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The information in this appendix is presented in three major sections:
The first section provides an overview of the state's long term care system, with a primary focus on the Medicaid program. Although a state may pay for services in residential care settings through the Medicaid program, the program's financial eligibility criteria and related financial provisions for home and community services can present barriers to serving Medicaid clients in these settings. Thus, the first section of each state's description presents detailed information about rules related to financial eligibility, spousal financial protections, and cost sharing requirements.
The second section describes the state's residential care system.
The final section presents the views of respondents interviewed for this study on a range of issues related to Medicaid coverage of services in residential care settings in their state.
Because the information in the first two sections is intended to serve as a reference, some information is presented under more than one heading to reduce the need for readers to refer back to other sections for relevant information.
Unless otherwise cited in endnotes, all information presented here was obtained from the sources listed at the end. Supplemental Security Income levels, the federal poverty level, federal spousal protection provisions, state supplemental payments, and state reimbursement rates are for 2003, unless otherwise noted.
The state has a process for determining where new nursing home beds will be allowed based on the nursing home occupancy rate in a given county. The statewide occupancy rate is approximately 72 to 74 percent.1 The state also has a process for determining the proportion of nursing home beds allocated for Medicaid.
Two groups are financially eligible for nursing home services:
Group A includes individuals who are eligible because they are receiving SSI.
Group B includes persons with incomes up to the special income standard of 300 percent of SSI, which is $1,656.
Asset limits for both groups are $2,000 for an individual and $3,000 for a couple.
The monthly personal needs allowance is $60 for individuals and $120 for couples.2
Because Texas does not have a medically needy program, in accordance with federal law, categorically eligible individuals in need of nursing home care--whose income exceeds the special income standard but is insufficient to cover the cost of care--may place income in excess of the special income level in a Qualified Income Trust, known as a Miller Trust. Once the trust is operative, they receive Medicaid coverage for both nursing home care and other Medicaid state plan services.
The institutionalized individual's eligibility is determined using the individual income limit before the protected spousal needs allowance is determined.
Community spouses may keep any income in their own name, and the state allows the institutionalized spouse's income to supplement the community spouse's income up to the federal maximum permitted, which is $2267 per month.
The protected resource amount will be the greater of the following: the state minimum resource standard, which is $18,132; or one-half of the couple's combined countable resources not to exceed the maximum resource standard of $90,660; or the amount transferred to the community spouse under a court order. All assets over this maximum must be spent on nursing home care before Medicaid will begin to pay.
In cases where there is a community spouse, the client can appeal to increase the protected resource amount to produce additional income for the spouse. The hearing officer may then increase the protected resource amount to a level adequate to produce income up to, but not exceeding, the monthly maintenance needs allowance.
Family members may pay a nursing home facility the difference in cost between a semi-private and private room.
Applicants for Medicaid coverage of nursing home care must meet one of the following criteria:
Must require licensed nursing care (RN or LVN);
Must meet two or more of the criteria for nursing home risk, as specified in the Resident Assessment Instrument-Home Care Assessment for Nursing Home Risk as revised in April 1996 and summarized as follows:
Must have been living for 30 consecutive days in a medical facility that has a contract to accept Medicaid patients. Persons in this category must still be screened for medical necessity.
The Community Based Alternatives (CBA) waiver program provides home and community services to persons age 21 and older who qualify for nursing facility care. The goal of the CBA waiver program is to provide individuals with meaningful choices regarding long term care services. Waiver funds are used to allow individuals to avoid premature nursing facility placement and to provide current nursing facility residents an opportunity to return to a home or community living arrangement.
The CBA waiver program currently serves 32,793 persons and has more than 39,000 on an interest list. Placement on an interest list means potential clients have declared an interest in a program for which funding is limited, but have not yet been assessed for financial or service eligibility. The list has an attrition rate of a few thousand per month. The waiting period from the time people get on the interest list to receiving services is approximately 10 months. Eligible individuals are enrolled from the CBA waiver interest list on a "first come, first served" basis.
Within the constraints imposed by the cost ceiling on a participant's Individual Service Plan, the waiver program promotes the participant's active involvement and choices regarding the services provided. Participants may choose to live in their own homes or in a residential care setting covered under the waiver: Adult Foster Care homes or Assisted Living/Residential Care facilities. A waiver participant needing nursing care may choose to have that care delivered by a licensed nurse or, in those situations where delegation is appropriate, by an unlicensed person providing services under the direction of a registered nurse.
