For older adults, until the introduction of the private pay assisted living model in the late 1980s, the most frequently used general term for residential care settings other than foster care was board and care. The new assisted living model differs significantly from traditional board and care. According to three of the major assisted living industry trade associations, privacy and flexible services that will meet residents needs and allow them to age in place are key elements of the assisted living philosophy.20 The new assisted living model of residential care became popular with older adults because it offered what nursing homes and traditional board and care facilities generally do not: privacy and control over ones daily activities. Another reason for its popularity is that assisted living facilities--many built in the 1990s--have much more desirable physical environments than do most board and care facilities and nursing homes, many of which were built in the 1960s and 1970s.21
Due to the popularity of the private pay model of assisted living, many operators of board and care homes and other types of residential care settings believe they will be put at a competitive disadvantage if they cannot market themselves as assisted living. Consequently, under pressure from the residential care industry, most states have amended their statutes to rename domiciliary care homes, board and care homes, and even adult foster care, as assisted living.22 Today, virtually all residential care settings for older adults market themselves as assisted living despite the fact that some provide few services and the physical character of a substantial portion of these settings is quite institutional, with two to four persons sharing a bedroom, and as many as 8 to 10 residents sharing a bathroom.23
This general use of the term assisted living is also found in the HCBS waiver application, which uses the term assisted living services to cover a wide range of services that can be provided in residential care settings. However, in its guidance, CMS encourages states to use a more accurate name, noting that the term assisted living describes a setting, not a service and that Medicaid never pays for assisted living in the ordinary sense of a monthly fee to the facility for room, board, and services. Rather, Medicaid may cover, as a waiver service, some of the supportive services provided to beneficiaries in residential care settings.24
Core Definition of Assisted Living Services in the HCBS Waiver Application
Personal care and supportive services (homemaker, chore, attendant services, meal preparation) that are furnished to waiver participants who reside in a homelike, non-institutional setting that includes 24-hour on-site response capability to meet scheduled or unpredictable resident needs and to provide supervision, safety, and security. Services also include social and recreational programming, and medication assistance (to the extent permitted under state law). Nursing and skilled therapy services are incidental rather than integral to the provision of assisted living services. Payment is not made for 24-hour skilled care.
CMS guidance notes that when a waiver includes assisted living services, the locations of service delivery must meet criteria described in Appendix C-2 of the HCBS waiver application with regard to the home-like character and community integration of the facility.25 On June 22, 2009, CMS issued an advance notice of proposed rulemaking in the Federal Register to solicit comments about defining standards for what constitutes home-like and community under HCBS waivers.