7 Things Assisted Living Administrators Should Know about Medicaid

Resumen
From which states? Medicaid programs offer funding to how many people receive it, how long a Medicaid application takes to prepare and how long to receive a determination, denials and retroactive benefits, these are things assisted living administrators should know about Medicaid for their residents, even if their community is not Medicaid-certified.

1) 46 states offer some form of funding for care services in assisted living, but there is no consistency across these states. The type of Medicaid program, eligibility criteria, reimbursement rates, wait-lists policies, and even the names vary dramatically from state to state.

Assisted living services are most commonly provided via 1915(c) Home and Community Based Services (HCBS) Medicaid Waivers. These programs can limit participation to state residents in select geographic regions and / or limit participation to specific groups, such as those with Alzheimer?s disease and related dementias. HCBS Waiver programs are not an entitlement; the number of program participants are capped and extensive waiting lists can, and do, exist in some states. While some states have more than one HCBS Medicaid Waiver, others have none. In states that offer HCBS Medicaid Waivers, not all programs cover assisted living services. Further complicating matters, HCBS Waiver program names are state and program-specific. Assisted living services may also be provided under 1115 Demonstration Waivers or Managed Care Waivers, which also have state-specific names, and could potentially have waiting lists.

Another avenue through which states provide personal care assistance in assisted living is under their Medicaid State Plan or a Medicaid State Plan Option. Services provided under the State Plan are generally an entitlement; there is no waiting list for assistance.

Some states only provide assisted living services via their Medicaid State Plan, some only through Medicaid Waivers, and others through both avenues.

AL, KY, LA & VA either do not currently offer funding or their programs are unknown.

This list has been compiled by us at Eldercare Resource Planning. It is possible some programs have been missed or very recent rules changes have impacted Medicaid benefits. This table may not be reproduced without written permission from Eldercare Resource Planning.