The majority of services offered under the CBA waiver program are provided by licensed home and community support services agencies. These agencies provide services to participants living in their own homes, adult foster homes, assisted living/residential care facilities (formerly known as personal care facilities), and other locations where services are needed.
As part of its Olmsted initiative, the State has tried to increase the ability of individuals in nursing facilities who could transition into the community to do so through the CBA waiver program. Because there are too few slots in the waiver program relative to demand, the State is using a money follows the person initiative to fund home and community care.
Under Rider 37, when there are insufficient slots or funding in the CBA waiver program, funding follows the individual from the nursing home into the community. The cost of services comes from the nursing home budget instead of the CBA waiver budget. Thus, individuals in nursing homes who are Medicaid eligible can move to the community and receive home or community residential care even when CBA waiver funding is not available.
During a recent twelve-month period, 952 individuals have taken advantage of Rider 37, with about 45 percent transitioning to residential care. Many of those who transitioned were between the ages of age 21 and 64.
The lack of CBA waiver slots can result in a person who spends down in the community having to enter a nursing home for a month in order to apply for funding under Rider 37. The state is grappling with the question of what to do with funds when persons funded through Rider 37 are no longer served. Currently, the money that funded their care is being returned to the nursing home budget.
Two groups are financially eligible for waiver services:
Group A includes individuals who are eligible because they are receiving SSI.
Group B includes persons with incomes up to the special income standard of 300 percent of SSI, which is $1656.
Asset limits for both groups are $2,000 for an individual and $3,000 for a couple.
The state does not allow spend-down to waiver eligibility levels. For individuals with income that exceeds the institutional limit, federal policy requires the state to allow the use Qualified Income Trusts, known as Miller Trusts, to become eligible for Medicaid.
The state does not require persons in Group B who are receiving waiver services in their own home to share the cost of services.
For people in Group B who are living in residential care settings, the cost sharing amount is equal to the client's remaining income after all allowable expenses have been deducted. These deductions include:
the cost of the client's maintenance needs allowance, which is equal to the SSI federal benefit rate of $552 per month. The client keeps $85 as a personal needs allowance and the remainder is used to pay for room and board costs;
the cost of the maintenance needs of a spouse if the spouse is the only dependent of the recipient. This amount is equal to the monthly SSI federal benefit rate less the spouse's income;
the cost of the maintenance needs of the client's dependent children. This amount is equivalent to the Aid to Families with Dependent Children (AFDC) basic monthly grant for children or a spouse with children, using the recognizable needs amounts in the AFDC Budgetary Allowances Chart;4 and
the costs incurred for necessary medical or remedial care, which are not covered by Medicare, Medicaid or any other third party insurance, including the cost of health insurance premiums, deductibles and co-insurance.
If any income remains after all these deductions, the cost sharing amount is applied only to the cost of services covered by the waiver program and specified on the client's individual service plan and must not exceed the actual cost of services delivered. Clients must pay the cost sharing amount to the provider contracted to deliver authorized waiver services.
The state's maximum monthly maintenance needs allowance for the spouse of a waiver client is the monthly SSI limit for an individual. The spouse's income is deducted from the SSI limit and the wavier recipient's income is diverted to make up the difference.
Resource protection is the same as for the spouses of institutionalized persons. The protected resource amount will be the greater of the following: the state minimum resource standard, which is $18,132; or one-half of the couple's combined countable resources not to exceed the maximum resource standard of $90,660; or the amount transferred to the community spouse under a court order. All assets over this maximum must be spent before Medicaid will begin to pay.
Family payments for an individual's food, clothing, and shelter are considered support and maintenance for waiver clients and a value is assigned. Because support and maintenance are not considered for clients in institutional settings, and institutional and waiver financial eligibility rules are the same, support and maintenance is not considered for waiver clients.5
To be eligible for waiver services, a person must meet the nursing home level-of-care criteria and several CBA waiver specific criteria. They must:
In 1979, Texas added personal care to its Medicaid State Plan. The personal care program is called the Primary Home Care Program, and it serves the aged and disabled. The program provides non-technical, medically related personal care services prescribed by a physician as part of a client's plan of care. Primary Home Care is available to eligible Medicaid clients whose health problems cause them to be functionally limited in performing activities of daily living. It is available statewide, and there is no waiting list.
Services are provided by a primary home care attendant employed by a licensed home and community support services agency. The agency's license must cover the provision of home health services, personal assistance services, or both.
