Using Medicaid to Cover Services for Elderly Persons in Residential Care Settings: State Policy Maker and Stakeholder Views in Six States. General Comments on Medicaid's Role in Residential Care Settings


On the whole, most respondents were pleased with the success of the Assisted Living for the Elderly waiver program and the more recently introduced Assistive Care Services (ACS) program. They felt that these Medicaid programs have made a real contribution to long term care options for low-income elderly.

  • The state added Medicaid funded personal care services because the state supplement was woefully inadequate to cover services.

  • People were becoming more frail and needing more services, but not qualifying for a nursing home, and couldn't afford a private ALF. Under ACS they can now get some services.

  • The waiver program has achieved the primary goals of cost saving, reduction in the nursing home bed base, and more humane alternatives. Each dollar spent on the waiver would have cost $2.70 cents in the nursing home. The Nursing Home Medicaid average cost is $2,835 per month.

  • More exciting than the ALE waiver was the inclusion of personal care in the Medicaid state plan and the creation of the Assistive Care Services program. It is the key to the state's efforts to provide additional revenues to ALFs.

  • ACS has been instrumental in attracting providers who were reluctant to take state supplement recipients in the past and provides Medicaid funding for frail elders who are not as impaired as waiver clients.

  • We have made some real strides, even in the last 5 years; it was a big step to get Medicaid funds into assisted living.

However, there were criticisms regarding unequal treatment for those with mental health diagnoses, and other inequities.

  • The biggest barriers in Medicaid are for those with serious mental illness (SMI). A high percentage of people receiving state supplements have SMI and have not been able to access Medicaid-funded services.

  • There is an arbitrary definition of mental illness according to income. In the statute it specifically states that persons with "certain psychiatric impairments who receive a state supplement" must be served in a facility with a Limited Mental Health (LMH) license. Because facilities that serve private pay residents did not want to meet LMH requirements, only poor people get a mental health diagnosis.

  • The waiting list for waiver services is prioritized by acuity levels. Based on acuity some people can wait two years for waiver services and others can be served straight away.

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