A few respondents expressed concerns about the effect of high rates on the overall amount of funding available for HCBS.
The more money spent in RCACs, the less available for home care. Additionally, because RCACs require private apartments, they can be more expensive than CBRFs. Counties are also reluctant to pay for private rooms for Medicaid beneficiaries in CBRFs due to the additional cost. Many counties perceive RCACs as too costly for the waiver program and won't pay for waiver clients who've spent down in these facilities.
One respondent noted that with so Waiver participants living in RCACs (189 out of about 13,500 individuals), many RCAC providers have little experience working with counties and vice versa. Counties are afraid they will be charged too much and providers are concerned that they won't be paid enough. Another noted that the state does not have a cost-effective method for reimbursing services in CBRFs and RCACs, noting that these settings should offer economies of scale but, in fact, it costs more to serve people in these settings than it does to provide services in their homes.
One respondent noted that the state is aware of these issues and is taking steps to address them.
The state is developing a rate setting methodology and a model contract for counties and facilities to use for waiver clients in RCACs, and is exploring ways to bill the Medicaid fee-for-service system for coverable services provided in assisted living as a way to make optimal use of limited waiver funds. To do this, the facility would have to partner with a home health agency or county agency that is certified to bill Medicaid.
A few respondents stated that the rates are not just for the services themselves, but that they need to cover other costs, particularly those incurred to meet regulatory requirements such as training. At that same time, most recognize that the state does not have the money.
I see both sides of the issue. But if there's not enough money we need to look at the state's priorities -- isn't taking care of our parents and brothers and sisters who can't be cared for at home more important than some other priorities?
A few others stated that the problem was not the rate per se, but the lack of a payment system that offers incentives to provide good care.
We need to get to the point where we have a system that purchases quality and pays fairly for it. We don't have a way to reward the higher quality providers.
The state needs to get away from a cost-based program because there is no incentive to be efficient. When you get efficient your rate goes down. Negotiated rates are better. One rate does not work for everyone. Family Care uses negotiated contracts with a capitated rate that is not a function of cost. The County operates as a managed care provider and is therefore exempt from audit requirements. Audits are required for cost-based systems and you have to fill out an 80 page contract.
Most respondents suggested changes to address the specific issues and barriers they had identified.
The overriding issue is that more people need services than services are available, so we need to generate revenue to make it possible to serve more people. We also need to downsize nursing home capacity.
We need more affordable facilities that provide good care. We need the non-profit and religious-based mission sector to develop affordable assisted living.
Mandate that only RCACs can call themselves assisted living. This would reduce the current confusion among consumers.
Make qualitative evaluations of facilities available to consumers. This would be very useful. We need to make it easy for consumers to get information from regulatory agencies about facilities. Some facilities feel enforcement activities do not reflect quality of care. But with folks making decisions in a brief time in a crisis situation, they must have information.
Lift restrictions around hours of care in CBRFs and RCACs. Nursing homes are the most regulated industry and they have the worst care.
Use more process measures built on outcomes -- not regulations about the length of the blanket and the food pyramid. This is what Family Care does. Does the person live with whom they want to live with? Do they engage in desired activities? Do they choose what they want to eat?
Allow oversight by Ombudsman Program in RCACs. The Ombudsman can really help with quality assurance. They can't issue fines but they can report things. They can get involved in areas that the state regulatory body can't get into, e.g., they can consult with a facility about quality. At a minimum, the Ombudsman program should have the ability to investigate complaints in RCACs. I'm not for over regulation -- but residents of RCACs need some independent advocacy entity to call if they can't get a grievance addressed.
Make sure assisted living is part of a coordinated service package under Family Care or Partnership throughout the state, and develop a state plan for assisted living development (distribution) -- address over bedding.
Develop more public housing models with a service component.
Address the staffing problems by funding the community college system to train workers and create a career ladder; institute more requirements for staff who work in assisted living -- training and standards to measure the quality of work; give them more money and benefits.
Give more power to the counties in running the long term care system because they are accountable to local residents.