Each eligible client may receive up to 50 hours of primary home care per month (42 hours per week for a client with priority status). The Primary Home Care Program provides three services:
Personal care: help with bathing, dressing, grooming, routine hair and skin care, preparing meals, feeding, exercising, helping with self-administered medication, toileting, and transferring/ambulating.
Home management: assistance with housekeeping activities that support the client's health and safety, such as changing bed linens, housekeeping, laundering, and shopping.
Escort: accompanying the client on trips to obtain medical diagnosis or treatment, or both. This service does not include the direct transportation of the client by the attendant.
Excluded services that must be provided by a person with professional or technical training, include:
To be eligible for the Primary Home Care program an applicant must be eligible for SSI or have income no higher than the SSI level, or meet 1929(b) income and resource limits (see Community Attendant Services Program described below).
There are no spousal income and asset protections for community spouses of persons receiving personal care services.
Family payments made for support and maintenance may be counted when determining Medicaid eligibility, in accordance with SSI policy.
A client's degree of functional impairment is measured on a 60-point functional needs assessment to determine if the impairment is severe enough to qualify for services. Applicants for primary home care services must meet functional needs criteria as follows:
Must score 24 or above on the Client Needs Assessment Questionnaire.
Must have a medical need for assistance with personal care.
Must have a signed and dated Physician's Order for Primary Home Care.
Must require at least six hours of primary home care per week. An applicant/client requiring fewer than six hours per week may be eligible if she meets at least one of the following criteria:
For primary home care clients, the client's medical diagnosis(es) must be the cause of the client's functional impairment in performing personal care tasks. Although mental illness and mental retardation are not considered medical conditions, they do not disqualify a client for eligibility as long as the client's functional impairment is related to a coexisting medical condition.
To receive services the applicant/client must reside in a place other than a hospital, a skilled nursing facility, an intermediate care facility, or any other environment where family members or sources outside the primary home care program are available to provide personal care. Services cannot be authorized if the client lives in a home licensed as an assisted living facility (ALF). If the home is not a licensed ALF, services may be authorized under the following two circumstances:
Three or fewer persons live in the home. The proprietor can be the attendant for the client(s) who resides there. A client may not receive adult foster care services as well as primary home care services.
If the home provides only room and board to four or more persons living in the home, it does not require licensure as an assisted living facility. Services can be authorized for clients in this setting, but the proprietor, his agent, or employee cannot be the attendant for clients who reside in the home.
In the 1980s, Texas implemented a demonstration waiver program called the Frail Elderly Program, which provided only attendant services. Texas was the only state that participated in the demonstration and in the early 1990s when the program ended, federal law permitted Texas to retain the program as a personal care option under 1929(b) regulations, which essentially allow higher income eligibility criteria (300 percent of SSI) than is used for other Medicaid state plan services. However, clients served under the program are not eligible for any other Medicaid services, e.g., primary and acute medical care, prescription drugs, and home health services.
Although the program was called Frail Elderly, the statute allowed the program to serve persons of all ages. In 2003, the State changed the name of the program to the Community Attendant Services Program. The program's eligibility criteria and services are the same as for the Primary Home Care program. It currently serves 30,000 persons.
There are two types of Medicaid in Texas: traditional and STAR. People in both programs get the same benefits. Under the traditional program, individuals get medical care from any doctor or provider who accepts Medicaid. Under the STAR program, the enrollee has one provider who coordinates and manages their care.
The STAR+Plus pilot program is a Medicaid pilot project operating since 1998. It is designed to integrate delivery of acute and long term care services through a managed care system. The project requires two Medicaid waivers--1915(b) and 1915 (c)--in order to mandate participation and to provide home and community services.
The project serves approximately 55,000 SSI aged and disabled Medicaid recipients in Harris County (Houston). STAR+PLUS provides a continuum of care with a wide range of options and increased flexibility to meet individual needs. The program has increased the number and types of providers available to Medicaid clients.
Participants may choose from two health maintenance organizations. Certain participants have a primary care case management option in addition to the two HMO choices. The HMO provides both acute and long term care services. STAR+PLUS Medicaid Only clients are required to choose an HMO and a Primary Care Provider (PCP) in the HMO's network. These clients receive all services--both acute and long term care--from the HMO.
