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


Texas believes that services provided in assisted living facilities should enhance a person's ability to age in place while receiving increasing or decreasing levels of service as the person's needs change.10 The key distinction between nursing homes and assisted living facilities is that the former provides regular nursing care. Licensing rules do not permit assisted living facilities to serve those who require more than intermittent, short-term acute, or terminal nursing services. If an assisted living resident--either private pay or CBA waiver--requires intermittent, short-term or terminal nursing services, the provider has to contract with an agency to provide them.

The regulations specify that assisted living facilities may admit residents who:

  • exhibit symptoms of mental or emotional disturbance, but are not considered at risk of imminent harm to self or others;
  • need assistance with movement;
  • require assistance with bathing, dressing, and grooming;
  • require assistance with routine skin care, such as application of lotions, or treatment of minor cuts and burns;
  • need reminders to encourage toilet routine and prevent incontinence;
  • require temporary services by professional personnel;
  • need assistance with medications, supervision of self-medication, or administration of medication;
  • require encouragement to eat or monitoring due to social or psychological reasons of temporary illness;
  • are hearing impaired or speech impaired;
  • are incontinent without pressure sores;
  • require established therapeutic diets;
  • require self-help devices; and
  • need assistance with meals.

If residents have a change in health or conditions related to the amount and type of care required, the case manager, in conjunction with the other members of the Interdisciplinary Team, the provider and the resident or their legal representative, may explore other means to continue serving them in assisted living. CBA waiver participants (and private pay residents) may receive licensed nursing services in an assisted living facility if they are provided through contracts with certified home health agencies. Another option is to have the resident attend a day activity and health services program, which provides some nursing care. In either case, the cost of all services combined may not exceed the waiver cap.

Rules regarding retention criteria include:

  • If participants exhibit behavior that threatens the health or safety of themselves or others, or their needs exceed the licensed capacity of the facility, the AL/RC provider must request the case manager to assess the participant's continued eligibility for CBA waiver services.

  • If a CBA waiver client is hospitalized or admitted to a nursing facility, the facility must hold their room as long as they pay the daily room and board charge. The facility may not bill for services while the client is residing elsewhere.

  • An ALF resident may be allowed to stay in a facility as long as the resident and/or the family, a personal physician and the assisted living provider all agree that the residents' needs can be adequately met.

  • To address concerns regarding the inappropriate retention of residents with a high level of need, the State enacted a requirement, effective September 2002, that facilities conduct a formal assessment of residents' needs annually and whenever there is a significant change in the resident's condition. This requirement is applicable to both Medicaid eligible and private pay residents.

  1. Texas Administrative Code, Title 40, Social Services and Assistance, Chapter 92, Licensing Standards for Assisted Living Facilities, Subchapter A, Rule 92.2,a.

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