Understanding Medicaid Home and Community Services: A Primer, 2010 Edition. Endnotes: Citations, Additional Information, and Web Addresses

10/29/2010

  1. Janet O’Keeffe and Robin Cooper co-authored this chapter. Some sections of this chapter draw liberally from other published sources, which are referenced in the endnotes.

  2. Medicaid-covered “institutional” services refer to specific services and settings as authorized in the Social Security Act. While the term “institutional” is also commonly used to describe specific characteristics of a facility--such as structuring its operation to accommodate the facility’s needs rather than the residents’ choices--in Federal Medicaid statute and regulations the term institutional generally has the following meanings:

    (1) The service is institutional, that is, a provider accepts responsibility for residents’ overall care, and furnishes food and shelter in addition to services; (2) the setting is institutional--subject to state licensure requirements and survey and certification process; (3) payment is made through separate provisions for institutional services; and (4) eligibility rules may be specific to institutional services.

    Taken together, these requirements mean, among other things, that an institutional service such as Medicaid nursing facilities can only be provided in a Medicaid-certified nursing facility, and only reimbursed under the Medicaid nursing facility benefit. It is important to note that a facility does not have to have many beds to be considered an institution, despite the popular image of institutions as being large. (See endnote 5 regarding the minimum size of an ICF/ID.)

  3. Come-in staff generally work 8-hour shifts (day, evening, night) but can also work 12-hour day or night shifts.

  4. ICFs/ID are considered institutions under Federal regulations. Although some ICFs/ID are large state-operated facilities, the majority are now smaller. CMS regulations provide for a “community size” ICF/ID option. Facilities that have 15 or fewer beds are considered “community” ICFs/ID, and facilities with 16 or more beds are considered to be “large.” A number of states operate community ICFs/ID, many of which have few beds.

    For example, California, Texas, Illinois, Indiana, and Louisiana, among other states, all have ICFs/ID that serve six or fewer individuals. Thus, a state could potentially provide services under the HCBS waiver in group homes that serve the same number of residents (or more) than an ICF/ID, so that the two settings are the same in size. The difference is that the ICF/ID setting provides the ICF/ID institutional service, must comply with numerous Federal regulations, and receives the comprehensive institutional reimbursement, which includes payment for room and board.

  5. CMS. (2008). Application for a §1915(c) Home and Community-Based Waiver [Version 3.5], Instructions, Technical Guide and Review Criteria, Appendix C-2-c-ii, p. 117. See the Resources section of this chapter for a web link to the application, instructions, and appendices.

  6. Ibid.

  7. Found at http://www.minnesotahelp.org/Public/taxonomy_glossary.aspx?code=BH-840.600-28.

  8. Section 1616(e) of the Social Security Act requires that the state must “establish, maintain, and insure the enforcement of standards for any category of institutions, foster homes, or group living arrangements in which a significant number of SSI recipients resides or is likely to reside. The standards must be (a) appropriate to the needs of residents and the character of the facilities involved; and (b) govern such matters as admission policies, safety, sanitation, and protection of civil rights.”

    Section 1616(e) also requires states to maintain records of information concerning standards, procedures available to ensure enforcement of the standards, and a list of waivers of standards and violations of standards by specific facilities. These records must be made available annually to the public. States must certify annually to the Commissioner of Social Security that they are in compliance. Office of the Inspector General (March 31, 1997). Review of the Social Security Administration Procedures to Ensure State Compliance with §1616(e) of the Social Security Act -- A-01-96-62001. Available at http://www.ssa.gov/oig/ADOBEPDF/audit_htms/96-62001.htm.

  9. Mollica, R., Sims-Kastelein, K., and O’Keeffe, J. (2007). Residential Care and Assisted Living Compendium: 2007. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, Office of Disability, Aging and Long-Term Care Policy. Available at http://aspe.hhs.gov/daltcp/reports/2007/07alcom.htm .

  10. CMS. (2008). Application for a §1915(c) Home and Community-Based Waiver [Version 3.5], Instructions, Technical Guide and Review Criteria, pp. 168-169, and 265-266. See the Resources section of this chapter for a web link to the application, instructions, and appendices.

  11. Mollica, R., Booth, M., Gray, C., and Sims-Kastelein, K. (2008). Adult Foster Care: A Resource for Older Adults. New Brunswick, NJ: Rutgers Center for Health Policy, p. 7. Available at http://www.hcbs.org/moreInfo.php/doc/2273 .

  12. Alba, K., Prouty, R.W., and Lakin, K.C. (2007). Chapter 4: Number of Residential Settings and Residents by Type of Living Arrangement on June 30, 2007. In Prouty, R.W., Alba, K., and Lakin, K.C. (Eds.).Residential Services for Persons with Developmental Disabilities: Status and Trends through 2007. Minneapolis: University of Minnesota, Research and Training Center on Community Living, Institute on Community Integration, p. 45. Available at http://www.hcbs.org/moreInfo.php/doc/2312.

  13. Mollica, R.L., Simms-Kastelein, K., Cheek, M., Baldwin, C., Farnham, J., Reinhard, S., and Accius, J. (2009). Building Adult Foster Care: What States Can Do. Washington, DC: AARP, Public Policy Institute, p. 9. Available at http://www.aarp.org/health/doctors-hospitals/info-09-2009/2009_13_building.html .

  14. Supported living in an individual’s own home and any other type of residential supports a state wants to cover are also subsumed under residential habilitation.

  15. CMS. (2008). Application for a §1915(c) Home and Community-Based Waiver [Version 3.5], Instructions, Technical Guide and Review Criteria, pp. 151-152. See the Resources section of this chapter for a web link to the application, instructions, and appendices.