State Medicaid Programs Providing Funding in Assisted Living ? Updated Jul. 2023
State	Medicaid Program Name & Type	Entitlement?
Alabama	AL Medicaid does not pay for assisted living services.	N/A
Alaska	Alaskans Living Independently (ALI Waiver) ? 1915(c) HCBS Waiver	No
Arizona	Arizona Long Term Care System (ALTCS) ? 1115 Demonstration Waiver (managed care program)	Sí
Arkansas	1. State Plan Personal Care ? State Plan Medicaid 2. Living Choices Assisted Living Waiver ? 1915(c) HCBS Waiver	1. Yes 2. No
California	Assisted Living Waiver (ALW) ? 1915(c) HCBS Waiver	No
Colorado	Elderly, Blind, and Disabled Waiver (EBD Waiver) ? 1915(c) HCBS Waiver	No
Connecticut	Connecticut Home Care Program for Elders (CHCPE) ? there are two Medicaid-funded categories ? 1915(c) HCBS Waiver & 1915(i) State Plan HCBS Benefit	Not necessarily. Participant slots may be limited, or funding may run out.
Delaware	Diamond State Health Plan ? Plus Program (DSHP-Plus) ?1115 Demonstration Waiver (managed care program)	Sí
Distrito de Columbia	Elderly and Persons with Physical Disabilities Waiver (EPD Waiver) ? 1915(c) HCBS Waiver	No
Florida	Statewide Medicaid Managed Care Long-Term Care (SMMC-LTC) ? 1915(c) HCBS Waiver / 1915(b) Managed Care Waiver	No
Georgia	Community Care Services Program (CCSP) & Services Options Using Resources in Community Environments (SOURCE) ? both programs are under the Elderly & Disabled Waiver ? 1915(c) HCBS Waiver	No
Hawai	QUEST Integration Home ? 1115 Demonstration Waiver (managed care program)	Not necessarily. Participant slots may be limited.
Idaho	1. Aged and Disabled Waiver (A&D Waiver) ? 1915(c) HCBS Waiver 2. State Plan Personal Care Services ? State Plan Medicaid	1. No 2. Yes
Illinois	Supportive Living Program ? 1915(c) HCBS Waiver	No
Indiana	1. Aged and Disabled Waiver (A&D Waiver) ? 1915(c) HCBS Waiver 2. Traumatic Brain Injury Waiver ? 1915(c) HCBS Waiver	1. No 2. No
Iowa	Elderly Waiver ? 1915(c) HCBS Waiver	No
Kansas	Frail Elderly Waiver (FE Waiver) ? 1915(c) HCBS Waiver	No
Kentucky	KY Medicaid does not pay for assisted living services	N/A
Luisiana	LA Medicaid does not pay for assisted living services	N/A
Maine	Medicaid Long Term Care Program	Currently unknown and under investigation
Maryland	Community Options Waiver ? 1915(c) HCBS Waiver	No
Massachusetts	1. Group Adult Foster Care Program (GAFC) ? State Plan Medicaid 2. Moving Forward Plan ? Residential Supports Waiver (MFP-RS) ? 1915(c) HCBS Waiver	1. Yes 2. No
Michigan	1. MI Choice Waiver ? 1915(c) HCBS Waiver 2. MI Health Link HCBS Waiver ? 1915(c) HCBS Waiver	1. No 2. No
Minnesota	Elderly Waiver (EW) ? 1915(c) HCBS Waiver	No
Misisipí	Assisted Living Waiver (AL) ? 1915(c) HCBS Waiver	No
Misuri	1. Medicaid State Plan Personal Care 2. AIDS Waiver (for persons with HIV / AIDS) ? 1915(c) HCBS Waiver	1. Yes 2. No
Montana	Big Sky Waiver (BSW) ? 1915(c) HCBS Waiver	No
Nebraska	1. Aged and Disabled Waiver (AD Waiver) ? 1915(c) HCBS Waiver 2. Traumatic Brain Injury Waiver (for persons 18-64 years old with a traumatic brain injury ? 1915(c) HCBS Waiver	1. No 2. No
Nevada	1. Waiver for the Frail Elderly (FE) ? 1915(c) HCBS Waiver 2. Waiver for Persons with Physical Disabilities ? 1915(c) Waiver (must have a primary diagnosis of a physical disability)	1. No 2. No
nuevo hampshire	Choices for Independence Waiver (CFI) ? 1915(c) HCBS Waiver	No
New Jersey	Managed Long Term Services and Supports Program (MLTSS) – part of 1115 Demonstration Waiver	Sí
Nuevo Mexico	Community Benefit Program (CB) – part of 1115 Demonstration Waiver (managed care)	Not necessarily. Participant slots may be limited.
Nueva York	Assisted Living Program ?State Plan Medicaid	No. The number of beds are limited.
Carolina del Norte	Personal Care Services Program ? State Plan Medicaid	Sí
Dakota del Norte	1. Medicaid Waiver for Home and Community Based Services (may also informally be called the Aged and Disabled Waiver and provides assisted living services for persons with dementia or brain injuries) ? 1915(c) HCBS Waiver 2. Medicaid State Plan Personal Care	1. No 2. Yes
Ohio	1. Assisted Living Waiver ? 1915(c) HCBS Waiver 2. MyCare Ohio (also called Integrated Care Delivery System Waiver) ? 1915(b) Managed Care Waiver / 1915(c) HCBS Waiver	1. No 2. No
Oklahoma	ADvantage Waiver Program ? 1915(c) HCBS Waiver	No
Oregón	Community First Choice State Plan Option	Sí
Pensilvania	Community HealthChoices (CHC) ? 1915(b) Managed Care Waiver / 1915(c) HCBS Waiver	No
Rhode Island	Medicaid Long-Term Services and Supports (Medicaid LTSS) ? operates under an 1115 Demonstration Waiver called the Rhode Island Comprehensive Demonstration	Not necessarily. Participant slots may be limited.
Carolina del Sur	Community Choices Waiver ? 1915(c) HCBS Waiver	No
Dakota del Sur	Home & Community Based Options and Person Centered Excellence Waiver (HOPE Waiver) ? 1915(c) HCBS Waiver	No
Tennesse	TennCare CHOICES – part of 1115 Demonstration Waiver (managed care program)	No
Texas	STAR+PLUS HCBS (managed care) – part of 1115 Demonstration Waiver	No
Utah	1. New Choices Waiver ? 1915(c) HCBS Waiver 2. State Plan Personal Care Services ? State Plan Medicaid	1. No 2. Yes
Vermont	1. Choices for Care Program – part of 1115 Demonstration Waiver 2. Assistive Community Care Services ? State Plan Medicaid	1. Not necessarily. Participant slots may be limited. 2. Yes
Virginia	Currently unknown and under investigation	N/A
Washington	1. Medicaid Personal Care Program ? State Plan Medicaid 2. Specialized Dementia Care Program (SPCP) ? 1915(k) State Plan Amendment 3. Community Options Program Entry System Waiver (COPES Waiver) ? 1915(c) HCBS Waiver	1. Yes 2. No 3. No
Virginia del Oeste	Medicaid Personal Care Services Program ? State Plan Medicaid ? via this program a third party vendor can potentially provide personal care services, but services provided by the assisted living facility cannot be duplicated.	Sí
Wisconsin	1. Family Care Program / Family Care Partnership Program ? Managed Care Waiver Program 3. IRIS (Include, Respect, I Self-Direct) Waiver ? 1915(c) HCBS Waiver	1. Yes 2. No
Wyoming	Community Choices Waiver (CCW) ? 1915(c) HCBS Waiver	No

2) Nationwide 18% of assisted living residents receive Medicaid-funded services, but this percentage varies by state from a low of 0% in Louisiana to a high of 66% in Connecticut.

