Using Medicaid to Cover Services for Elderly Persons in Residential Care Settings: State Policy Maker and Stakeholder Views in Six States. Background


For the past several decades, North Carolina has depended heavily on domiciliary care to meet the long term care needs of its population.7Domiciliary care was a term North Carolina used to define three types of residential care settings: Homes for the Aged (also called Adult Care Homes), Family Care Homes, and Group Homes for Adults with Developmental Disabilities. These homes are licensed by the Department of Human Resources' Division of Facility Services and monitored by county Departments of Social Services staff.

Domiciliary homes were defined in statute as any facility, by whatever name it is called, that provides residential care for aged or under 65 disabled persons whose principal need is a home that provides the supervision and personal care appropriate to their age or disability.

  • Personal care is defined as including bathing, dressing, and feeding and instrumental activities of daily living such as shopping and laundering clothes.

  • These homes are not permitted to provide medical care, except on an occasional or incidental basis, but they are expected to administer medications.

  • These homes are to be distinguished from nursing homes. Their license does not permit them to serve persons who meet the state's nursing home level of care criteria, and so the residents of these homes, even if they meet the state's HCBS waiver eligibility criteria, cannot receive waiver services in this setting. The homes provide custodial care, and if residents needed nursing care or skilled therapies, the state covers them through the Medicaid Home Health benefit.

Prior to 1995 when the state began paying for some personal care in these homes through the Medicaid program, domiciliary care was solely privately purchased. However a significant amount of the payments to residential care settings was publicly subsidized through the federal SSI program and the state's SSI supplement, called Special Assistance.

Persons eligible for SSI who live in domiciliary care homes are eligible for Special Assistance. Each month they receive a check, which is paid to the home. Monthly benefits for the combined SSI and Special Assistance benefit are established by the North Carolina General Assembly as the "rate" for domiciliary home care. Prior to the use of Medicaid to pay for some personal care in these homes, this rate covered room and board and custodial care provided by the home.

7. 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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