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


  • The Assisted Living Plus package, which can only be provided to residents of a Housing with Services Establishment, permits counties to approve monthly packages under the maximum rate available to the client.

  • The Elderly Waiver monthly service plan limit is the statewide average monthly Medicaid payment rate to nursing facilities for the 11 case mix categories to which the person would be assigned under the Medicaid case mix reimbursement system.29 Around 90 percent of Elderly Waiver participants fall into the first five of the eleven categories, the monthly rates for which range from $1,963 to $2,985.30

  • For Elderly Waiver clients who do not participate in a Pre-Paid Medical Assistance Plan (PMAP), a state managed care program, the cost of all state plan home care and Elderly Waiver services including extended medical supplies and equipment, skilled nursing, home health aide, and personal care services reimbursable by Medicaid are included when determining the cost effectiveness of Elderly Waiver community support plans. For PMAP clients, some of these services are services provided under the PMAP contract and premium.

  • Additional services, which do not duplicate any of the services provided by the Residential Care or Assisted Living service package, may be added to the person's community support plan and authorized for payment if the total cost of services does not exceed the person's monthly service cap.

  • The Group Residential Housing program also makes service payments for disabled and elderly adults in foster care and other settings if the person is not eligible for service payment from another source. The GRH limit for services is $461.36 per person per month. The services, called "supplemental services", must be necessary for an individual to remain independent, and are typically provided to an individual who has not been able to get Alternative Care or Elderly Waiver services due to their not meeting nursing home level of care criteria.

  1. The Alternative Care Program's monthly service cap is limited to 75 percent of the monthly service cap in effect for persons assigned the same case mix classification as persons receiving Elderly Waiver services.

  2. Mollica, R. J., State Assisted Living Policy: 2002, National Academy for State Health Policy, 2002.

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