OLR Research Report

February 21, 2008





By: Nicole Dube, Legislative Analyst II

You asked for information regarding continuing care retirement communities (CCRCs). Specifically, you wanted to know (1) which states have continuing care “at home” programs, (2) who regulates these states' CCRCs and their at home programs, and (3) whether these states had any comments on their programs' implementation. You also asked for state statutes pertaining to continuing care at home programs.


A Continuing Care Retirement Community (CCRC) is a facility that provides seniors with a lifetime “continuum of care,” although there is no legal age requirement. Residents usually pay a one-time entry fee and continuing monthly payments in exchange for housing, other services, and nursing care, usually all in one location, enabling seniors to remain in the same location as they age.

Some states now offer what are commonly referred to as “Continuing Care At Home” (CCAH) programs. These programs offer seniors the traditional services and benefits of CCRCs while allowing them to remain in their own homes. Participants pay the CCRC a one-time entrance fee and monthly premiums to access a range of home-based services, including: care coordination, routine home maintenance, in-home assisted living and nursing services, transportation, meals, and social and wellness programs. CCAH programs allow seniors to develop personalized care plans and are generally much less expensive than moving into a CCRC.

We found five states that offer CCAH programs: New Jersey, Pennsylvania, Ohio, Tennessee, and Maryland. California is currently considering legislation to establish CCAH programs.

Regulation of CCRCs and CCAH programs varies across states. Ohio and Tennessee do not regulate them. New Jersey and Pennsylvania require CCAH programs to be licensed by state agencies. Maryland is the only state we found whose statutes specifically regulate CCAH programs.

The states we contacted had little or no information on the benefits and challenges of implementing CCAH programs. But, we are including comments from a program executive in Pennsylvania and an expert consultant who helped design CCAH programs in New Jersey, Ohio, and Pennsylvania. We will report to you under separate cover any additional comments we receive from states.


A CCRC provides elderly people (although there is a no legal age requirement for residency) with a lifetime “continuum of care.” Residents must usually pay a one-time entry fee, which can easily be $100,000 or more, and continuing monthly payments, often ranging between $1,000 and $3,000. Thus, people must have considerable private resources to live in a CCRC. They usually obtain the entry price by selling their houses.

At first, the senior lives independently in an apartment and later, when he or she becomes more frail, can receive assisted living services in it or move into an assisted living unit. CCRCs often have small nursing homes on their premises or contract with a nearby nursing home for residents who ultimately need 24-hour care. They also provide some common meals; have other common spaces for leisure and recreation programs; and provide housekeeping, laundry, and transportation services.

Continuing Care at Home Programs

Some states now offer what is commonly referred to as “Continuing Care At Home” programs as an affordable alternative to the traditional CCRC. These programs allow people to remain in their own homes as they age and receive the traditional health and personal care services provided by CCRCs. The structure of CCAH programs vary across states, but most offer life care plans where members pay an initial enrollment

fee and monthly premiums to access future services. CCAH programs must accurately project future costs and invest fees and premiums so they can fulfill their obligation to provide care.

In order to qualify, new members must meet age requirements, be in good health, and not in need of services now. Most programs do not accept individuals with existing degenerative diseases.

CCAH services typically include: care coordination, routine home maintenance, in-home caregivers that provide the services of an assisted living or nursing facility, transportation, meals, and social and wellness programs. While the goal is to maintain members in their own homes, most CCAH programs provide nursing or assisted living facility care if needed. They either provide services directly or through a network of sub-contracted providers. CCAH programs allow seniors to develop personalized care plans and are typically much less expensive than moving into a CCRC.

Most CCAH programs are independent 501c(3) non-profit organizations and are licensed as CCRCs rather than long-term care insurance products. Regulation of these programs varies by state. Some states do not regulate CCRCs and CCAH programs while others regulate and license them.


Friends Life Care at Home

Friends Life Care At Home (“Friends”) is a non-profit Quaker organization that provides home health care services, personal care services, and facility care to members. Established in 1985, Friends was the first CCAH program in the country.

