You asked whether there are any obstacles to providing assisted living services in licensed residential care homes.

SUMMARY

There are two obstacles to providing assisted living services in licensed residential care homes (RCHs). The first is that RCHs do not meet the regulatory requirements for facilities in which these services can be provided. State law would have to be changed to waive these requirements. Secondly, the Connecticut Home Care Program for Elders (CHCPE), the only program that currently subsidizes assisted living services, does so only in facilities that the General Assembly has designated. The legislature would have to extend such subsidies to RCHs. And CHCPE's cost-sharing requirements could affect some RCH residents.

Department of Public Health (DPH) regulations allow assisted living services to be provided only in managed residential communities. These are defined as places primarily for people age 55 and older that consist of "private residential units. " These units must (1) belong to residents and (2) include a full bathroom and access to food preparation and storage facilities and equipment. RCHs are not limited primarily to people over age 55. And many do not provide private bath and toilet facilities or have food preparation and storage facilities in each unit.

The CHCPE provides Medicaid- and state-funded home- and community-based services to people age 65 and over who are, or are at risk of being, institutionalized. But it currently pays for assisted living services only for people living in state and federally supported elderly congregate housing facilities and some demonstration projects. CHCPE uses three categories to determine eligibility. These are based on a person's physical needs and financial status. People with income over $ 1,477 a month must use most of their excess income to pay for their services. This latter requirement could pose a problem to some RCH residents with incomes over that level.

RESIDENTIAL CARE HOME FACILITIES

DPH assisted living services regulations would have to be waived before such services could be offered in RCHs. The waiver is needed because the regulations require assisted living services to be provided in managed residential communities. These are defined as places primarily for people age 55 and older that consist of "private residential units. " These units must (1) belong (through ownership, lease, or other contractual form) to residents and (2) include a full bathroom and access to food preparation and storage facilities and equipment (Conn. Agency Regs. 19-13-D105).

RCHs are not limited to people over age 55, although many of their residents fall into this age group. They typically provide residents with a single or double furnished room, some of which have private bath and toilet facilities while others have shared facilities, and congregate meals.

The regulations governing RCHs speak of residents being "admitted" to them and do not specify the legal nature of their residency (e. g. , tenancy or contract)(Conn. Agency Regs. 19-13-D6).

RCHs could be included in the waiver provided for state-funded congregate housing in PA 00-02, June Special Session (CGS § 19a-6c) or covered in a separate, parallel waiver. That act requires the DPH commissioner to allow these facilities to offer assisted living services and allows him to waive some regulations to accomplish this end. But he cannot permit waivers he determines would:

1. endanger the life, safety, or health of any resident receiving assisted living services;

2. affect the quality or provision of services to any resident; or

3. revise or eliminate requirements for an assisted living service agency's quality assurance program, grievance and appeals process, or clients' bill of rights and responsibilities.

The act allows him to (1) impose other conditions to protect residents when he waives a regulatory requirement and (2) revoke a waiver if he finds it jeopardizes residents or that the facility is not complying with a condition he imposed.

PAYING FOR ASSISTED LIVING SERVICES IN RCHS

Connecticut Home Care Program for the Elderly

Most people must pay for assisted living services out of their own pocket. Neither Medicaid nor state funds currently pay for these services in private facilities in Connecticut. But federal law allows states to use Medicaid to pay for assisted living services (but not room and board in facilities where services are provided), and in PA 00-2, JSS the General Assembly permitted the CHCPE to cover assisted living services offered in (1) state-funded congregate housing and (2) other assisted living pilot or demonstration projects established under state law (CGS § 17b-3432(c)).

The CHCPE provides home- and community-based services, such as dressing, bathing, toileting, and eating, to people age 65 and over who are, or are at risk of being, institutionalized. It pays for assisted living services only for people living in those state and federally supported senior housing facilities designated by PA 00-2, JSS.

CHCPE Medical Eligibility Categories. CHCPE uses a three-tiered eligibility structure based on each participant's service needs.

_ Category 1 provides limited, state-funded home care for moderately frail people who are at risk of hospitalization or short-term nursing home placement. Per-client expenditures are capped at 25% of the average cost of nursing home care (about $ 1,000 per month).

_ Category 2 services are for people who need short- or long-term nursing home care. This category is also state-funded. Per-client expenditures are capped at 50% of nursing home costs (about $ 2,000 per month).

_ Category 3 services are for people who would otherwise be in a nursing home and whose care there would be paid by Medicaid. It uses state and federal funds under a Medicaid waiver. Per client expenditures cannot exceed 100% of the average nursing home cost.

CHCPE Financial Eligibility. CHCPE has both income and asset limits, depending on which medical category a person fits.

_ Categories 1 and 2, the state-funded portions, have no income limit. Their asset limit is $ 17,856 for individuals and $ 26,784 for couples. Individuals must pay on sliding scale for part of their services depending on their income.

_ Category 3, the Medicaid waiver portion, has a $ 1,635 monthly income limit (300% of the maximum federal Supplemental Security Income benefit). The asset limit for an individual is $ 1,600. Clients in this category whose income exceeds 200% of the federal poverty level (FPL, $ 1,477 per month) must pay that excess toward their cost of care.

Applicability to Residential Care Home Residents

Some RCH residents automatically qualify for Medicaid because they receive benefits under the State Supplement Program (SSP), which essentially provides room and board payments for aged, blind, and disabled people with very low incomes. If CHCPE assisted living services were extended to RCHs, SSP recipient residents would automatically qualify for the Medicaid-waiver category if they met the medical eligibility criteria. And remaining RCH residents who met the medical eligibility criteria could qualify for state-funded CHCPE if their assets fell within those categories' limits.

But residents with incomes over $ 1,477 a month (200% of FPL) could have a problem. CHCPE's rule requiring them to contribute most of their excess income to the cost of the assisted living services could leave them with insufficient funds to pay for their room and board in the RCH or for other monthly expenses.

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