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


  • The state does not regulate admissions. Consequently, facilities have total discretion over who they will admit. admissions. Facilities may care for residents for whom they are able to provide appropriate services; there are no other limitations. The facility determines whether a potential resident meets its admission requirements. Prior to the resident moving in, the facility performs an assessment to determine the prospective resident's service needs and preferences and the facility's ability to meet those needs and preferences.

  • Providers with Medicaid contracts are not obligated to admit Medicaid recipients if they do not believe they can meet their needs. When considering an admission, the Medicaid contract permits the facility to determine if it can meet the needs of person in addition to the needs of the residents they already have.

  • Facility capabilities vary and some facilities can take care of people who have high needs and impairments. The state's regulations set the minimum standard of what a facility must provide, but facilities generally go above that standard. Just how much above the standard requirements usually correlates to the resources available to the facility.

  • Facilities with Medicaid contracts may not discharge a resident who has spent down to Medicaid eligibility. Conditions under which they may ask residents to move are: if their needs exceed the level of ADL services available; the resident exhibits behaviors or actions that repeatedly interfere with the rights or well being of others; the resident, due to cognitive decline, is not able to respond to verbal instructions, recognize danger, make basic care decisions, express need, or summon assistance; the resident has a complex, unstable, or unpredictable medical condition; or for non-payment of charges.

  • Facilities without Medicaid contracts are not obligated to keep a resident who spends down to Medicaid eligibility.

  • There is no mandatory bed hold, but a facility can not discharge a resident as long as they pay room and board. If a resident breaks a hip, goes to the hospital, and then to a nursing home for rehabilitation, the assisted living facility may not discharge them. As long as they continue to pay the $449.70 while they're out of the facility, the facility will hold their unit.

  • If a managed risk plan is needed it must be developed with the resident's input or that of their designated representative and be included in the care plan. Facilities are responsible for determining when a risk plan is needed and developing it according to guidelines in state regulation. The results of the agreement must be included in the service plan and the plan must be reviewed at least quarterly and more often if needed.24

  • Persons who are unable to recognize the consequences of their behavior or choices may not enter into or continue with a managed risk plan. There is no uniform or systematic method used to determine whether a person is capable of doing so. The state allows the facility administrator and RN to determine if a person can recognize the consequences of their behavior relative to entering into a managed risk agreement.

24. Managed risk: OAR 411-056-0015(2)(i) - (L) The facility must document the information set forth in (j) of this rule.

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