The 5 states with the highest percentage of residents receiving Medicaid-funded assistance are:
1) Connecticut – 66%
2) Maine – 50%
3) Alaska – 49%
4) Oregon – 47%
5) North Carolina – 43%

The 5 states with the lowest percentage of residents receiving Medicaid-funded assistance are:
1) Louisiana – 0%
2) Alabama – 1%
3) California – 2%
4) Pennsylvania -2%
5) West Virginia – 2%

Other large populations states of note include:
1) Texas – 8%
2) Florida – 24%
3) New York – 38%

State Medicaid Programs for Assisted Living and the Percentage of Residents Receiving Assistance
States	% of AL Residents Receiving Medicaid Funding	States Alphabetically	% of AL Residents Receiving Medicaid Funding
Connecticut	66%	Alabama*	1%
Maine	50%	Alaska	49%
Alaska	49%	Arizona	22%
Oregón	47%	Arkansas	22%
Carolina del Norte	43%	California	2%
Nueva York	38%	Colorado	27%
Illinois	34%	Connecticut	66%
Vermont	31%	Delaware	8%
Idaho	30%	Distrito de Columbia	9%
Dakota del Norte	30%	Florida	24%
Kansas	28%	Georgia	8%
Washington	28%	Hawai	7%
Colorado	27%	Idaho	30%
Indiana	27%	Illinois	34%
New Jersey	25%	Indiana	27%
Florida	24%	Iowa	11%
Nebraska	24%	Kansas	28%
Rhode Island	23%	Kentucky*	7%
Dakota del Sur	23%	Louisiana*	0%
Arizona	22%	Maine	50%
Arkansas	22%	Maryland	9%
Minnesota	22%	Massachusetts	12%
Montana	22%	Michigan	9%
Utah	22%	Minnesota	22%
Wisconsin	22%	Misisipí	7%
Wyoming	20%	Misuri	16%
Carolina del Sur	17%	Montana	22%
Misuri	16%	Nebraska	24%
nuevo hampshire	15%	Nevada	8%
Nuevo Mexico	14%	nuevo hampshire	15%
Massachusetts	12%	New Jersey	25%
Ohio	12%	Nuevo Mexico	14%
Iowa	11%	Nueva York	38%
Distrito de Columbia	9%	Carolina del Norte	43%
Maryland	9%	Dakota del Norte	30%
Michigan	9%	Ohio	12%
Delaware	8%	Oklahoma	5%
Georgia	8%	Oregón	47%
Nevada	8%	Pensilvania	2%
Texas	8%	Rhode Island	23%
Hawai	7%	Carolina del Sur	17%
Kentucky*	7%	Dakota del Sur	23%
Misisipí	7%	Tennesse	6%
Tennesse	6%	Texas	8%
Oklahoma	5%	Utah	22%
Virginia*	4%	Vermont	31%
California	2%	Virginia*	4%
Pensilvania	2%	Washington	28%
Virginia del Oeste	2%	Virginia del Oeste	2%
Alabama*	1%	Wisconsin	22%
Louisiana*	0%	Wyoming	20%

3) While federal law prohibits Medicaid from paying for room & board in assisted living, there are 3 ways states make this cost more affordable for Medicaid recipients.

Capping Room & Board Fee
Some states cap the amount a Medicaid-certified Assisted Living Facility can charge a Medicaid-recipient for room and board. In many states, this limit is the current SSI Federal Benefit Rate (FBR), which is $914 / month, minus a state-specific Personal Needs Allowance. Ohio?s Assisted Living Waiver Program is one such example. The room and board payment is capped at $864 / month ($914 – $50 PNA). Another example is Assisted Living Services via Texas? STAR+PLUS HCBS program, which has a room and board cap of $829 ($914 – $85 PNA). For Colorado?s Elderly, Blind, and Disabled Waiver, the room and board cap is $755 ($914 – $159 PNA).

