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


  • The average age of RCAC residents is 83.6 years. The average length of stay is 1.6 years, significantly below the national average of just under 3 years. The average turnover rate is 30 percent, consistent with the national average of 29 percent. About half leave because of increasing care needs (53 percent), one in four die, 12 percent spend down and move elsewhere to receive Medicaid services, and 14 percent move to another assisted living setting.

  • RCACs cannot admit someone who is incompetent or who has dementia. Individuals who are subject to guardianship through a court determination of incompetence, people who have an activated POA for health care, and those who have been found by a physician or psychologist to be incapable of recognizing danger, summoning assistance, expressing need or making care decision cannot be served in RCACs. Facilities are required to do a thorough assessment, but there is no standardized method for determining competence.

    The rationale for the prohibition is that RCACs are minimally regulated. There are no surveyors for registered facilities. To enable some degree of aging in place, a facility may choose to retain residents who develop cognitive impairment or dementia, but if they do, they are required to provide appropriate services. Because the developmentally disabled and many people with serious mental illness cannot meet the competency test, in effect, RCACs serve only elderly persons.

  • There are provisions to protect residents from premature involuntary discharge. There is no bed hold policy, but RCACs have to give 30 days notice for discharges.

  • Private pay residents have the option to buy services from somewhere else but they still have to pay the facility base rate. Thus, private pay residents have the ability to age in place if they have the resources to bring in additional help. However, people can't necessarily age in place better in an RCAC than in a CBRF because RCACs can choose to provide a minimum amount of care or a maximum amount.

    For example, RCACs can provide minimal nursing services, such as health monitoring and medication administration. They can select their own discharge criteria as long as they do not conflict with regulatory minimum requirements. One of these minimum requirements is that residents can not be discharged based on hours of services purchased until the total number of hours of service purchased from all sources reaches 28 hours per week.

  • RCACs cannot limit the amount of care provided to Medicaid waiver clients by setting limits on hours of care. They have to provide whatever is needed up to 28 hours. They can discourage a high level of care for private pay clients through pricing. Most RCAC residents on the waiver have spent down. RCACs are willing to accept them as Medicaid clients because the overwhelming majority of their residents are private pay.

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