Payment/Eligibility Questionnaire


This instrument was developed for the National Board and Care Survey project. This project was conducted by the Bureau of the Census under contract for the Department of Health and Human Services (HHS) Office of Disability, Aging and Long-Term Care Policy. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the office at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. The e-mail address is: webmaster.DALTCP@hhs.gov. The DALTCP Project Officer was Robert Clark.


NOTE: This is a recreation of this form. See the PDF version for a scanned version of the actual form.

 

QUESTIONNAIRE 3
PAYMENT/ELIGIBILITY

FIFTY STATE SURVEY OF AGENCIES INVOLVED
IN THE REGULATION OF BOARD AND CARE HOMES

 

STATE: _________________________
AGENCY: _________________________
CONTACT: _________________________  
POSITION: _________________________
DATE: _________________________
INTERVIEWER: _________________________  

 

START TIME: _________________________    

PART I: PAYMENTS TO RESIDENTS

1. Does this agency make any payments to board and care residents for room, board and oversight, supervision or personal care or case management for elderly residents?

_____Yes Y = Yes
N = No
D = Don't Know  
_____No (IF NO, SKIP TO QUESTION 8.)  
_____Don't Know

2. What are the eligiblity criteria for clients whose care is paid for by this agency? (LIST CRITERIA SEPARATELY.)

A. _________________________  
B. _________________________  
C. _________________________  
D. _________________________  
E. _________________________  

3. Does the reimbursement level vary by the following:

a. Resident care needs/disability level?

_____Yes Y = Yes
N = No

Specify dollar amounts only, no cents.  

If unknown, code "9's."

_____No
IF YES, SPECIFY:
Minimum reimbursement $_____
Maximum reimbursement $_____
Average reimbursement $_____

b. Resident's age?

_____Yes Y = Yes
N = No

Specify dollar amounts only, no cents.  

If unknown, code "9's."

_____No
IF YES, SPECIFY:
Minimum reimbursement $_____
Maximum reimbursement $_____
Average reimbursement $_____

c. Services provided to a client?

_____Yes Y = Yes
N = No

Specify dollar amounts only, no cents.  

If unknown, code "9's."

_____No
IF YES, SPECIFY:
Minimum reimbursement $_____
Maximum reimbursement $_____
Average reimbursement $_____

d. Other? (SPECIFY) _________________________

_____Yes Y = Yes
N = No

Specify dollar amounts only, no cents.  

If unknown, code "9's."

_____No
IF YES, SPECIFY:
Minimum reimbursement $_____
Maximum reimbursement $_____
Average reimbursement $_____

e. No variation in reimbursement levels.

_____Yes Y = Yes
N = No

Specify dollar amounts only, no cents.  

If unknown, code "9's."

_____No
IF YES, SPECIFY:
Minimum reimbursement $_____
Maximum reimbursement $_____
Average reimbursement $_____

4. If rates are based on client disability, how often are the clients re-evaluated? _________________________

5. What is/are the source(s) of the funds available for payments to board and care residents? (CHECK ALL THAT APPLY.)

_____Medicaid program If checked, code "Y;" if not checked, code "N."  
_____Medicaid Waiver Program ("2176 waivers")
_____SSI
_____State Supplementary payment
_____Other state-only funding (DESCRIBE)
_____County funds
_____Other (SPECIFY) _________________________  
_____Don't Know

6. How often are rates reviewed? _________________________ Specify in yearly intervals.

7. When was the last time the rates were reviewed? _________________________, 19_____ Give month and year.

 

PART II: PAYMENTS TO HOMES

8. Does this agency make any payments to board and care HOMES for room, board and oversight, supervision or personal care or case management for elderly residents?

