Residential Care and Assisted Living Compendium: 2007. Tiered Rates

11/30/2007

Tiered rates have been developed to more accurately and fairly reimburse providers for services provided to frailer residents. Tiered systems usually include 3-5 tiers based on the type, number, and severity of ADL limitations and/or cognitive or behavioral impairments, and create incentives for providers to serve residents with higher service needs. Eight states use tiered rates, examples of which are described below.

  • Arizona’s Long-Term Care System has three rate levels based on resident needs. The rate levels vary by type of setting; assisted living homes that serve ten or fewer residents and assisted living centers that serve 11 or more residents. The service payments are negotiated and vary by program contractor (county). Daily rates for Level 1 range from $41.23 to $70.11; for Level 2 from $55.00 to $91.91; and for Level 3 from $51.00 to $143.75.

  • Delaware has three levels of waiver service monthly payments, which were developed based on an analysis of spending for HCBS waiver clients living in their own homes and in AFC. Level I is $1,034; Level II is $1,271; and Level III is $1,544. Facilities receive an additional ten percent for residents with cognitive impairments. The state limits the room and board payment for SSI beneficiaries to $598 in 2007. The maximum payments rates for each level range from $1,632 to $2,142.

  • Oregon has five payment levels based on the type and degree of residents’ impairments. ADLs assessed include eating/nutrition, dressing/grooming, bathing/personal hygiene, mobility, bowel and bladder control, and behavior. Table 1-15 lists the impairments needed for each level, and the payments per level. The state limits the room and board payment for Medicaid beneficiaries to $483.70, which is less than the full SSI payment because of the PNA retained by the beneficiary.

  • Texas uses a tiered payment system for HCBS waiver services derived from their nursing home case-mix system. Payments, which vary by level and by setting, are listed in Table 1-16. The state limits the room and board payment for Medicaid beneficiaries to $479 a month.

TABLE 1-15. Oregon Service Priority Categories and Monthly Payment Rates: Assisted Living (January 1, 2007)

  Impairment  
Level
Service Priority   Service   R&B   Total Rate  
Level 5 Dependent in 3-6 ADLs OR dependent in behavior and 1-2 other ADLs $2,010   $483.70*   $2,493.70
Level 4 Dependent in 1-2 ADLs OR assistance in 4-6 ADLs plus assistance in behavior $1,628 $483.70 $2,111.70
Level 3 Assistance in 4-6 ADLs OR assistance in toileting, eating, and behavior $1,245 $483.70 $1,728.70
Level 2 Assistance in toileting, eating and behavior or behavior AND eating or toileting $942 $483.70 $1,425.70
Level 1 Assistance in 2 critical ADLs or assistance in any 3 ADLs or assistance in 1 critical ADL and 1 other ADL $712 $483.70 $1,195.70

* The room and board payment is less than the SSI payment to allow the beneficiary to retain a PNA.


TABLE 1-16. Texas Daily Reimbursement Rates Effective September 1, 2007

 

    Assisted Living  
Apartment
  Double Occupancy  
Apartment
  Residential Care  
Non-Apartment
AL 1   $67.76 $60.76 $42.21
AL 2 $62.80 $55.81 $37.25
AL 3 $56.04 $49.05 $30.50
AL 4 $58.63 $51.64 $33.08
AL 5 $52.40 $45.42 $26.86
AL 6 $50.68 $43.69 $25.13

 

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