Agency for Health Care Administration

Assisted Living Facilities

September 23, 2011

State & Local Government Roles & Responsibilities

Agency for Health Care Administration Licensure and Regulation Medicaid – Assisted Care Services, Various Waivers

Department of Children and Families Adult Protective Services Mental Health Clients in ALFs Specific Medicaid Waiver

Agency for Persons with Disabilities Developmentally Disabled Clients in ALFs

Attorney General Medicaid Fraud Control Patient Abuse, Neglect and Exploitation (PANE) Operation Spot Check

Health Department Health & Sanitation Inspections

State & Local Government Roles & Responsibilities

Department of Elder Affairs Rule Development for Assisted Living, Adult Family Care

Home, Adult Day Care, Hospice Comprehensive Assessment and Review of Long-Term

Care Services (CARES) Long-Term Care Ombudsman Program Statewide Public Guardianship Office Assisted Living Trainer Certification Specific Medicaid Waivers

Local Authorities (ALF) Fire Authority – Fire & Life Safety Approval Zoning / Building Code Approval &Enforcement

Assisted Living Growth

• 30% Increase in Assisted Living Facilities (ALF)

• 2,272 2003• 2,960 2011

• 80% Increase in ALFs with Limited Mental Health

• 30% Increase in Indigent Beds (Optional State Supplementation – OSS

• Over Half of ALF beds have Six or Fewer Beds

AHCA Inspections• Re-Licensure Surveys - Every Two Years• Monitor Visits

• Limited Nursing Services License - Twice/Year• Extended Congregate Care License - Quarterly

• Complaint Investigations• Prioritize Allegations• Investigate Based on Severity • Priority One – Investigate in Two Days• All Investigated on Average in 27 Days• 40% Find Deficiencies• Fee for Complaint Investigations with Deficiencies

Regulatory Oversight Revisions

• Statewide Complaint Training of Survey Staff

• Revised ALF Inspection Process

• Focus on Consistency

Revised Assisted Living Survey• Enhanced Focus on Residents• Concentration on Interviews, Observations, and Record

Review• Improve Consistency/ Revised Regulation (Tags) • Abbreviated Review as Authorized by Law

• Two Survey Periods (Four Years)• Consistent Ownership• Survey History• Licensure Complaint History• Ombudsman Complaint History

• Largely Based on Wisconsin Model

Abbreviated Survey• Focus on Resident and Family Feedback• Observations by the Surveyor• Record Reviews Based on Observations and Interviews• Concerns Identified Result in Expanded Sample

Selection up to Standard Survey

Regulatory Violations / Deficiencies

• Class I – Immediate danger or substantial probability that death or serious physician or emotional harm would result. Fine $5,000 to $10,000.

• Class II – Directly threaten the physical or emotional health, safety, or security of clients. Fine $1,000 to $5,000.

• Class III – Indirectly or potentially threaten physical or emotional health, safety or security of clients. Fine

• Class IV – related to maintenance of provider or required reports, forms, or documents that do not negatively affect clients

Regulatory Sanctions• Emergency Actions – Limited to Serious Ongoing Issues

(Imposed Before Due Process)

• Moratorium• Suspension

• Sanctions for Violations• Fines / Conditional Licenses• Denial of License Renewal or Initial Application• Revocation of License

• Closure During Litigation

• Due Process for Sanctions • Opportunity to Challenge• Agency Has Clear and Convincing Burden of Proof• Actions Pend During Litigation• Imposed by Final Order

• May Also Be Challenged• Court Can Enjoin Agency Imposition

Consumer Information and Outreach

• Florida Health Finder• Consumer Awareness Brochures• Outreach to Partners and Providers

• Regulators• Managed Care Plans• Health Care Providers

Outreach Activities• Interagency Staffing Meetings• Joint Training Activities Include Other Departments

• Provider Training• Staff Training

• Access to Systems and Data Used by Partners• Joint Visits With Partner Agencies

Medicaid Reimbursements in Assisted Living Facilities

Presented by

Darcy Abbott

AHC Administrator

Bureau of Medicaid Services

September 23, 2011

Assistive Care Services

•Medicaid state plan service provided in assisted living facilities (ALF), adult family-care homes (AFCH), and residential treatment facilities (RTF)•Population – Age 18+•Eligibility – Services medically necessary as determined by a physician or licensed health practitioner; require two of the four service components of Assistive Care Services; and reside in a Medicaid enrolled ALF, RTF, or AFCH•Service Area – Statewide•FY 2010-2011 enrollment – 12,130 •FY 2010-2011 expenditures – $27,240,926 •Medicaid maintains the administrative rule for this state plan program.

Assistive Care Services

•Assistive Care services include:

assistance with activities of daily living, assistance with instrumental activities of daily living, and assistance with self administration of medications.

•Medicaid reimburses enrolled providers $9.28 per day for assistive care services provided to Medicaid eligible recipients.

Assisted Living Waiver

• Population – Age 60+• Eligibility – Medicaid Institutional Care Program, and meet

additional clinical impairment criteria • Services – case management, assisted living, and incontinence

supplies• Service Area – Statewide • FY 2010-2011 enrollment – 3,941 • FY 2010-2011 expenditures – $30,039,071 • Managed by the Department of Elder Affairs in cooperation

with the Agency for Health Care Administration

Assisted Living Waiver Reimbursement

• The waiver reimburses for assisted living services and if necessary, incontinence supplies.

• Medicaid reimburses up to $32.20 per day for the assisted living facility (ALF) assisted services provided to waiver residents.

• Medicaid also reimburses for Incontinence supplies up to $125.00 per month.

• Room and board costs detailed in the ALF resident contract are paid by the resident.

Nursing Home Diversion Waiver

• Population – Age 65+• Eligibility – Medicaid Institutional Care Program, Medicare parts

A & B, and meet additional clinical impairment criteria • Services – Case management, and 20 other home and

community-based services including assisted living services, 11 acute care services, Medicare co-payments and co-insurance, and unlimited nursing facility care in enrolled facilities

• Service Area – 41 counties • 17 managed care plans provide services• FY 2010-2011 enrollment – 23,158 • FY 2010-2011 expenditures – $312,771,163 • Managed by the Department of Elder Affairs in cooperation

with the Agency for Health Care Administration

Nursing Home Diversion Reimbursements in ALFs

• The Nursing Home Diversion waiver serves eligible aged adults who can be safely served in standard licensed assisted Living facilities (ALFs).

• Assisting Living services under this waiver include personal care, homemaker, escort, medication administration, adult companion, and other medically necessary long term cares services

• Plan members select ALFs available in each Nursing Home Division provider’s network.

• ALFs negotiate daily or monthly rates for services provided in the facility with each Nursing Home Diversion plan.

• Room and board costs detailed in the ALF resident contract are paid by the resident.

Questions ??