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


When asked about each state's future plans with regard to Medicaid funding of services in residential care, most respondents discussed efforts to address problems with the current systems. A few discussed efforts to address barriers to increasing the number of people served.

Florida. A few respondents noted that Medicaid funded residential care could only expand if nursing home use was reduced and mentioned that a task force was meeting to study ways to reduce the nursing home bed base.

Minnesota. Most respondents agreed that the state is likely to continue the model of assisted living that is currently in place. However, they noted that while the budget is not having an impact on the availability of waiver service in the short term, it is not clear what will happen in the longer term, particularly if the Assisted Living Plus service continues to grow at its current rate.

Minnesota is developing ways to help the counties that administer the waiver program to set accurate service rates. One respondent stated that consumer advocacy was needed in the future to advocate for a bill of rights and to develop requirements for staffing and supervision.

North Carolina. The state is planning to move from a tiered rate for Medicaid personal care in adult care homes to a case mix reimbursement system to better match payment rates to residents' needs. It is developing a computerized system to enable them to perform the data analysis needed to support a case mix reimbursement methodology. In another area, a number of stakeholders are working with the legislature on a bill to allow family supplementation of room and board costs for people who spend down in assisted living facilities, as is currently allowed in nursing homes.

Oregon. One respondent stated that in the absence of a budget crisis, Oregon would probably want to expand and improve the current HCBS system, noting that the state is pretty close to a balanced system. Another said that the state's program has changed since its inception and will continue to change, noting that it is important for the state to continually assess the strengths and weaknesses of its program and make necessary changes. For example, the state is currently updating its residential care facility rules and is examining the role of community nurses in all residential care settings. It is also working on initiatives related to person-centered planning.

Another noted that the state's system for determining eligibility for nursing home and waiver services has been helpful in times of budget cuts because it provides a mechanism for the state to reduce the number of people being served based on level of need. However, this respondent said that the system is not perfect and the state wants to revise the criteria to incorporate more risk factors, such as chronic health care needs and medical acuity.

Texas. A number of respondents mentioned ongoing activities related to the Olmstead decision, with several advisory boards working on a range of issues. They noted that the state is asking for more waiver slots in the next legislative session, and that the state is conducting a pilot study using Olmstead relocation specialists to provide individuals in nursing homes with information on the full range of community options. The state is also developing a standardized care assessment process.

A number of respondents mentioned regulatory issues that the state is planning to address, including the 120 day bed hold rule that many providers oppose. The state is also tracking individuals transitioning out of nursing facilities into the waiver program. Because their funding is supported by the nursing home budget, the state wants to see if there are cost savings or whether those leaving the nursing facilities are simply replaced by new Medicaid clients.

Wisconsin. Wisconsin is developing a rate setting methodology and a model contract for counties and facilities to use for waiver clients in Residential Care Apartment Complexes, and is exploring ways to bill the Medicaid fee-for-service system for coverable services provided in residential care as a way to make optimal use of limited waiver funds. To do this, the facility would have to partner with a home health agency or county agency that is certified to bill Medicaid.

Several respondents noted that Wisconsin is also attempting to address the shortage of affordable residential care for low income persons in rural areas through a grant from the Robert Wood Johnson Foundation's Coming Home Program. They noted that the state was very interested in identifying new ways to combine housing and services that would be affordable for low income and Medicaid-eligible persons, such as maximizing the use of HUD Section 8 housing vouchers. However, others noted that these vouchers were not the solution because the amount of the voucher is not sufficient to pay rent in some areas. Additionally, they said that there are too few vouchers and many locales keep them for families with children because there is a real housing crisis for low income families and seniors have more housing subsidies. Given this, they felt it would be difficult to get housing authorities to designate money for residential care for elderly persons.

One respondent mentioned a legislative proposal under development that would enable persons leaving nursing homes to have the nursing home funds follow them to the community instead of having the money stay in the nursing home budget. This respondent noted that this measure is particularly important given that future Medicaid expansions are unlikely.

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