In all the states, while some respondents had concerns about specific Medicaid-related issues, there was unanimous agreement that Medicaid payment for services in residential care settings was overall a positive development. Medicaid payment was universally viewed as a way to reduce nursing home utilization, and in so doing, both save money and increase community alternatives to nursing homes, thereby providing consumers with more choice. A respondent in Oregon stated that the public has many more options because Medicaid participates in the funding of residential care services.
Respondents in Florida noted that prior to the use of the personal care option in residential care settings, many people needed services but did not meet the nursing home level of care criteria and could not afford to pay privately for residential care. Adding personal care under the Medicaid plan was key to the state's efforts to provide additional revenue to residential care settings that previously received only SSI and a state supplement as full payment for room and board and services. Medicaid coverage of personal care in residential care settings has attracted providers who, in the past, were reluctant to take state supplement recipients.
Florida respondents also noted that covering services in residential care settings through the waiver program was responsible for major cost savings. One stated that each dollar spent on the waiver would cost $2.70 in the nursing home. Minnesota respondents expressed satisfaction with Medicaid coverage because it enabled many people to be served in settings outside the nursing home.
North Carolina respondents felt that Medicaid coverage of personal care in residential care settings had improved the quality of care and had saved the state money by shifting some of the cost of personal care to the federal government. However, some felt that the adult care home population is becoming more and more impaired, and that the homes are not able to provide the level of care that many residents need. One respondent felt that the state is using limited resources inefficiently by providing nursing care to large numbers of people in residential care settings through the Medicaid Home Health benefit. Another noted that even though occupancy rates in some adult care homes were low, some facilities did not want to accept Medicaid residents because they would have to submit cost reports.
Single Occupancy vs. Double Occupancy Rooms
Of the six states, only Oregon requires assisted living facilities to provide private apartments to Medicaid clients.20 In the other states, Medicaid contracting rules may encourage, but do not require, private bedrooms and bathrooms. Yet, in every state, nearly all respondents who commented on the issue of single vs. double occupancy rooms felt strongly that Medicaid clients should have private rooms and baths in residential care settings, noting that most older people highly value their privacy and want private rooms.
Many were highly critical that the term "assisted living" was used to describe facilities that had two and as many as four people in a room (in Florida). One respondent criticized Florida's Extended Congregate Care regulations for defining privacy as "encompassing dual-occupancy with a choice or roommate where possible." However, some noted that the low room and board rates mandated for Medicaid clients could make it difficult for some providers to offer private rooms.21
In North Carolina, dual occupancy is the standard for Medicaid-eligible residents. Several North Carolina respondents felt that many facilities that called themselves assisted living were similar to institutional care. In Wisconsin, whether a waiver client is served in a single room depends on the availability of these rooms in the area they live in, and whether the facility will accept the low amount that waiver clients typically have to pay for room and board.
Oregon respondents felt that success of the state's assisted living program lay in its offering Medicaid waiver clients the same residential care options available to the private pay market. As one said, "if the private pay market gets privacy and independence, then so should the Medicaid client." Another noted that while giving Medicaid clients private rooms in assisted living had been very successful, the downside was that the state has not invested in the physical upgrading of nursing homes, which are viewed as being "stuck in the 50s and 60s."
One Oregon respondent noted that the assisted living physical plant requirements had generated a greater degree of accessible housing for persons under age 65 with disabilities, noting that ALFs offer a housing option for the younger disabled who need some oversight and services but want privacy and independence.
Oregon also serves waiver clients in adult foster care and residential care facilities, which may not have private rooms and bathrooms.
Of the six study states, only Minnesota and Wisconsin do not restrict the amount that Medicaid residents can be charged for room and board.