There is a correlation between oversight and care. I'd move all oversight to the local level, to the people who pay for services. That will improve quality. The closer the money is to the local level, the better will be the quality assurance. Quality assurance needs to be tied to reimbursement. If a county pays millions of dollars it has the ability to demand quality. One county asked the state to de-license a facility that it felt was providing poor quality but the state said there were not enough technical violations. However, the county terminated its contract with the facility. When a Family Care client enters a nursing home, the R.N./ Social Worker team monitors care and will pull clients out of nursing homes if the care plan isn't met.
Fix the room and board issue. People on Medicaid should be able to live in RCACs.
The whole home and community care system needs to be better funded. In many cases people need congregate care because there is insufficient home care.
Increase funding and staff to enforce regulations and increase the sanctions against the bad operators. Most of the industry is not in the business to make a profit -- rather, they want to provide a service. We need to get to the point to trust the caregivers and facilities -- get rid of the people not doing a good job -- enforce what's there and don't reinvent the wheel every few years.
Develop more residential care options by expanding the supply of adult foster homes. Oregon has a lot and I wish Wisconsin had more. We have some counties that make a lot of use of them; they have a staff person who recruits them.
With very few exceptions, the respondents cited the state's pilot Family Care Program as the solution to many of the current issues regarding accessibility and believe that the program should be expanded statewide. However, most recognized that expansion was unlikely due primarily to the state's budget crisis, but also because many counties do not yet have the capability of implementing the program.
The Family Care program should be expanded throughout the state -- it has eliminated waiting lists in the five pilot counties (bringing the statewide list from 11,000 to 9,000) and it gives people choices. However, in the current budget climate, nothing remotely like that would happen.
A few respondents expressed concern that the cost of expanding Family Care statewide would "bankrupt" the state because it treats home and community services as an entitlement.
As a taxpayer I do not want to see Family Care go forward. If Family Care was universal there would be no need to purchase private long term care insurance in Wisconsin. People could take a year's worth of long term care insurance premiums, hire an estate planning lawyer and create a trust that will make them eligible for Family Care when they need long term care.
Others felt that the fear was unwarranted or could be dealt with.
There is a fear that the cost of expanding Family Care statewide will bankrupt the state. But you could tighten up the eligibility criteria if needed.
Reducing the waiting list by 9000 folks would make Family Care expensive to implement. It's an entitlement now -- though it didn't start that way. In the current system, the nursing home is an entitlement -- but people may not need to be there. The state does not believe in a strict continuum of care. Family Care looks at what people need and tries to find where they can best be served and folks with severe disabilities can be served in homes. Family Care operates according to the assumption that people should have the choice to live in the community. It's difficult to know if expanding Family Care statewide would be more expensive.
Several respondents expressed more general concerns about the ability of the publicly funded long term care system to meet the needs of the Baby Boom cohort, and made suggestions to address this concern.
To reduce the number of people on Medicaid, the state has to stop the divestiture of assets that is going on by tightening loopholes. There are a set of older people who don't' see Medicaid as welfare, and a lot of people divest assets. There is a lot of estate planning -- a seminar every day. Older people think they need to leave a legacy to their children. They don't understand the difference between Medicare and Medicaid. They paid into Medicare when they were working and they think it covers Medicaid and that they are entitled to it.
Something needs to be done other than the very small tax break for long term care insurance to get people to start planning for and funding their future long term care needs.
More financial planning is needed for folks thinking about entering an RCAC. They need to understand how to financially plan for it -- deal with the spend down issue.
A number of respondents mentioned state activities aimed at addressing the shortage of affordable assisted living for low income persons.
The state is trying to get developers to do affordable RCACs in rural areas.
The state is working on developing a service rate that will vary according to the services provided and a more effective contracting mechanism for the counties to use, which will tie the service rate to the care plan.
A proposal is being developed for the legislature to enable persons leaving nursing homes to have the nursing home funds follow them to the community instead of having the money stay in the nursing home budget. This is particularly important given that future Medicaid expansions are unlikely.
