State Residential Care and Assisted Living Policy: 2004. Flat Rates that Vary by Setting

03/31/2005

States may vary its flat rates for different types of residential care settings. Texas pays a higher rate for apartment and other private occupancy settings, reflecting the states' preference for these settings. Varying rates by setting may reflect differences in the average level of resident service needs in each setting. For example, a state may reimburse for services in both traditional elderly housing buildings and purpose-built assisted living facilities. Generally, tenants in elderly housing sites are less impaired than those in purpose-built assisted living facilities. Unlike purpose-built assisted living facilities, elderly housing sites typically do not have 24-hour staffing and the capacity to meet the unscheduled needs of tenants. Consequently, elderly housing facilities receive a lower rate than purpose-built assisted living facilities with 24-hour staffing.

New Jersey licenses assisted living services, which are provided in a range of settings. The state developed rates for each of three settings regardless of the level of services needed (see Table 1-14). Newly constructed assisted living residences receive $1,800 a month to cover waiver services, and comprehensive personal care homes receive $1,500 a month. Assisted living programs (services provided in subsidized housing) receive $1,200. The state limits room and board charges in both settings to $630.55. Residents in subsidized housing pay a percentage of their income for rent; the housing subsidy pays the difference between this amount and the actual rent.

    Assisted Living  
Residences
  Personal Care  
Homes
  Assisted Living  
Programs
TABLE 1-14. New Jersey Rate Schedule
Room and Board $630.55 $630.55 n.a.
Medicaid waiver services $1,800.00 $1,500.00 $1,200.00
Total $2,434.55 $2,134.55  

Tiered Rates

Tiered rates have been developed to more accurately and fairly reimburse providers for services provided to frailer residents. Tiered systems usually include three to five 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 serve 10 or fewer residents and assisted living centers serve 11 or more residents. The service payments are negotiated and vary by program contractor (county). Daily rates for Level 1 range from $42.59 to $59.26; for Level 2 from $49.10 to $69.00; and for Level 3 from $49.10 to $87.27.

  • 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 adult foster care. Level I is $940; Level II is $1,180; and Level III is $1460. Facilities receive an additional 10 percent for residents with cognitive impairments. The state limits the room and board payment for SSI beneficiaries to $598 in 2004, so maximum payments rates for each level range from $1,538 to $2,058. Residents whose incomes exceed $704 may be charged a higher amount for room and board.

  • 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 $455.70. The distribution of residents by level is: Level 1--2 percent; Level 2--1 percent; Level 3--6 percent; Level 4--59 percent; and Level 5--32 percent, resulting in an average monthly service cost of $1,643 a month.

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

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