Friends offers an “Affordable Life Care Plan” similar to a long-term care insurance product. But, unlike long-term care insurance, Friends also provides services, either directly or through a contracted network of providers. Its model is similar to a traditional CCRC “Extensive or Type A” contract in which the CCRC assumes the risk of uncertain future health care costs. Its model also offers members portability if they travel or relocate out of state. It will contract with caregivers in other states to provide the same level of services for the same fee.

To be eligible, a person must be between age 40 and 81, living independently and in good health. Enrollees have a choice between two plans: (1) the Home Care Only Plan, which pays for services provided in the home and (2) the Life Care Plan which pays for home-based services and, if necessary, assisted living and nursing home care. The actual cost of the plan is individualized and depends on factors including the person's age, the type of plan, length of coverage, and level of daily benefit selected. Enrollees may choose to pay fees monthly or annually.

After enrolling, a person is assigned a care coordinator who arranges and monitors needed services. These services include home health aides, in-home nursing services, emergency response services, nutritional support, adult day care, periodic home safety review, and facility care when necessary.

Services are provided either directly through Intervention Associates, a fee-for-service care management provider and subsidiary of Friends, or a network of contracted providers. A member who chooses a nursing home or assisted living facility outside of the Friends Network is responsible for any additional fees above the daily plan benefit. The program currently has 1,750 members.

Longwood At Home

Modeled after Cadbury At Home in New Jersey (see below), Longwood At Home is a nonprofit CCAH program affiliated with a campus-based CCRC, Longwood at Oakmont. The program is open to residents of Allegheny, Beaver, Butler, Washington, and Westmoreland counties who are at least 60 years old and in good health. The program enrolled its first members in June 2003 and currently has 150 members.

According to Joan Krueger, Longwood at Home's director, members can choose from six program options with different coverage levels, some of which require co-payments. Members pay a one-time enrollment fee based on their age at the time of enrollment and monthly maintenance fees based on the program they chose. While the program's goal is to maintain service provision in the home, most program options include facility care if necessary. Longwood at Home contracts with its affiliate CCRC, Longwood at Oakmont, to provide nursing home care. Krueger notes that unlike long-term care insurance, members can receive services as soon and for as long as they are needed.

Longwood at Home's services are similar to those offered by a traditional CCRC. They include: care coordination; home inspection; transportation; home nursing care; companion/homemaker, referral, and emergency response services; live-in assistance; wellness and social programs; adult day care; and facility care if needed.


Both Friends Life Care At Home and Longwood At Home are licensed and regulated by the Pennsylvania Department of Insurance. According to Krueger, the department does not have a separate licensing category for CCAH programs. The Continuing Care Provider Registration and Disclosure Act (40 Pennsylvania Statues 3204 Chapter 12) requires all continuing care providers to obtain a certificate of authority from the Department of Insurance. Both programs are considered a CCRC “without walls” and must meet all the regulatory requirements of a continuing care provider, including financial reserves, membership meetings, disclosure, entry fees, and annual financial audits. A copy of the state statutes are enclosed.


Cadbury At Home was established in 1998. It was the first CCAH program in New Jersey and the first CCAH program in the country established by a campus-based CCRC. It currently serves 219 seniors between the ages of 60 and 99. Members pay a one-time enrollment fee and monthly maintenance fees. Members may choose from several plan options with different levels of coverage and payment. For example, “Gold Plan” members receive 100% coverage for all Cadbury at Home services, whereas “Silver Plan” members must pay co-payments for some services in exchange for lower enrollment and monthly fees.

Once enrolled, members are assigned a personal care coordinator who arranges services. Services include care coordination, home inspections, annual physical examinations, transportation, emergency response systems, companions, meals, home health care, social and wellness programs and facility-based care if needed.

Cadbury at Home purchases administrative services including payroll, accounts receivable and payable, benefits, and finance from its affiliated CCRC (Cadbury at Cherry Hill) reducing its administrative overhead.

