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


Requirements include the following provisions:

  • An ALF must have an ECC or LNS license and must be enrolled as a provider in order to bill for services under the Medicaid Waiver program. The ALF must also provide private or semi-private rooms and bathrooms for all waiver clients.

  • Medicaid residents may be required to share the cost of services depending on their cost sharing obligation. The ALF can bill the maximum billable amount of $28.00 per day less the resident's required cost share. The ALF is responsible for collecting the cost share obligation from the resident. In addition to the daily rate, ALFs may bill Medicaid up to $125.00 per month for incontinence supplies.

  • Case management activities are provided by enrolled case management agencies and are paid on a fixed monthly rate of $100. Case Management agencies must be enrolled as Medicaid waiver providers and maintain a contractual relationship with the state. No cost-sharing is required for case management services.

  • Assisted Living Facilities participating in the ALE Waiver are required to bill Medicaid for both the ACS state plan service and the ALE waiver services for recipients who are enrolled in the waiver and have income below $730 per month. The services must be specified in the resident's plan of care and must not be duplicative. ACS is billed first, which in effect, saves waiver dollars.

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