The information in this appendix is presented in three major sections:
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The first section provides an overview of the state's long term care system, with a primary focus on the Medicaid program. Although a state may pay for services in residential care settings through the Medicaid program, the program's financial eligibility criteria and related financial provisions for home and community services can present barriers to serving Medicaid clients in these settings. Thus, the first section of each state's description presents detailed information about rules related to financial eligibility, spousal financial protections, and cost sharing requirements.
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The second section describes the state's residential care system.
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The final section presents the views of respondents interviewed for this study on a range of issues related to Medicaid coverage of services in residential care settings in their state.
Because the information in the first two sections is intended to serve as a reference, some information is presented under more than one heading to reduce the need for readers to refer back to other sections for relevant information.
Unless otherwise cited in endnotes, all information presented here was obtained from the sources listed at the end. Supplemental Security Income levels, the federal poverty level, federal spousal protection provisions, state supplemental payments, and state reimbursement rates are for 2003, unless otherwise noted.
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III. Summary of Interviews
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In addition to consulting with 9 state staff and policy makers regarding the technical details of the state's programs, we also interviewed four of them. In addition, we interviewed 9 stakeholders, including representatives of assisted living provider associations, consumer advocates, a former county service administrator, and two university-based policy analysts, one of whom previously worked for the NC Department on Aging.
The interviews focused on respondents' views about several key areas and issues. This section summarizes their views and provides illustrative examples of their responses. These comments are not verbatim quotes, but have been paraphrased to protect the respondents' anonymity and edited for brevity. A list of information sources for the state description and the individuals interviewed can be found at the end of this summary.
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Endnotes
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Gregory, S.R. and Gibson, M.J., Across the States: Profiles of Long Term Care. Public Policy Institute, AARP, November 2002.
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Prior to 1995, North Carolina (North Carolina) was a 209(b) state and had the option of using more restrictive financial eligibility criteria than that of the Supplemental Security Income (SSI) program to determine financial eligibility for Medicaid. During this time, persons who were eligible for SSI, either because they were disabled or 65 years or older, were not automatically eligible for Medicaid, as they were in most states.
Individuals could become eligible for Medicaid by spending down to $242, or $317 for a couple. Resource limits were also more restrictive than SSI. The one exception to this income standard was linked to receipt of the SSI state supplement, called Special Assistance (SA), which was provided only to individuals residing in adult care homes.
In January 1995, the state began covering all SSI recipients under Medicaid, and in 1999 increased the income standard to 100 percent of the federal poverty standard. This standard is used to determine eligibility for all long term care services in the state, including nursing homes. The state also has a medically needy program.
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As permitted under the §1902(r)(2) less restrictive income methodologies, the state excludes wages paid by the Census Bureau for temporary employment; it also does not count the following: personal effects & household goods; life estate interest and tenancy in common interest (except for optional state supplements); burial plots; cash value of life insurance if the total face value does not exceed a specified amount.
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At a county's option, blind and disabled adults who are not eligible for SSI may also receive a supplement in a private living arrangement. They are covered under "certain disabled" provisions but receipt of the SA does not confer Medicaid eligibility as it does to individuals residing in Adult Care Homes.
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In August 1995, the combined SSI/SA payment was lowered from $982 to $800. The savings were used to provide the state match for the new Medicaid personal care benefit. The reduction resulted in some people in adult care homes not meeting the Special Assistance income eligibility criteria, and thus losing Medicaid eligibility. However, the state grand-fathered them for continued coverage.
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There are some exceptions, a discussion of which is beyond the scope of this report.
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The information in this section draws heavily from Elise Bolda's report: Initial report on North Carolina domiciliary care policy. The Long Term Care Resources Program, Duke University Center for the Study of Aging and Human Development (1991).
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Hawes, C., Lux, L., Wildfire, J., Green, R., Packer, L. E., Iannacchione, V., and Phillips, C. Study of North Carolina domiciliary care home residents. (February 15, 1995). Report submitted to the North Carolina Department of Human Resources.
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One respondent noted that some owners believe a minimum of 60 beds are needed to make a profit.
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One respondent stated that people on Medicaid could not afford private rooms because Medicaid only pays for services, not for lodging.
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Elise Bolda's report: Initial report on North Carolina domiciliary care policy. The Long Term Care Resources Program, Duke University Center for the Study of Aging and Human Development (1991).
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