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

12/01/2003

  1. There were 703 SNFs (including SNUs) in the year 2000 in Florida, with 81,163 beds; 52,649 were Medicaid beds. (Personal communication, Jennifer Salmon)

  2. Due to state budget shortfalls, the income eligibility criteria was reduced in April 2002 from 90 percent to 88 percent of FPL (from $662 to $651), which resulted in a loss of Medicaid eligibility for an estimated 5,000 people in Florida.

  3. Two additional waiver programs that serve elderly persons are:

    • The Consumer-Directed Care Research and Demonstration Waiver is an 1115 waiver program, which is available in certain counties for individuals receiving services through the Aged/Disabled Adult and other waivers. Individuals chosen to participate in the experimental group are allowed to "cash out" services on their current care plans and receive a monthly benefit through a fiscal intermediary to purchase services directly from a provider of their choice. The program was implemented in 2000. There was difficulty in getting CMS to approve operational protocols related to coverage of services in assisted living facilities.

    • The Medicaid Nursing Home Diversion (NHD) Waiver provides services to 868 functionally impaired elderly persons age 65 and over who are at risk of nursing home placement in Palm Beach and the Orlando area. Dual eligible (Medicare and Medicaid) individuals that meet clinical eligibility criteria may choose to receive both long-term care and acute care services under the NHD Waiver. Managed care providers that have contracted with the state under the NHD Waiver are responsible for Medicare co-payments and deductibles. Providers are reimbursed at a capitated rate, on a per member, per month basis to enrolled Medicaid providers.

  4. Due to state budget shortfalls, the income eligibility criteria was reduced in April 2002 from 90 percent to 88 percent of FPL (from $662 to $651), which resulted in a loss of Medicaid eligibility for an estimated 5,000 people in Florida.

  5. Cost sharing is required in only three waivers: Long Term Care Diversion Project (Nursing Home Diversion Waiver), Assisted Living for the Elderly and Cystic Fibrosis. There is no cost sharing required in other waiver programs, unless the individual qualified under an income trust.

  6. The maximum payment is $78.40 per month.

  7. Florida Statutes, Title XXX, Chapter 409.212.

  8. Chapter 59G-1.010, Florida Administrative Code, defines medical necessity as medical or allied care, or services furnished or ordered that must be necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain.

  9. The financial and service eligibility information is taken from Kassner, E. and Williams, L., Taking Care of their Own: State-funded Home and Community-based Care Programs for Older Persons, AARP, September 1997. Other details of the programs are from the Department of Elder Affairs website and personal communications.

  10. One respondent felt that this program is more cost effective than the waiver program in preventing nursing home placement because many caregivers become financially dependent on the subsidy, which while not large, can be critical for a poor family. If this situation occurs, it may not always be in the best interests of the elderly person who needs services that the family can not provide.

  11. The information in this section draws heavily from Manard, B. et al., op.cit., with some additional comments from personal interviews with current state staff. Adult Family Care Homes were originally called Adult Foster Home (AFHs), a licensing category created in 1968 to provide a community housing alternative for mental hospital patients being de-institutionalized. While some de-institutionalized mental health clients were also sent to Adult Congregate Living Facilities, proportionally more were in Adult Foster Homes. Over time the program evolved to serve elderly persons almost exclusively.

  12. Personal communication.

  13. One respondent stated that providers do not seem to understand that the rate is a little higher based on the assumption that residents will be away from time to time.

  14. Manard, B. et al., op.cit.

  15. The information on the creation of the ECC licensing category is drawn from a report prepared for the Commission on Long Term Care in Florida, Assisted Living and Extended Congregate Care: The Florida Experience, by Larry Polivka, Victoria M. Sims and Jennifer R. Salmon, Florida Policy Exchange Center on Aging, August, 1996, with additional comments from a number of personal interviews conducted in October 2002.

  16. Salmon, J. R., et al., Affordable Assisted Living Facilities: Government-Sponsored Benefits for Reimbursing Assisted Living Services, Room, and Board, Florida Policy Exchange Center on Aging, Tampa, Florida, September 15, 2002.

  17. The maximum OSS payment is $78.40 per month.

  18. One respondent stated that providers do not seem to understand that the rate is a little higher based on the assumption that residents will be away from time to time.

  19. Staff must receive four hours of initial training covering understanding Alzheimer's disease; characteristics of the disease; communicating with residents; family issues; resident environment; and ethical issues. An additional four hours of training must be obtained within nine months of employment covering behavior management; assistance with ADLs; activities for residents; stress management for the caregiver; and medical information. Four hours of annual training must be obtained on topics specified by the Department of Elder Affairs (DOEA).

  20. Florida Statutes, Chapter 400 is the "institutional" chapter and covers nursing homes, adult day care centers, adult family care homes, and assisted living facilities. Chapter 430 covers the community based services, such as Community Care for the Elderly, Home Care for the Elderly, Alzheimer's clinics, Respite for elders, and others.

  21. F.A.C. 58A.5.0185(7)(f) states: "The facility shall make every reasonable effort to ensure that prescriptions for residents who receive assistance with self-administration or medication administration are refilled in a timely manner." The respondent was not sure if the rule is actually interpreted this way and if facilities are doing it or making sure families understand that this is a reason for discharge (i.e., not paying their medication bills).

  22. The Nursing Home Transition Program, which began last year, provides funding for eligible nursing home residents who can be cared for under the ALE Medicaid Waiver. Separate funding for these residents was again provided for the 2002-2003 fiscal year at $2,300,000. The Capitated Nursing Home Diversion Program increased funding to $30,916,013 and will create approximately 100 additional slots for this program. The state also directed AHCA and DOEA to jointly develop a plan to expand the opportunities for diversion projects in rural and underserved areas of the state.

  23. The Assisted Care Services (ACS) State Plan Amendment maintained current funding for the 2002-2003 fiscal year at $32,871,249, which includes $3,200,000 for program growth. The Assisted Living for the Elderly (ALE) Medicaid Waiver maintained current funding for the 2002-2003 fiscal year at $30,754,351.

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