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

12/01/2003

Medicaid

  • Personal, supportive and nursing services provided in RCACs are reimbursable through Wisconsin's HCBS waiver program. Waiver funds pay for services appropriate for the individual participant. However, most counties have long waiting lists for their waiver program and in some cases the wait can be from one to three years or more. There are approximately 9,000 people on waiting lists for waiver services in Wisconsin. No waiver slots are dedicated for use in RCACs or any other facilities.

  • All counties administer the Medicaid HCBS waiver program but they are not required to use waiver funds for RCAC services.

  • Although the maximum waiver reimbursement is 85 percent of Medicaid nursing home costs, the Wisconsin HCBS waiver program provides counties with a budget and counties generally do not reimburse to the maximum, because doing so enables them to provide services to more people.

  • RCAC residents eligible for Medicaid may be eligible for personal care, home health, therapies, and disposable medical supplies and any other benefit under the state plan.12

Family Care

Wisconsin's pilot program to redesign long term care financing pays for RCAC services provided to enrollees in the five participating counties. Family Care pays for services in RCACs only in pilot counties where there is a care management organization (CMO) and when the facility is included in the CMO's provider network.

Food Stamps

Persons who live in group community living arrangements such as RCACs, which house no more than 16 persons can receive food stamps if they are either blind or disabled and meet the program's financial eligibility criteria.

Requirements and Funding Sources for Residential Care Facilities in Wisconsin
Facility Type Who Regulates Size and Care Limits Available Funding Sources
Adult Family Home (AFH)
  • County certifies homes for 1 or 2 residents
  • State licenses homes for 3 or 4 residents
  • Standards for certified and for licensed homes are different. Certification or license required for COP or MA Waiver funding
  • Maximum nursing care: 7 hrs. per resident per week in 3-4 bed AFHs. No limit on personal care.
  • Sponsor may arrange but not provide nursing care in 1-2 bed AFHs. No limit on personal care.
  • Private income and/or assets, SSI, SSI-E & insurance
  • Community Options Program (COP)
  • Community Integration Program (CIP) IA and IB
  • COP-W and CIP II / Brain Injury Waiver (BIW)
  • MA card, when service is provided by an MA-certified provider (e.g., home health or personal care agency). AFHs are not an MA provider type under the MA state plan and cannot bill MA directly.
  • Family Care & County funds/Community Aids
Community Based Residential Facility (CBRF)
  • State licenses facilities
  • Minimum # resident "beds": 5
  • No maximum # of "beds"
  • Minimum sleeping room size: 60-100 sq. ft. per resident
  • Max. amount nursing care: 3 hours/resident/week. Residents with temporary conditions may receive more than 3 hrs. of nursing care/week for up to 90 days or longer with DHFS approval.
  • No limit on personal or supportive care
  • Private income and/or assets, SSI and insurance
  • SSI-E (Exceptional Expense Supplement) in CBRFs with 20 or fewer beds and/or certified as independent apartment CBRFs
  • COP and COP-W/CIP II in CBRFs with < 20 beds and in CBRFs with over 20 beds when facility is a certified independent apartment CBRF or has DHFS approval.
  • CIP IA/IB and BIW: only when variance has been granted and CBRF has 8 or fewer beds.
  • MA card, when the service is provided by a MA-certified provider (e.g., HH or PC agency). CBRFs are not an MA provider type under the MA state plan and cannot bill MA directly. The MA card cannot be used for personal care in CBRFs with >20 beds.
  • Family Care & County funds/Community Aids
Residential Care Apartment Complex (RCAC)
  • State registration or certification is required.
  • Facilities serving only private pay residents are registered. Certification is needed for a facility to receive MA Waiver reimbursement. Standards are the same for both; the regulatory process and level of oversight differ
  • Minimum # units: 5
  • No maximum # units
  • Units must be apartments with full private bath and full kitchen
  • Min. unit size: 250 sq. ft., excluding closets
  • Max. amount of care: 28 hours/resident/week of personal, supportive and nursing services combined.
  • Private income and/or assets, SSI, and insurance.
  • SSI-E in Certified RCACs
  • COP-W and CIP II in certified facilities
  • Family Care
  • MA card, when service is provided by an MA certified provider (e.g., HH or PC agency). RCACs are not a provider under the state plan & cannot bill MA directly.
  • County funds (not including Community Aids)
  • Note: COP funds may not be used to supplement Waiver funds or pay room and board costs.

12. Some facilities have an arrangement with a Medicaid-certified home health or personal care agency to either (1) provide and bill Medicaid for these services or (2) "lease" their staff to the Medicaid-certified agency in order to be able to bill Medicaid. In 2001, eight percent of waiver recipients living in RCACs had personal care services billed to the Medicaid card (state plan), averaging $367/month. The state does not have comparable data for CBRF or AFH residents at this time.

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