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Robert L. Mollica

Medicaid and Assisted Living. Robert L. Mollica. October, 2002. Demand factors. Population growth Declining nursing home occupancy rates Shifting balance from NFs to residential and in-home settings Medicaid nursing home transition grants. Perspectives. Lenders/investors

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Robert L. Mollica

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  1. Medicaid and Assisted Living Robert L. Mollica October, 2002

  2. Demand factors • Population growth • Declining nursing home occupancy rates • Shifting balance from NFs to residential and in-home settings • Medicaid nursing home transition grants

  3. Perspectives • Lenders/investors • Developer/manager • State licensing agency • State Medicaid • Consumers/family/advocates • Local service delivery system

  4. The Perfect Storm? • Target population: “light” care • Continuous or intermittent nursing care requirement • Is Medicaid rate adequate, reliable? • State Medicaid: nursing home alternative, cost effective • Consumer expectations: Aging-in-place and “Olmstead” decision

  5. Low income coverage • 41 states cover under Medicaid and/or state funds • 4 states planning/discussing coverage (AL, CA, KY, LA) • 3 states making grants to convert nursing homes

  6. Medicaid considerations • State plan or waiver coverage • Waiver level of care criteria • Assisted living or broader waiver • Room and board cap? • Rate methodology • Service only or service and room and board

  7. Medicaid issues... • Temporary absences • Family supplementation • Eligibility process - “fast track” • Nursing homes relocation programs a priority

  8. Medicaid coverage for assisted living

  9. Source of coverage: Medicaid and state revenues WaiverAK IL NDAZ KS ORCO MD PACT MN RIDE MS SDFL MT TXGA NE UTHI NV VT*IA NH WAID* NJ WIIN NM WY State PlanState $ AR CT FL ME* ME MD MA MN MI* ND* MO SD* NY NC SC VT* Planned AL CA DC KY LA * Multiple sources CT under pending pilot program

  10. Making the case • Reduce Medicaid NF growth trend line NF reliance $$ Broad menu Time

  11. Public subsidy issues/options • SSI • Room and board only, or • Room and board and personal care services • Medicaid service options • Regular Medicaid state plan • 1915 (a) state plan amendment • Waiver approaches • HCBS Waiver - 1915 (c) • Managed care - 1115

  12. Medicaid state plan coverage • Cannot cover room and board • States cannot readily control spending • Entitlement program but may control provider type (FL, SC plan amendment) • Eligibility is based on need for a service • Available statewide - amount, scope, duration

  13. Medicaid waiver coverage • Cannot pay for room and board • No entitlement - can control spending • Can serve residents with income < $1,635/month ($19,620 annual) • Services include meal preparation and serving costs • Must meet nursing home level of care • Waive amount, scope, duration

  14. Rate issues • Some states include room and board paid by the resident in the rate • May be limited to SSI beneficiaries • Most cover Medicaid services only • R&B for SSI beneficiaries set by state policy • State SSI supplements may cover some personal care

  15. Cover R&B under Medicaid? • Requires change in statute • Basis in nursing home reimbursement • Weakens non-institutional preference • Shifts costs from Federal SSI to states • SSI benefit: personal needs allowance only • Likelihood of raising rates????

  16. Illinois • Pilot project • New licensing law does not allow Medicaid payments in licensed facilities outside of pilot • Regional payments: $45.54 - $61.94per day (2002) • Room and board: $455 ($90 PNA) • Food stamps: $96

  17. Chicago $61.941 Northwest $53.90 West/central $47.54 Central $51.05 St. Louis region $50.75 South suburban $59.11 South $45.54 Regional rates/day (2002) Rate increases tied to average nursing home rate increase

  18. Oregon (2002) Level Service R&B Total 5 $1840.46 $446.70 $2287.16 4 $1490.76 $446.70 $1937.46 3 $1139.93 $446.70 $1587.63 2 $ 861.74 $446.70 $1308.44 1 $ 651.69 $446.70 $1098.39

  19. Oregon... Level Impairment 5 Depend in 4-6 ADLs or dependent in behavior & 1-2 other ADLs 4 1-2 ADLs or assistance in 4-6 ADLs + behavior 3 Assist w/4-6 ADLs or assist w/toileting, eating & behavior 2 Assist w/behavior AND eating or toileting 1 Assist in 2 critical ADLs or any 3 ADLs or assist w/1 critical and 1 other ADL

  20. Washington 9/1/02 Level 1 Level 2 Level 3 King county $65.87 $73.36 $81.30 Metro counties $60.74 $67.l31 $74.29 Non-metro $59.52 $65.82 $72.22

  21. Family supplementation • Allowed in 19 states • Prohibited in 7 states • No policy - 4 states • Considered unearned income for SSI • Should be paid to facility rather than beneficiary • Federal SSI benefit reduced one-third

  22. Future issues.... • Quality assurance and outcome approaches • National or state standards • Aging in place challenge • Adequacy of Medicaid rates • Affordability and access • Housing subsidy and Medicaid linkages

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