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


  • Service requirements in RCACs are non-prescriptive, stating only that facilities must provide services that are sufficient to meet the care needs identified in the service agreement, both scheduled and unscheduled, and to have emergency assistance available 24 hours a day. Minimum services that must be provided include: meals, housekeeping and medical transportation; assistance with all ADLs; and nursing services such as health monitoring, medication management and administration.

    However, while the regulations require that an RCAC have the ability to meet the needs of residents, which may include a need for three meals a day, only about half of RCACs offer three meals a day in their meal packages. The state does not dictate how many meals need to be provided, only that 3 meals be provided if a resident needs them. If the basic package includes only two meals, the facility can charge an additional amount for the third meal, and if they don't want a lot of residents who need three meals a day, they can charge a very high rate for a third meal.

  • Both registered and certified facilities may provide up to 28 hours of supportive, personal or nursing services per resident per week, with no additional restriction on the type or amount of nursing care provided. They may choose to provide fewer than 28 hours a week if they wish. RCACs can discourage the entry of residents with high needs by including only a limited amount of care per week in the basic package (e.g., ten hours) and charging a very high rate for any additional hours.

    One respondent noted that when the RCAC regulations were being developed, the nursing home lobby expressed concern that RCACs not become a substitute for nursing homes. In response, the state limited all supportive, personal, and nursing services that can be provided in an RCAC to 28 hours of supportive, personal, or nursing services per week, with no additional restriction on the type or amount of nursing care provided. Private pay residents may pay for additional services they need or want above the 28 hour limit, as long as the service are provided by an outside vendor.

    Among the respondents interviewed there was agreement that 28 hours enables a significant amount of physical care, in fact, more than many nursing home residents get. In contrast, CBRFs are permitted to provide only up to 3 hours of nursing care per week with no restriction on the amount of personal care. For temporary conditions lasting no more than 90 days or longer, RCACs may bring in home health services. They may choose whether or not to keep waiver clients under hospice care.

  • RCACs may provide all services directly with their own staff or through contracts with outside entities. The waiver program pays the facility for the care provided. Residents may contract for additional services not included in the service agreement, as long as they comply with applicable facility policies and procedures. Facility policies may limit the total amount of services purchased from the RCAC and outside providers to no more than 28 hours. They may not put an hour limit on services up to 28 hours. Facility policies may require that services be provided by licensed personnel, that providers check in when they enter or leave the property, or comply with other requirements they may set.

  • As in CBRFs, to be reimbursed for the provision of personal care services, RCACs have to either employ people to provide the care or have the county secure services through an agency that provides personal care. Even if the facilities directly employ people to provide personal care, the county still has to bill for the pre-authorized hours provided, because the state allows only certain types of providers to bill for personal care: Medicaid certified home health agencies, counties, and Independent Living Centers. If an RCAC wants to be reimbursed for Medicaid personal care, it must have a billing partner, typically a county. The rationale for this restriction is that it ensures county oversight of the care recipient's entire care plan, and assures that duplication of services does not occur.

  • Staff must be trained and staffing levels must be sufficient to meet resident needs. The state does not set minimum staffing levels or required training hours. Staff at an adjacent care facility can provide coverage, as long as they are available to provide care on short notice. The average staffing ratio in RCACs is one caregiving staff for 12 residents. Sixty-two percent of staff are certified nursing assistants, and employee turnover is 31 percent per year.

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