State Assisted Living Policy: 1998. State Policy Developments


The rapid development of assisted living regulations and revision of board-and-care regulations continued in 1997 and during the first half of 1998. Thirty-three states have taken steps to implement an assisted living policy, and 11 others have instituted a process to study the issue.3 In 1997 and 1998, laws were passed in Florida, Indiana, Nebraska, and Oklahoma. Florida amended its existing statute to modify training requirements especially for facilities serving persons with Alzheimer's disease. Laws passed in Indiana create a disclosure requirement and direct the Department of Health to conduct a study of assisted living facilities.

Regulations were finalized in Delaware, Iowa, Kansas, Kentucky, Maine, Nebraska, Oklahoma, Tennessee, and Wisconsin. Draft regulations were issued in Hawaii, Louisiana, Maryland, and Vermont, and efforts to consolidate or revise regulations are now underway in Alabama, Arizona, New York, and Oregon. New Hampshire's rules sunset the end of 1998, and new rules will be developed.

Three states added assisted living to their Medicaid waivers: Kansas, Rhode Island, and Wisconsin, and waiver coverage is planned or under consideration in Connecticut, Delaware, Hawaii, Nebraska, New Hampshire, South Carolina, and Utah.

Proposed rules in Hawaii are still in the comment period. Iowa has created a certification process for assisted living, developing rules which certify facilities providing home-like environments and follow the principles of assisted living. Regulations in Kansas were finalized and a Medicaid Home and Community Based Services (HCBS) waiver has been approved that allows assisted living facilities to become providers of waiver services. Kentucky's regulations voluntarily certify facilities offering apartment or home-style housing units in assisted living residences. Regulations in Tennessee were effective in April 1998 and were developed by a 13 member task force headed by a state agency.

Four states are developing demonstration programs designed to test models for serving low-income residents. Two pilots are being conducted in Illinois, one by the Department of Public Aid (DPA) and another by the Department of Aging. The DPA program targets lighter-need nursing facility residents who are unable to remain in their homes or independent settings but do not need 24-hour nursing care. As participants in the project, contractors may convert nursing home units or free standing buildings to units that integrate housing, health, personal care, and supportive services in home-like residential settings. The program is consistent with the definition of assisted living used by the HCBS program.

The Illinois Department on Aging is testing a Community Based Residential Facilities service model. Services will be reimbursed as home care services through the Medicaid Home and Community Based Services Waiver or state funds. The pilot may include three facilities and serve no more than 360 people. The authorizing statute allows the programs to serve people with short or long term needs as a means of relieving family caregivers. Two facilities have been selected, including an Alzheimer's care facility. The Department may contract with a third program involving a nursing home seeking to convert its facility.

The Rhode Island legislature authorized the Housing and Mortgage Finance Agency (HMFA), working in collaboration with the Department of Human Services and the Department of Elderly Affairs, to implement a pilot program. The pilot can serve (in facilities certified and financed by the HMFA) up to 200 low- and moderate-income chronically impaired or disabled adults who are eligible for or at risk of entering a nursing home.

Louisiana agencies are designing a pilot program to test the feasibility of covering assisted living under Medicaid. The project will be implemented by the Department of Health and Hospitals. A task force was appointed to draft guidelines for the project. The project will include two assisted living facilities and use Medicaid waiver funds to pay for assisted living services. The bill defines assisted living as "a residential congregate housing environment combined with the capacity by in-house staff or others to provide supportive personal services, twenty-four-hour supervision and assistance, whether or not such assistance is scheduled, social and health related services to maximize residents' dignity, autonomy, privacy, and independence and to encourage facility and community involvement." One rural and one urban site will be selected through an RFP. Each facility may serve up to 30 Medicaid beneficiaries. Residents must be offered a chance to live in private quarters with a lockable door, bedroom, kitchenette, and bathroom.

Legislation authorizing a pilot program has passed in Connecticut. The bill authorizes Medicaid coverage for assisted living services in three cities with a maximum of 300 units.

To summarize state activity:4

  • Thirty-one states had existing regulations (22) or Medicaid provisions (9) using the term "assisted living" as of June 1998.

  • Six states have issued draft rules.

  • Twenty-eight states provide Medicaid reimbursement for services in assisted living or board-and-care.

    • Nine states plan to add Medicaid coverage of services in assisted living facilities.
    • Six of the twenty-eight states reimburse for services in board-and-care facilities.
  • Eleven states are studying assisted living.

  1. Several states with existing policy have formed a task force to review the policy and make recommendations.

  2. States may be counted in more than one category.

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