Several respondents mentioned that the state had a grant from the Robert Wood Johnson Foundation's Coming Home Program to develop affordable assisted living in rural areas, and that the state was very interested in identifying new ways to combine housing and services that would be affordable for low income and Medicaid-eligible persons, such as maximizing the use of HUD Section 8 housing vouchers. However, others noted that these vouchers were not the solution.
There are too few Section 8 Vouchers, and the amount of the voucher is not sufficient. In some locales, the vouchers are not being used because the do not provide the subsidy needed to make up the difference between what a person can afford and what the rents are. Many locales keep the vouchers for families with children because seniors have more housing subsidies. There is a real crisis with low income families. Getting housing authorities to designate money to assisted living is very difficult.
We asked the respondents to make recommendations for other states interested in using Medicaid to fund services in residential care settings, based on their experience doing so in their own state. The majority of recommendations related to assuring a method to pay for room and board for low income persons, assuring adequate funding, and recognizing that different licensing and more restrictions are needed to serve the Medicaid population, particularly those who meet the criteria for a nursing home level of care.
Figure out what affordable really means, both for the Medicaid eligibles and for low and moderate income folks. For Medicaid make room and board affordable first.
You can't make it work for large numbers of low income people and Medicaid eligibles without subsidies for room and board.
Gibson, M. J. and Gregory, S. R., Across the States 2002: Profiles of Long-Term Care, AARP, 2002.
Kassner, E. and Williams, L., Taking Care of their Own: State-funded Home and Community-based Care Programs for Older Persons, AARP, September 1997.
Kassner, E. and Shirley, L., Medicaid Financial Eligibility for Older People: State Variations in Access to Home and Community-Based Waiver and Nursing Home Services, AARP, April 2000.
Manard, B. et. al., Policy Synthesis on Assisted Living for the Frail Elderly: Final Report, submitted to Office of the Assistant Secretary for Planning and Evaluation, December 16, 1992. [Executive Summary]
Mollica, R.L., State Assisted Living Policy: 1998, Report (ASPE and RTI) June 1998. [Full Report]
Mollica, R.L., State Assisted Living Policy: 2000, National Academy for State Health Policy; funded by The Retirement Research Foundation (LTC13). August 2000.
Mollica, R.L., 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.
Adult Family Homes http://dhfs.wisconsin.gov/rl_DSL/AdultFamilyHomes/AFHintro.htm
Aged, Blind and Disabled Medicaid Eligibility Survey http://www.masterpiecepublishers.com/eligibility/
Assisted Living Facilities http://dhfs.wisconsin.gov/bqaconsumer/AssistedLiving/AsLivindex.htm
Board on Aging and Long Term Care http://longtermcare.state.wi.us/home/
Community Based Residential Facilities Rules and Regulations http://dhfs.wisconsin.gov/rl_DSL/CBRF/CBRFregs.htm
Community Waivers Program http://www.dhfs.state.wi.us/medicaid1/recpubs/factsheets/phc10059.htm
Elderly, Blind and Disabled http://www.dhfs.state.wi.us/medicaid1/recpubs/eligibility/book_b.htm#Elderly,%20Blind,%20and%20Disabled
Medicaid Deductible Fact Sheet (Medically Needy) http://www.dhfs.state.wi.us/medicaid1/recpubs/factsheets/phc10052.htm
Patient Liability or Cost of Care http://www.dhfs.state.wi.us/medicaid1/recpubs/factsheets/phc10061.htm
Residential Care Apartment Complexes http://dhfs.wisconsin.gov/rl_DSL/RCACs/RCACintro.htm
Spousal Impoverishment Fact Sheet http://www.dhfs.state.wi.us/medicaid1/recpubs/factsheets/phc10063.htm
The Ombudsman Program http://longtermcare.state.wi.us/home/Ombudsman.htm
Wisconsin Administrative Code, Community Services http://www.legis.state.wi.us/rsb/code/hfs/hfs030.html
Wisconsin Medicaid http://www.dhfs.state.wi.us/medicaid1/index.htm
Wisconsin Updated Statutes and Annotations http://www.legis.state.wi.us/rsb/stats.html
Irene Anderson, Supervisor
Department of Health and Family Services
Sunny Archambault, President
Wisconsin Association of Aging Unit Directors
Director, Aging Resource Center of Brown County
John Bechly, President
Wisconsin Association of Residential Facilities
D'Anna Bowman, State Director
Jeff Brikowski, Food Stamp Policy Analyst
Department of Health and Family Services
Rita Cairns, Financial Eligibility Specialist
Department of Health and Family Services
Beth Christie, Executive Vice President
The Laureate Group
Wendy Fearnside, Program and Policy Analyst
Bureau of Aging and Long Term Care Resources
Department of Health and Family Services
The Coalition of Wisconsin Aging Groups
Neil Gebhart, Assistant Legal Counsel.
