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Report (OEI-09-08-00360)

Home and Community-Based Services in Assisted Living Facilities

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Under the 1915(c) waiver, CMS may waive certain requirements to allow State Medicaid programs to cover home and community-based services (HCBS) for beneficiaries residing in assisted living facilities (ALF). However, little information exists about the HCBS furnished to beneficiaries in ALFs, the costs of those HCBS, or the extent to which those HCBS are furnished in compliance with Federal and State requirements.


To identify the costs and types of HCBS covered under 1915(c) waivers for Medicaid beneficiaries residing in ALFs, we surveyed and collected claims data from 35 State Medicaid programs. From these 35 States, we selected the 7 States with the highest numbers of beneficiaries receiving these services in ALFs: Georgia, Illinois, Minnesota, New Jersey, Oregon, Texas, and Washington. Using claims data from these 7 States, we selected a random sample of 150 beneficiaries. To determine the extent to which Medicaid programs complied with Federal and State requirements for HCBS furnished under the waiver, we reviewed State survey agency inspection reports for ALFs in which beneficiaries from our sample resided. We also reviewed plans of care associated with the sampled beneficiaries. The period of our review was 2009.


In 2009, 35 Medicaid programs reported that, under 1915(c) waivers, they covered various HCBS for beneficiaries in ALFs at an annual cost of $1.7 billion. Each State had federally mandated provider standards; however, ALFs in the seven selected States did not always comply with them, and federally required plans of care did not always meet Federal requirements. In the seven States, 77 percent of beneficiaries received HCBS under the waiver in ALFs cited for a deficiency with regard to (i.e., noncompliance with) at least one State licensure or certification requirement. Nine percent of beneficiaries' records did not include plans of care required by the States. Further, 42 percent of the federally required plans of care did not include the frequency of HCBS furnished, as required. Five of the seven States also required that plans of care specify the beneficiaries' goals and the interventions to meet them. In these 5 States, 69 of 105 plans of care for beneficiaries receiving these services in ALFs did not meet that requirement. Two of the seven States also required that plans of care be signed by beneficiaries or their representatives. In these 2 States, 12 of 25 plans of care for beneficiaries receiving HCBS in ALFs did not meet that requirement.


We recommend that CMS issue guidance to State Medicaid programs emphasizing the need to comply with Federal requirements for covering HCBS under the 1915(c) waiver. CMS concurred with our recommendation.

Copies can also be obtained by contacting the Office of Public Affairs at Public.Affairs@oig.hhs.gov.

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