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


Effective March 1997, the state carved out a portion of the residential care market that was most suitable for deregulation and created a new category of residential care setting (RCS), called assisted living, with its own specific regulations. The state's intent was to reduce regulatory burden, give providers the flexibility to be creative in developing quality residential environments, and permit residents to have maximum control over their daily lives. Residential Care Apartment Complexes (RCACs) were intended to be a less regulated type of RCS than CBRFs and to increase residential care choices for older persons.

This new category of RCS required that each unit be a separate lockable apartment with a private bath and kitchenette. The statute clearly defines RCACs in accordance with the assisted living philosophy, with specific provisions to assure privacy, autonomy, and the ability to age in place. The statute says that RCAC residents retain control over their personal space, care decisions, and daily routines, and that services are individually tailored to each resident's capacities and preferences.

Because the new assisted living regulatory category required private rooms, other RCSs were prohibited from using the term assisted living. Because many AFHs and CBRFs called themselves assisted living or used the term in marketing, they lobbied the state to allow them to use the term. The state agreed but wanted to distinguish the new model from other CBRFs and AFHs. Consequently, in March 1997, the state issued a new rule changing the name of the new model from assisted living to residential care apartment complex.

RCACs are frequently described as "nice assisted living facilities," but they vary with regard to the availability of amenities, e.g., some have washers and dryers in each unit while others have laundry rooms; some have more common space, such as private dining rooms for family parties, libraries, and computer rooms.

RCACs that do not serve Medicaid waiver clients need only to register with the state. Those that wish to receive Medicaid waiver funding must be certified. Standards for both are the same, but certified facilities are subject to a higher level of regulatory oversight and enforcement, including yearly site visits, and a full range of enforcement actions. One respondent noted that the state's policy is to visit certified facilities once a year, but in actual practice, there are not enough regulatory staff to do so. Registered facilities are reviewed only in response to complaints and the state cannot levy fines or impose other "intermediate sanctions."

Wisconsin has 129 RCACs. Forty six percent are registered because they do not plan to admit Medicaid waiver clients. Sixteen registered facilities have become certified, generally because residents have spent down to Medicaid eligibility.

Over 5000 units have been built in the last 5 years. The newer ones are real apartments with separate bedrooms and living areas; the older ones are more like a large studio apartment.

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