Content by Keyword: Aging and Elderly

Several states have adopted payment systems based on their nursing home case-mix methodology. Like tiered rate approaches, the case-mix approach creates incentives to serve more impaired residents by linking reimbursement to the LOC needed. Case-mix approaches typically have more categories that tiered rates. The case-mix approach requires the col

Tiered rates have been developed to more accurately and fairly reimburse providers for services provided to frailer residents. Tiered systems usually include 3-5 tiers based on the type, number, and severity of ADL limitations and/or cognitive or behavioral impairments, and create incentives for providers to serve residents with higher service nee

States may vary its flat rates for different types of residential care settings. Texas pays a higher rate for apartment and other private occupancy settings, reflecting the state’s preference for these settings. Varying rates by setting may reflect differences in the average level of resident service needs in each setting. For example, a state m

Under a flat rate system, providers receive the same monthly payment regardless of the amount of services and staff assistance a resident requires. As in the health care system, flat rates for residential care create incentives for facilities to admit residents with lighter care needs, rather than those with multiple impairments in ADLs, cognitive

The extent to which low income older people have access to residential care settings as an alternative to nursing homes depends in large part on the extent to which states use Medicaid to cover services in these settings, and providers’ views on the adequacy of Medicaid’s service reimbursement rates. In addition to the amount of the payment, t

Some states may not determine eligibility for services until financial eligibility has been determined, a process that can take up to 45 days or longer if further documentation of income or assets is needed. An extended time frame for determining Medicaid eligibility can be a major deterrent to participation in the Medicaid program, because provid

About half of the states limit the amount that facilities can charge Medicaid beneficiaries for room and board -- usually to an amount equal to the federal SSI payment plus a state supplement (if offered). Others do not restrict the amount that can be charged, but providers need to understand their states’ income-eligibility rules and cost shar

Some states have long waiting lists for waiver services, which can present a significant obstacle to serving Medicaid beneficiaries in assisted living. If waiver slots are not available, Medicaid eligible persons who cannot be served at home will need to enter a nursing home (if they meet the state’s nursing home LOC criteria) and the ALF will h

As discussed earlier, states can cover services in residential care settings through a waiver program that provides services in the full range of home and community settings, or through a waiver that covers services only in residential care settings. The type of waiver can affect the pattern of referrals. States that include assisted living as on

State plan services are an entitlement and all beneficiaries who meet the service requirements must be served. Personal care is the most common service covered in residential care settings under the state plan. States that do not already cover personal care through their state plan have been reluctant to add it because it is an entitlement and ser

States have the option of covering medically needy beneficiaries under their Medicaid programs. The medically needy are persons who, except for income, would qualify in one of the other Medicaid eligibility categories (such as being over age 65 or meeting SSI disability criteria). Medicaid payments can begin for this group once they have “spent

The use of food stamps to pay for meals subsidizes the board component of the room and board cost, making it more affordable for Medicaid beneficiaries and others with low incomes. USDA regulations allow meals provided in certain group living arrangements to elderly, blind, or disabled residents to be supported by food stamps (7 CFR §271.2). Grou

Family members may be able and willing to help with room and board costs when the beneficiary is unable to pay them. States set their own rules governing family supplementation. As presented in Table 1-12, 25 states reported that they allow family supplementation, 12 states do not allow supplementation, and eight states have no policy. The rema

States have the option to use more liberal income-eligibility criteria for the waiver program -- up to 300 percent of the federal SSI payment -- ($1,869 per month in 2007). This option is attractive for waiver programs that cover services in residential care settings, because it expands the program to include beneficiaries who are better able to a

Many states are exploring ways to combine Medicaid funding and subsidized housing to develop residential care options for low income persons. Housing subsidies can reduce housing costs for Medicaid beneficiaries and other low income persons, and are available through a number of programs:

To increase access for SSI beneficiaries in areas with high development costs, states can create a special SSI state supplement for persons in residential care facilities and limit what providers may charge to the amount of the federal payment plus the state supplement. 28  Many states have such State Supplemental Payment (SSP) programs to su

HUD’s housing subsidy rules do not allow residential care settings to impose an additional charge for rent and utilities, but they can charge the resident for board (i.e., meal costs), or for services that are not covered by the Medicaid state plan or waiver program in a residential care setting. The amount of the permitted meal charge depends o

States can limit the amount that can be charged for room and board by setting a combined “rate” for Medicaid beneficiaries that includes service costs and room and board costs, but the state only pays for services. This approach essentially caps the room and board rate that Medicaid beneficiaries pay. Other states simply limit by policy the am

Medicaid beneficiaries with limited income may not be able to pay residential care facilities’ room and board rates. As noted earlier, Medicaid pays for room and board only in institutions, except in limited circumstances such as for the provision of respite care and for meals served as part of a day care program. For Medicaid purposes, room and