Increasing SSI with Optional State Supplements
Forty-two states and the District of Columbia provide an Optional State Supplement (OSS) to ?supplement? one?s federal SSI payment. (Arizona, Arkansas, Mississippi, North Dakota, Tennessee, and West Virginia do not). The State Supplementary Payments help to cover state-specific differences in costs of living that SSI does not take into account. The maximum OSS amount is state-specific and sometimes varies based on one?s living situation. Unfortunately, not all states that provide OSS make it available to persons in Assisted Living. In those that do, persons in Assisted Living often receive the highest OSS payment. This can help cover room and board costs, and sometimes also helps to cover care services. OSS payments can vary from approximately $10 / month to $700 / month.

As an example, CA provides a maximum SSI + OSS payment (Non-Medical Out-of-Home Rate) of $1,492.82 / month for individuals residing in Assisted Living. For persons receiving assistance via California?s Assisted Living Waiver, room and board costs are limited to a state-set SSI facility rate, which is $1,324.82 / month. This amount is the SSI + OSS payment amount minus a Personal Needs Allowance of $168 / month ($1,492.82 – $168 = $1,324.82).

Family Supplementation
Most, but not all, states allow for ?family supplementation?. This allows a relative or friend to pay for room and board of the Medicaid beneficiary at the Assisted Living residence. This payment is not counted as income to the Medicaid beneficiary and therefore they are not disqualified from Medicaid for having income over the Medicaid limit.

4) Preparing for a Medicaid application (not waiting for an approval) takes an average of 79 days.

Based on an analysis of more than 500 Medicaid cases, Eldercare Resource Planning has found that it takes an average of 79 days to submit a client?s completed long-term care Medicaid application with supportive documentation. This period begins the day the Medicaid planner is hired and ends the day the application is submitted.

For persons who are not working with a Medicaid Planning Professional, it can take much longer than 79 days to apply. A significant amount of documentation is required and it can be overwhelming as to what exactly is required and how to obtain it. Examples of required documents might include one?s birth certificate, marriage certificate, Social Security card, Medicare card, proof of income, copies of property deeds, recent property tax bills, copies of health insurance cards, burial space statements, copies of trust documents, and title or vehicle registrations. Furthermore, due to Medicaid?s Look-Back Period, financial documentation may have to be provided for the last 5 years, including documentation of any sales of homes, cars, motorcycles, etc. If an adult child or another relative is applying on behalf of their loved one, they might first have to get power of attorney before requesting documentation. Inexperienced persons navigating the Medicaid application process without the assistance of an experienced Medicaid Planner can expect delays in the Medicaid application process.

5) Receiving a Medicaid determination (waiting for an approval or denial) takes an average of 83 days despite the federal law that gives Medicaid agencies 45 days to respond.

Federal law gives Medicaid agencies 45 days (90 days for persons who apply on the basis of disability) to approve or deny one?s Medicaid application. However, based on Eldercare Resource Planning?s analysis, it takes an average of 83 days for a Medicaid agency to make a determination. This period begins the day one?s Medicaid application is submitted and ends the day the client receives their determination notice.

If one is approved for benefits, benefits may start immediately. In some cases, there may be a waiting list for assisted living services. Recall that these benefits are often provided via HCBS Medicaid Waivers, which limit the number of participant slots. In some states, this wait can be years.

6) Incorrect Medicaid denials are surprisingly common. Denied applications, regardless of who?s at fault, can add months to the process.

Based on Eldercare Resource Planning?s analysis, well over 50% of first-time applicants are either denied Medicaid eligibility incorrectly or have errors in the calculations of their spousal supports (their Monthly Maintenance Needs Allowance or their Community Spouse Resource Allowance). The reasons for incorrect denials are varied and include mathematical errors, unrealistic deadlines, automated systems, lost documentation, and Medicaid offices applying out-of-date eligibility criteria.

Actions following a denial include diplomatically highlighting an error and informally asking for a case reversal. If this doesn?t work, an appeal could be filed, a hearing date set, followed by a hearing.

With so many first-time Medicaid applicant denials, the application process can become much longer than the 162 day average (79 days to prepare + 83 days to receive a determination).

7) Assisted living administrators should not count on Retroactive Medicaid to cover payment gaps during the Medicaid application process.

Retroactive Medicaid allows Medicaid-eligible persons to receive Medicaid coverage for up to 3 months prior to the date of Medicaid application if they were also Medicaid-eligible during the retroactive period. However, relevant to Assisted Living, federal law prohibits retroactive coverage of home and community based services, and states that these services cannot be covered until the date a service plan has been approved. That said, some states may still allow for retroactive coverage for some HCBS Waivers, but administrators should not count on this coverage especially given the further challenges in obtaining retroactive coverage. Furthermore, other states have eliminated or restricted Retroactive Medicaid on the whole utilizing 1115 Demonstration Waivers. As an example, Florida, only offers 3-month retroactive coverage to pregnant women and children under 21.