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


Minnesota is one of the few states that does not have a licensing category for assisted living. There were differing points of view regarding this. While those representing the providers voiced that from their perspective there is an adequate regulatory structure and they did not see anything that needs to be added, this sentiment was not consistently shared by others.

  • We need to license administrators of assisted living to assure a minimum skill set or knowledge base for dealing with this vulnerable population.

  • Licensing the services but not the property or building is not sufficient.

  • Many providers of assisted living are former nursing home managers that are trying to avoid what they perceive as the-over regulation that is found in the nursing home industry. They understand that to avoid this type of over-regulation they need to self-impose quality standards.

  • We think there is an adequate regulatory structure--we don't see that anything needs to be added. Home care entities can be surveyed, and anyone receiving waiver or alternative care services has to go through the counties, so that's another vehicle for oversight.

  • Quality assurance--the people who do the surveying of the home care agencies are very concerned about the frail elders who are not getting adequate care. There is concern that licensure of the services--but not the building--is not sufficient. The owner can obtain a home care provider license, which is not a big deal, but an outside home care agency needs to have a home care Medicaid license, which is a big deal.

  • Housing with services registration has been in place since '95 or '97. It was promoted by long term care trade associations because state regulations to set up assisted living were not available and the industry wanted some regulations. Over time, this has worked fairly well and is supported by private and public entities. One of the non-profit long term care associations has a quality initiative. They want to keep what Minnesota has: flexibility without extensive regulation.

  • Right now, assisted living is primarily private pay--80 percent or more. The way it works in Minnesota is that there is a presumption in the Housing with Services Act that two competent parties enter an agreement: the provider and the resident. We think this creates the best opportunity to create maximum choices. We fear that as more and more waiver dollars flow into assisted living, there will be pressure to create a regulatory scheme that will look like nursing homes. We do not regulate assisted living to the worst case scenario like nursing homes do and don't think we should have to.

  • Minnesota doesn't have very specific regulations, e.g., about how and when meals are to be provided. We operate under the assumption--whether it's private pay or Medicaid--that you have two competent parties entering an agreement. There is a 17 point contract that must be signed by both parties. This eliminates the need for lots of regulations. Alterra had a problem at one of their places and the state attorney general had them in court over a contract violation and it was in the paper. This is a faster way to address quality problems than lots of regulations.

  • The state should not have approved Assisted Living Plus in the Elderly Waiver program without additional standards.

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