The Department of Community Affairs regulates both CCRCs and CCAH programs in New Jersey. While state statutes govern CCRCs, no statutes specifically pertain to CCAH programs. According to Sarah Spellman, developer and former operator of Cadbury at Home, in 1998, the state determined that CCAH programs fit within existing CCRC statutes due to their similarities and felt a change in law was unnecessary. A copy of the statutes are enclosed.


Kendall At Home, also modeled after New Jersey's Cadbury at Home program, is Ohio's first and only CCAH program. It is offered through a campus-based CCRC, Kendall at Oberlin. The program began offering continuum of care contracts for people living at home in 2004. It was developed and implemented with funding received from the Cleveland Foundation and other Kendall affiliates. The program currently has 100 members.

Membership is available to people who are at least age 60 and in good health. To qualify, the person must submit to a medical and financial review. Like other CCAH programs, members pay a one-time entry fee based on their age at enrollment and monthly fees based on the program they chose. Members can choose from four membership options, two of which provide full coverage (with or without facility services) and two of which require co-payments (15% or 30%).

Services are arranged by a care coordinator assigned to each member and include: assisted living; emergency response system; adult day care, home health, homemaker/companionship, therapy, and transportation services; meals; nursing home care; wellness and social programs; and fitness and home assessments.

According to Lynn Giacobbe, executive director of Kendall at Home, Ohio does not license or regulate CCRCs and CCAH programs. A legal review conducted by the law firm of Baker and Hostetler during the CCAH planning process concluded that no existing state laws prevented an existing CCRC from offering a CCAH. Giacobbe noted that Kendall at Home is accredited under the Commission on Accreditation of Rehabilitation Facilities (CARF), an independent, nonprofit accreditor of rehabilitation and human service providers.


Alexian Brothers Life Care At Home program offers lifetime care contracts to certain residents of Chattanooga County ages 55 and older. Claire Geren, executive director of Life Care At Home, describes the program as an actuarial model similar to a long-term care insurance product. The program is affiliated with Alexian Brothers, a multistate parent corporation that operates a network of residential, retirement, and community resources for seniors in two Tennessee counties.

The program was established in 2002 and currently has 230 enrollees. Clients pay an entry fee and monthly fees based on their age at the time of enrollment and their service needs. Enrollees receive four levels of care arranged by a care coordinator and provided by members of the Alexian Brothers network.

Live At Home Program – Levels of Care

Level 1: Wellness By Design

● An emphasis on improving wellness and health;

● Includes a baseline health assessment;

● Counseling and education on nutrition, exercise and medical treatments; and

● Referrals to trustworthy services for home maintenance and repair.

Level 2: Intervention By Design

● All services of level one;

● Increased support from the services coordinator and staff in response to specific needs;

● Support with normal tasks of daily living, such as driving and food preparation; and

● Assistance with light home chores.

Level 3: Support By Design

● All services of level one and two;

● Intensive care management from the Live At Home staff; and

● In-home assistance with meals, bathing, grooming and homemaking.

Level 4: Care By Design

● Intensive, daily support and services in the home and in Alexian facilities;

● Transportation;

● Enrollment in Program of All-Inclusive Care of the Elderly (PACE), at no additional charge;

● Prescription medications at no additional charge, if PACE option is chosen;

● Medical care, hospital care and rehabilitation without copayment, if PACE option is chosen; and

● Option to move to Alexian facilities.

*Source: Alexian Brothers Live At Home website

According to Geren, CCRCs and CCAH programs are not regulated in Tennessee. But, the state licenses and regulates individual components of a CCRC or CCAH program such as assisted living facilities or home health agency providers.


Since December of 2002, Maryland has offered CCAH programs to residents age 60 and older with moderate to high incomes who live independently in the community. Maryland is the only state we found that has enacted legislation establishing CCAH programs (Md. Ann. Code art. 70B, 22A (Supp. 1996)). A copy of the statutes are enclosed.