  16. 45 CFR 1355.20.

  17. CMS. (2008). Application for a §1915(c) Home and Community-Based Waiver [Version 3.5], Instructions, Technical Guide and Review Criteria, p. 131. See the Resources section of this chapter for a web link to the application, instructions, and appendices.

  18. Utah’s Community Supports Waiver for Individuals with Intellectual Disabilities and Related Conditions, Waiver # 0158.90.r#.02.

  19. States do not have to include citations of state rules, which can change over time. The application must also include the state’s quality assurance plans.

  20. Hawes, C. (2001). Introduction. In Zimmerman, S., Sloan, P.D., and Eckert, K. (Eds.). Assisted Living: Needs, Practices, and Policies in Residential Care for the Elderly. Baltimore, MD: The Johns Hopkins University Press.

  21. The supply of older residential care facilities that serve individuals eligible for SSI and Medicaid is much larger than the supply of private pay assisted living facilities. Robert Newcomer, University of California at San Francisco. Personal communication, November 25, 2009.

  22. Mollica, R., Sims-Kastelein, K., and O’Keeffe, J. (2007), op. cit.

  23. Mollica, R. (2009). State Medicaid Reimbursement Policies and Practices in Assisted Living. Washington, DC: National Center for Assisted Living; American Health Care Association. Available at http://www.ahcancal.org/ncal/resources/Documents/MedicaidAssistedLivingReport.pdf . Hawes, C., Rose, M., and Phillips, C.D. (1999). A National Study of Assisted Living for the Frail Elderly: Results of a National Survey of Facilities. U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, Office of Disability, Aging and Long-Term Care Policy. Available at http://aspe.hhs.gov/daltcp/reports/facres.pdf .

  24. The Guidance also notes that states may modify or supplement the core definition to reflect the scope of assisted living services furnished under the waiver.

  25. CMS. (2008). Application for a §1915(c) Home and Community-Based Waiver [Version 3.5], Instructions, Technical Guide and Review Criteria, pp. 117, 170. See the Resources section of this chapter for a web link to the application, instructions, and appendices.

  26. Ibid. Appendix C, Attachment: Core Service Definition, pp. 151-153.

  27. This section draws liberally from Mollica, R., Sims-Kastelein, K., and O’Keeffe, J. (2007), op. cit.

  28. An HCBS waiver may cover services provided in participants’ homes or in residential care settings. Some states have implemented specialized assisted living waivers, which provide services only in residential care settings.

  29. Mollica, R. (2009), op. cit. Individuals with developmental disabilities who meet a state’s nursing home level-of-care criteria may also be served in Aged or Aged/Disabled HCBS waiver programs. But only persons with developmental disabilities can be served in ID/DD waiver programs, because the level-of-care criteria for ICFs/ID require a specific diagnosis of developmental disabilities to be eligible.

  30. Information in the Boxes is mainly from Mollica, R. (2009), op. cit., and Mollica, R., Sims-Kastelein, K., and O’Keeffe, J. (2007), op. cit.

  31. Licensing requirements adopted in 1995 and 1996 established the umbrella term of “assisted living residences” for two types of residential care facilities: (1) licensed adult care homes and (2) multi-unit assisted housing with services (which are not licensed, but must be registered with the State).

  32. Residents may be asked to leave under the following conditions: (a) their needs exceed the level of ADL services provided by the facility; (b) the resident’s behavior interferes with the rights and well-being of others or poses a danger to self and others; (c) the resident has a medical or nursing condition that is complex, unstable or unpredictable and exceeds the level of health services the facility provides; or (d) the facility is unable to accomplish resident evacuation in accordance with OAR 411-054-0090 (Fire and Life Safety).

  33. As noted, above, states do not have to include citations of state rules, which can change over time. The application must also include the state’s quality assurance plans.

  34. Oregon and Washington also allow other types of residential care settings that contract with Medicaid to have shared rooms.

  35. The information in this section is taken verbatim from Mollica, R., Sims-Kastelein, K., and O’Keeffe, J. (2007), op. cit.

  36. Medicaid will pay for food costs in specific situations, such as meals served as part of an adult day health program.

  37. CMS. (2008). Application for a §1915(c) Home and Community-Based Waiver [Version 3.5], Instructions, Technical Guide and Review Criteria, Appendix I-5: Exclusion of Medicaid Payment for Room and Board, pp. 265-266. See the Resources section of this chapter for a web link to the application, instructions, and appendices.

  38. Many states have a state supplement for residential care settings that may be too low to cover more intense services needs and higher capital costs in some residential care settings.

  39. Mollica, R., (2009), op. cit.

  40. The net cost to the state will depend on Medicaid payment rates for both nursing homes and services in residential care facilities.

  41. Mollica, R. (2009), op. cit.

  42. Family contributions that do not affect SSI eligibility--and therefore do not affect Medicaid eligibility--might have an affect in 209(b) states because Medicaid eligibility in these states is not linked to SSI eligibility. (When SSI replaced state-only programs of aid for elderly persons and persons with disabilities, the change was expected to lead to large increases in the numbers of SSI beneficiaries. The 209(b) option was enacted along with SSI in 1972 to enable states to limit large increases in Medicaid enrollment and costs.

  43. See IRS Code Section 131b1 that defines a qualified foster care payment as “a payment made pursuant to a foster care program of a state or a political subdivision of the state: that is paid by a political subdivision of a state, or a qualified foster care placement agency; and that is paid to the foster care provider for caring for a qualified foster care individual in the foster care provider’s home, or a difficulty of care payment.”


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