Using Medicaid to Cover Services for Elderly Persons in Residential Care Settings: State Policy Maker and Stakeholder Views in Six States. Suggested Changes to Improve the Medicaid-Funded Residential Care System


A few respondents did not make specific suggestions about Medicaid, but instead noted that there were general areas that the state needed to pay more attention to.

  • With increased emphasis on aging in place, more attention to quality might be needed in ALFs. There have been some reports that the quality issues in ALFs--regarding food, activities, and staffing--are similar to those in nursing homes.

Others had very specific recommendations.

  • CBA waiver cost-neutrality should be determined on an aggregate rather than individual basis. Therefore, if one individual's cost for remaining in the community in an integrated setting was higher than the nursing home payment, that individual could remain eligible because overall cost neutrality would be upheld.

  • More education is needed for discharge planners so they will present the full range of options for living in an integrated community setting. While assisted living services should be part of the CBA waiver program, they should be alternatives to nursing homes, not the wing of a nursing home.

  • More staff are needed in ALFs. Greater attention to quality and oversight is given to nursing homes than assisted living facilities due to resource constraints and the need to give priority to clients in higher levels of care.

  • The state needs to improve the screening process to make sure that clients are set up for the most appropriate services based on their needs. It also needs to increase coordination to support a streamlined point of access into the CBA waiver program. Administrative and contracting processes should be simplified so that the grandmother seeking and receiving CBA waiver services and the child and mother seeking and receiving TANF assistance could go into the "same door" to seek and receive services.

  • The state needs to do a better job marketing and promoting the CBA waiver program to providers. It also needs to reduce the duplication of effort that results from multiple agencies being involved (licensing/regulation and CBA waiver program staff). The state could also be more flexible in its paperwork requirements. For example, the state requires hand-written ledger forms whereas a company may operate a computerized form. Similarly, the state requires a daily service delivery record whereas a company authorizes a service plan for each client that identifies the service and how many times a week it will be provided.

  • The state should develop an extensive comprehensive assessment process that all providers would use. Some providers do not know what they are looking for when conducting pre-admission assessments. This is more an issue for private pay clients, because for CBA waiver clients, the DHS managers and home health nurses are involved in the admission decision process with the providers.

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