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


There was a consensus among the respondents that the state's home and community services program -- both the state funded portion and the Medicaid portion -- were exceptionally good. Most felt that the state's goal in using Medicaid to cover services in residential care settings is to provide an alternative to nursing homes for people who can not live at home, and that CBRFs are fulfilling this goal.

  • The most important feature of Medicaid paying for services in residential care facilities is the ability to be flexible and to provide services based on people's needs.

  • It's important that the state is involved in residential care -- it's trying meet the needs of residents and operators.

  • Wisconsin has done especially good work with CBRFs because Medicaid funding has driven the expansion of the pool of facilities. It has no effect on RCACs -- the private pay market is driving the development of RCACs.

  • Just having the option of residential care other than nursing homes is a good thing. Better than having just a choice of a nursing home if you can't live at home. Some people do choose to live in CBRFs. It's also a safety net for people who wind up there because they have no other choice.

  • I think the use of Medicaid funds to support older persons with dementia in CBRFs has been highly successful. A good CBRF environment is highly preferable to a nursing home.

However, some thought that the state has not done a good job of developing facilities that are alternatives to nursing homes for the Medicaid population.

  • People shouldn't have a choice only of CBRFs and nursing homes -- they should also be able to choose home care and adult family homes (Wisconsin does not have a lot of them.) We need more alternatives to nursing homes for the Medicaid population -- like Oregon has -- we're getting there.

With regards to RCACs, there was agreement that the state had met its objective for facilitating the development of apartment style assisted living, given that 5000 RCAC units were built since 1997. This model, however, was not developed specifically to serve Medicaid clients; only 189 RCAC residents are receiving waiver funded services.

  • The state wanted to encourage the development of an apartment style of assisted living modeled after the Oregon model, which it believed was a good model. At the time, the state was also committed to deregulation, and the idea was to create a model of assisted living that was less regulated than the existing model at the time -- CBRFs. Coverage of the Medicaid population was not a driving factor. The state knew it would have to find a way to pay for the Medicaid population in these settings and to get providers interested in accepting Medicaid eligibles.

  • The state never intended to cover room and board or to limit it to an affordable amount for Medicaid eligibles. There were insufficient powerful people in the housing and social services field to take on the industry. They couldn't even enforce the exclusive use of the term assisted living for RCACs.

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