Friday, October 15, 2010

Paying for Assisted Living: Pennsylvania to follow Indiana model

Paying for Assisted Living: Pennsylvania to follow Indiana model


By Jeffrey A. Marshall, CELA*


Like most states, Pennsylvania provides a continuum of support services that allow frail seniors to remain in the community rather than a nursing home.  These services range from limited, such as home delivered meals, to much more intense in-home services for individuals needing higher levels of care.  


Providing seniors with home and community-based care has become accepted as a cost effective alternative to nursing facility care.  In addition to purportedly saving the Government money, providing care in the home and community is seen as promoting independence and self-reliance, and maximizing opportunities for family and community involvement.  It is also consistent with surveys of consumer preferences and with a 1999 United States Supreme Court decision in Olmstead v. LC which held that unnecessary institutionalization constitutes illegal discrimination based on disability. 


A major funding source states use to pay for long term care for seniors is the federal/state Medicaid program. Services for seniors who do not meet Medicaid’s strict financial and clinical eligibility requirements are funded through other revenue sources such as the lottery and state general revenues.  Individuals may be required to contribute towards the cost of these services.


But there is a serious gap in the continuum of care that Pennsylvania has been providing to keep frail seniors out of the nursing home. In Pennsylvania, Medicaid funding cannot be used to pay for the cost of care in an assisted living facility. This means that some individuals who could have been accommodated in an assisted living setting if they received some limited financial assistance from Medicaid have been forced into higher cost skilled nursing facilities. The Government pays more each month and the senior is institutionalized.  Not a good result, but one that is sometimes required because currently Medicaid pays for care in a skilled nursing home but not in assisted living.  


Overcoming this “institutional bias” has been a stated goal of the Rendell Administration and I anticipate it will receive continued support from whoever becomes Pennsylvania’s next Governor.  Pennsylvania is moving slowly but steadily towards providing Medicaid funding for some assisted living residents with higher needs.  It appears that funding may begin in 2011.  We are now beginning to get some idea of the criteria that will be used to determine whether a resident of an assisted living residence can qualify for Medicaid. 


First a little background. Currently assisted living facilities in Pennsylvania are classified as personal care homes. They are barred from accepting residents who need the more intense level of care required for Medicaid to pay for that care. 


In 2007 Pennsylvania enacted a law, Act 56, to create a new classification of assisted living providers that will be able to accept individuals with higher care needs and who can thus meet Medicaid’s clinical eligibility standards. Unlike personal care homes, this new Assisted Living Residence (ALR) provider class will be able to deliver some health care services to their residents. ALRs are intended to have more of a private home-like feel than a nursing facility, including such amenities as separate bedrooms and baths and kitchen facilities and provide consumers will more direct control over their care.


Act 56 directed the Department of Public Welfare (DPW) to develop regulations for ALRs. This complex and contentious task required DPW to regulate in a manner that would entice facilities to apply for the designation while providing reasonable protections of consumer interests.  Earlier this year, DPW promulgated final regulations and the Department is moving forward to seek a waiver from the federal government so that Medicaid funding can be used to help pay the cost of care for some ALR residents. Much more information on these controversial regulations, including comments from stakeholders, is available through the Pennsylvania Independent Regulatory Review Commission website.


A federal waiver is required because most of the money comes from the federal government. In 1981, Congress enacted section 1915(c) of the Social Security Act, which provides states with a Medicaid financed alternative to institution-based care. Congress recognized that many individuals who would otherwise be institutionalized could be cared for in their own homes and communities at lower cost. In 1981 it authorized the creation of Home and Community-based Services Waiver programs. One requirement is that waiver services costs are no higher than that of institutional care. In the intervening years, Pennsylvania has utilized Medicaid Waiver funding to cover a range of services and supports needed by people to remain in the community.


Currently, DPW is in the process of preparing a Waiver application for filing with the federal government to cover ALR services.  There is every reason to assume that this application will be approved, although the feds often require changes to Pennsylvania’s waiver proposals. Once approved, federal dollars will become available to support qualified residents of Pennsylvania’s new class of Assisted Living Residences.


At its Medical Assistance Advisory Committee Long Term Care Subcommittee meeting last week DPW announced that it is using the Indiana Assisted Living Assisted Living Waiver as a model for Pennsylvania’s application.  Potential Assisted Living Residence providers and their residents may wish to review the Indiana regulations to get a preview of how Pennsylvania’s program will work.  It remains to be seen how successful this new program will be in serving frail seniors.  Once the Waiver is approved, consumers should discuss qualification with a certified elder law attorney.


Many thanks to Marielle Hazen, CELA,* for updating me on the discussions at the recent MAAC subcommittee meeting on this issue. 


*Certified as an Elder Law Attorney by the National Elder Law Foundation

1 comment:

Rimme Wiker said...

Hello all,

Assisted living is for adults who need help with everyday tasks. They may need help with dressing, bathing, eating, or using the bathroom, but they don't need full-time nursing care. Some assisted living facilities are part of retirement communities. Others are near nursing homes, so a person can move easily if needs change. Thanks for sharing it.......

Assisted Living Seattle WA