Using Medicaid to Cover Services for Elderly Persons in Residential Care Settings: State Policy Maker and Stakeholder Views in Six States. Admission and Retention Requirements, and Aging in Place


Because Medicaid's assisted living program is not tied to a particular type of housing, admission and discharge decisions are left up to the housing owner or manager. Respondents had conflicting views about this approach.

  • The county case manager determines eligibility for assisted living services under the waiver and the hours of service needed, however, it is the property owner that decides whether the resident's needs can be met in their property. If a resident's condition deteriorates and more care is needed, then the property owner can claim that the increased need for services cannot be met, requiring the resident to leave that setting.

    Currently, there is no bill of rights that enables the resident or family to appeal this decision. Once the decision to terminate is made the resident is given a ten day termination notice and a list of other providers.

  • We need a resident bill of rights to give a right of appeal when discharged.

  • Giving the property owner discretion over discharge is not a problem because typically a lease addendum gets executed at the time the property is leased. This addendum informs the resident what services are available with the rent, services that are available a la carte and who can provide these, as well as information about when the resident would need to move on to a different residence.

  • Families are often unaware that a setting does not have the capability to provide 24 hour a day coverage. There needs to be a resident bill of rights that would support an appeal process. The resident in these settings is under a home care bill of rights which is much more limited than a nursing home bill of rights. This bill of rights was written when it was assumed that the individual receiving services was in their own home so that privacy and termination issues were not applicable.

  • When retention issues arise they are more typically due to an inability to pay the rent portion of the housing because the services can always be provided under the waiver.

  • To be honest it is an open question whether assisted living serves those headed for a nursing home. For some it does, but it tends to be for those who are not as disabled. When you have people who are very disabled or have a lot of incontinence, or get to the point that they can't be sustained in the assisted living setting, then they tend to end up in a nursing home.

  • Termination of lease requires only a 10 day notice, not a 30 day notice, and there is no appeal, the provider just gives you a list of other providers. This is not an eviction, it never gets to that point because once the services are stopped the person has to move to a nursing home. There are no appeal rights for service termination--even if you are a public assistance client and the case manager authorizes the services. But the home care provider can determine that they cannot meet your needs in that setting and the consumer is stuck.

  • If a provider accepts a Medicaid client and is providing services, and the resident begins to have other needs that the provider can't meet, the provider should not be required to use his or her capital and money to bring the services in for one person at the expense of other residents. The providers who keep people because they don't want to give up the money are the ones that will get into trouble.

    Providers have to fully disclose up front what they do and do not provide. Anyone moving in has to do so with the knowledge that at some point they may not be able to stay. If someone is receiving home health services but can no longer be served safely at home, he has to move. Someone living in a housing with services establishment is still considered to be living in his own home.

  • The biggest complaint in Minnesota is "they're making me move" not "they're not taking care of me."

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