The Maryland Department of Aging regulates CCRCs and CCAH programs. A CCAH provider must register with the department and meet the same requirements as CCRCs, including approval of a feasibility study with an actuarial review, reserve requirements, health care licensure standards, and review and approval of CCAH contract language.

Friends Life Care At Home MidAtlantic registered with the Department of Aging in 2002; it was the first and only provider to do so. According to Carol Barbour, president of Friends Life Care At Home in Pennsylvania (see above), the Aging Department's regulatory requirements make it very difficult for programs to operate. Specifically, she said, the reserve requirements forced Friends to inflate its prices by approximately 20%, resulting in its inability to attract adequate membership. Friends stopped accepting new members and transferred ownership of the program to Masonic Eastern Star Home, in the Washington, DC area. The program currently has 50 members and is in the process of being phased out. No other CCAH programs are registered with the department at this time.


California is currently considering legislation (AB 1022) to allow CCAH programs to operate in the state. CCRCs must obtain a certificate of authority and a residential care facility for the elderly (RCFE) license from the California Department of Social Services. In addition, CCRCs that offer skilled nursing services must hold a skilled nursing facility license from the Department of Health Services.

According to Eric Dowdy, associate director of public policy at Aging Services of California, an association representing 400 nonprofit providers of senior living and care, if a CCRC provides services in a private residence, DSS currently requires that residence to be licensed as a facility. AB 1022 proposes to exempt CCAH programs from these licensure requirements and create a new application process for them. A copy of the legislation and an analysis of the bill are enclosed.


The states we contacted had little or no information on the benefits and challenges of implementing CCAH programs. But, we did receive comments from Carol Barbour, president of Friends Life Care at Home in Pennsylvania and Sarah Spellman, principal consultant with Third Age, Inc. Ms. Spellman was the developer and operator of New Jersey's Cadbury At Home program from 1998 to 2005 and also helped design CCAH programs in Ohio and Pennsylvania.

Both Barbour and Spellman indicated that CCAH programs have experienced financial success and have reduced the need for facility-based care. CCAH programs are generally inexpensive to develop because they do not need to build facilities. According to Spellman, Cadbury At Home has no debt and has maintained a positive bottom line since its third year of operation.

Both programs have also experienced a reduced need for nursing home care. Spellman indicated that on average only one to two of Cadbury members require nursing home care at any given time. According to Barbour, only 50 out of 1,750 Friends members currently require facility care. This has resulted in actuaries lowering their projections for future nursing home care utilization and increasing projections for home care service utilization.

In addition, Spellman notes that CCAH programs provide an affordable option for the “gap population” of seniors who cannot afford to move into a traditional CCRC, but who do not qualify for government assistance programs. She feels CCAH programs benefit states because enrollees do not spend down their assets and rely on Medicaid for long-term care services.

When asked about the challenges of implementing CCAH programs Spellman provided the following response:

The challenges lie in the sales and admissions processes. Our society on the whole does not understand aging, denies that it will happen to “them” and believes the government will (and should) pay for all their needs as they age. The sales process must help consumers understand the realities of aging while not scaring them and turning them off. The admission criteria for a continuing care at home or CCRC at home program is that a consumer must not be in need of services when they join.  They must be independent, just as if they were moving into a campus based CCRC. Many people wait until they need services – until there is a crisis – to do something and at that point it is too late.

Utilization of services could be a challenge, but our industry is well adept at projecting utilization via actuarial studies that conservatively project the amount of future utilization and the costs associated. So far, the few programs that have been around for 10 years or more (and the programs that most new programs are modeled after) are performing very well financially. Staffing is not a problem, since the model typically will sub-contract out home care services using existing organizations that have been screened for quality. (email response, February 17, 2008)


California General Assembly pending CCAH legislation, AB 1022,, last visited on February 20, 2008.

New Jersey's Continuing Care Retirement Community Regulation and Financial Disclosure Act, New Jersey Statutes Annotated 52:27D-330 et. seq.,{15A69}&softpage=Doc_Frame_PG42, last visited on February 20, 2008.

Pennsylvania Department of Insurance,|, last visited on February 20, 2008.