Department of Health and Family Services
Marge Hannon Pifer
Division of Health Care Financing
Department of Health and Family Services
Bureau of Health Care Eligibility
Department of Health and Family Services
Residential Policy Specialist
Bureau of Aging and Long Term Care Services
Department of Health and Family Services
Jim Murphy, Executive Director
Wisconsin Assisted Living Association
George Potaracke, Executive Director
Board on Aging and Long term care
Director of Legal Services
Wisconsin Health Care Association
Tom Ramsey, Director of Government Affairs*
Wisconsin Association of Homes and Service for the Aging
Program and Policy Analyst
Division of Health Care Financing
Department of Health and Family Services
AARP volunteer / lobbyist
Bureau of Aging and Long Term Care Services
Department of Health and Family Services
Stefanie Stein, Director
Milwaukee County Department on Aging
Jeff Ulanski, Medicaid Program Policy Analyst
Department of Health and Family Services
Gregory, S.R. and Gibson, M.J., Across the States: Profiles of Long Term Care, Public Policy Institute, AARP, November 2002.
The state is currently revising the formula for determining the amount of assets that can be retained.
The state does not use any of the options for less restrictive income or resource methodologies for determining financial eligibility in the medically needy program.
The state is currently revising the formula for determining the amount of assets that can be retained.
The discretionary allowance is not in addition to a personal maintenance allowance.
Prior to 1995, a person could be eligible for the state supplement without being eligible for SSI.
Since 1995, a person must be eligible for some federal benefit to be eligible for the supplement. Persons ineligible under current law who were receiving the state supplement in 1995 continue to receive it under a grandfathering provision.
The state does not use less restrictive income disregards when determining eligibility than it does when determining eligibility for SSI. It uses the following Section 1902(r)(2) less restrictive resource methodologies for this group: income used to pay court ordered fees and guardianship and guardian ad litem fees is excluded.
The state does not use Section 1902(r)(2) less restrictive income or resource methodologies for this group.
Personal communication from state staff. Data on the number of persons receiving Medicaid personal care in residential care settings are not available.
While there are no data on how many were receiving personal care services through the state plan, given that the number receiving COP and waiver services was 2,363, only about .5 percent of the 11.5 percent could have been receiving services through the personal care state plan option.
The SSI-E benefit (a state SSI supplement for persons with high needs) also used to be limited to persons in CBRFs no larger than eight beds.
Most county contracts are for cost-based rates. Allowable cost distinguishes between what costs can be paid for with state/federal funds and what cannot; it says nothing about how much the rate is. The State requires an audit where publicly purchased services cost more than $25,000 per year. If the audit shows costs that were not allowable, which have been paid for in the rate, they must be returned.
Some facilities have an arrangement with a Medicaid-certified home health or personal care agency to either (1) provide and bill Medicaid for these services or (2) "lease" their staff to the Medicaid-certified agency in order to be able to bill Medicaid. In 2001, eight percent of waiver recipients living in RCACs had personal care services billed to the Medicaid card (state plan), averaging $367/month. The state does not have comparable data for CBRF or AFH residents at this time.