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


Many respondents felt the state needs to help individuals pay for medications if they are in a standard ALF and not eligible for Medicaid.

  • Residents living in ALFs or AFCHs who do not qualify for Medicaid because of too much income (e.g., those Medicaid clients who lost eligibility when the criteria was reduced from 90 percent FPL to 88 percent FPL) or who do not meet level of care criteria for the waiver, have only a personal needs allowance, which all residents retain regardless of income. This is totally inadequate to pay for medications as well as shoes or dentists. Sometimes elderly persons need to get new dentures because of old age or illness.

  • One of my residents no longer qualifies for Medicaid because she turned 62 and received an increase in her Social Security payment. Her medicines are over $400 per month and the facility is now having to pay for them, so I am losing money, but I can't throw her out on the street.

  • There is a regulation that could be interpreted to mean the facility is responsible for payment of medications. I went to a workshop on these rule changes and the trainer said that if the family or the individual does not pay for medications, the facility would be responsible for it.21

  • For people without families and resources, there is no backup, and it is left to the scruples of the provider whether to pay medication expenses themselves or discharge the resident.

  • I go to the drug companies with hardship cases, which requires loads of paperwork. I get samples from physicians and use generics. I also maintain a good relationship with the pharmacy to facilitate late payments of bills.

21. F.A.C. 58A.5.0185(7)(f) states: "The facility shall make every reasonable effort to ensure that prescriptions for residents who receive assistance with self-administration or medication administration are refilled in a timely manner." The respondent was not sure if the rule is actually interpreted this way and if facilities are doing it or making sure families understand that this is a reason for discharge (i.e., not paying their medication bills).

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