_____Yes Y = Yes
N = No
D = Don't Know  
_____No (IF NO, SKIP TO QUESTION 16.)
_____Don't Know

9. What are the criteria homes must meet to receive these payments? (LIST CRITERIA SEPARATELY.)

A. _________________________  
B. _________________________  
C. _________________________  
D. _________________________  
E. _________________________  

10. Who determines whether homes meet the criteria you just stated? _________________________

11. Is the rate the same for all homes (a "class-based" rate) or individual for each home?

_____Class-Based   C = Class-Based
I = Individual
D = Don't Know  
_____Individual
_____Don't Know

12. Does the reimbursement level vary by the following:

a. Size of a facility?

_____Yes Y = Yes
N = No

Specify dollar amounts only, no cents.  

If unknown, code "9's."

_____No
IF YES, SPECIFY:
Minimum reimbursement $_____
Maximum reimbursement $_____
Average reimbursement $_____

b. Services provided in a facility?

_____Yes Y = Yes
N = No

Specify dollar amounts only, no cents.  

If unknown, code "9's."

_____No
IF YES, SPECIFY:
Minimum reimbursement $_____
Maximum reimbursement $_____
Average reimbursement $_____

c. Staffing of a facility?

_____Yes Y = Yes
N = No

Specify dollar amounts only, no cents.  

If unknown, code "9's."

_____No
IF YES, SPECIFY:
Minimum reimbursement $_____
Maximum reimbursement $_____
Average reimbursement $_____

d. Licensure or certification status?

_____Yes Y = Yes
N = No

Specify dollar amounts only, no cents.  

If unknown, code "9's."

_____No
IF YES, SPECIFY:
Minimum reimbursement $_____
Maximum reimbursement $_____
Average reimbursement $_____

e. Location of a facility?

_____Yes Y = Yes
N = No

Specify dollar amounts only, no cents.  

If unknown, code "9's."

_____No
IF YES, SPECIFY:
Minimum reimbursement $_____
Maximum reimbursement $_____
Average reimbursement $_____

f. Other? (SPECIFY) _________________________

_____Yes Y = Yes
N = No

Specify dollar amounts only, no cents.  

If unknown, code "9's."

_____No
IF YES, SPECIFY:
Minimum reimbursement $_____
Maximum reimbursement $_____
Average reimbursement $_____

g. No variation in reimbursement levels.

_____Yes Y = Yes
N = No

Specify dollar amounts only, no cents.  

If unknown, code "9's."

_____No
IF YES, SPECIFY:
Minimum reimbursement $_____
Maximum reimbursement $_____
Average reimbursement $_____

13. What is/are the source(s) of the funds used for payments to homes? (CHECK ALL THAT APPLY.)

_____Medicaid program If checked, code "Y;" if not checked, code "N."  
_____Medicaid Waiver Program ("2176 waivers")
_____SSI
_____State Supplementary payment
_____Other state-only funding (DESCRIBE)
_____County funds
_____Other (SPECIFY) _________________________  
_____Don't Know

14. How offten are rates reviewed? _________________________ Specify in yearly intervals.

15. When was the last time the rates were reviewed? _________________________, 19_____ Give month and year.

16. If board and care residents receiving SSI have special one time emergency problems or needs (teeth, medicine, assistive devices such as canes or walkers, clothes) is additional money made available to them?

_____Yes Y = Yes
N = No
D = Don't Know  
_____No (IF NO, SKIP TO QUESTIONS 18.)  
_____Don't Know

How many clients received these funds in FY90?

Enter number: _________________________ If unknown, code "9's."

How many applied for these funds in FY90?

Enter number: _________________________ If unknown, code "9's."

17. What agency provides this funding?

Agency name: _________________________    
Agency name: _________________________  

18. Does this agency make any payments to elderly residents of board and care for services OTHER THAN room, board and oversight? For example, home health visits, transportation, adult day care.

_____Yes   If yes, also complete questionnaire 5.
_____No If no, ask for other contact who might provide this information. _________________________  

19. Are you satisfied with the current state and local division of responsibility for board and care within your state?

_____Yes Y = Yes  
N = No
_____No
Why not?_________________________  

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