Those also eligible for Medicare choose an HMO but not a PCP because they receive acute care from their fee-for-service Medicare providers. The STAR+PLUS HMO provides only Medicaid long term care services to dual eligible clients. Of the approximately 55,000 STAR+PLUS eligibles in Harris County, about half are "dually eligible" for both Medicaid and Medicare. The program has demonstrated significant savings, but there are no plans currently to expand it.
All clients receiving long term care services under STAR+PLUS receive care coordination for acute and long term services from the HMO. Care Coordination services include the development of an individual plan of care with the client, family members and provider, and authorization of long term care services for the client.
Long term care services provided by the HMOs include day activity and health services, personal attendant services, and short-term (up to 4 months) nursing facility care. Additional services provided to CBA waiver clients are adaptive aids, adult foster home services, assisted living/residential care services, emergency response services, medical supplies, minor home modifications, nursing services, respite care and therapies (occupational, physical and speech-language). Approximately 200 clients are receiving services in assisted living facilities.7
In 1998, the State amended the CBA waiver program to create a new waiver program specifically for Harris County (in effect, there are now two 1915(c) waiver programs in Texas). The providers contract with the HMOs and, as much as possible, deliver the same services as the CBA waiver program, by way of a capitated payment from the CBA waiver budget for Harris County. There is no waiting list. The HMOs may also provide additional "value-added" services, such as CBA waiver services to clients living in the community but not in a CBA waiver slot.
Community Care for Aged and Disabled (CCAD) is a state program that provides services in a person's own home or community for aged or disabled persons who are not able to take care of themselves, and who might otherwise be subject to unnecessary institutionalization or to abuse, neglect, or exploitation.
In addition to services provided through the waiver program and the personal care option, CCAD includes a number of home and community service programs funded by state general revenue funds and Title XX funds. Two of these programs cover services in residential care settings: Adult Foster Care (AFC) and Residential Care(RC). The state program serves approximately 200 people in AFC and 800 in RC each year. Reimbursement rates for services are less than those paid for waiver clients.
To be eligible for the Adult Foster Care and Residential Care programs through CCAD, individuals must be financially eligible for Title XX services or must meet the income criteria for Medicaid waiver services (300 percent SSI), and not have assets exceeding $5,000 for an individual and $6,000 for a couple. In calculating financial eligibility, a number of exclusions from income and resources are permitted. Clients keep a monthly allowance for room and board and personal and medical expenses, and the remainder of their income is contributed to the total cost of care. Applicants/clients must also score at least 18 on the Clients Needs Assessment Questionnaire and have the approval of the CCAD led unit supervisor. The applicant's needs may not exceed the facility's capability under its licensed authority.
Adult Foster Care is provided in homes enrolled with the Department of Human Services. This service provides 24-hour living arrangements and may include meal preparation, housekeeping, minimal personal care to help with activities of daily living, and provision of, or arrangement for, transportation.
The Residential Care program provides services to eligible adults who require 24-hour access to care, do not require daily nursing interventions, and do not meet waiver level-of-care criteria. Services include, but are not limited to personal care, home management, 24-hour supervision, social and recreational activities, and transportation. Services provided under this program are delivered through one of two arrangements:
Supervised living is a state-funded 24-hour living arrangement, e.g., an assisted living facility, in which clients are expected, if able, to contribute to the cost of their care. Clients also pay for their room and board, which is limited to the SSI payment minus a personal needs allowance.
Emergency care is a state-funded living arrangement that provides services to eligible clients while caseworkers seek a permanent care arrangement. Emergency care clients do not contribute toward the cost of their care.
Historically, personal care facilities (sometimes called personal care homes) and adult foster care were the primary residential care options in Texas. In 1999, personal care facilities were renamed assisted living facilities, which are defined as any facility that serves four or more adults who are unrelated to the proprietor. Adult Foster Care homes that serve four or more persons are also required to be licensed as an assisted living facility.
In the mid-1990's, the state became interested in supporting residential care alternatives to nursing homes for individuals who met a nursing home level of care but could not be safely cared for at home. The Department of Human Services worked with providers and advocates to develop a 1915(c) waiver program to provide services in both private homes and residential care settings. The new waiver program, called Community Based Alternatives (CBA), was implemented in 1994. Initially, the cost of CBA waiver services was capped at 90 percent of nursing home cost, but the state has now raised the cap to 100 percent.
The primary goal of the CBA waiver program is to offer home and community alternatives to institutional care and to provide the opportunity for those in institutions to transition to the community. In keeping with this goal, the state made efforts to bring about a "culture change" among hospital discharge planners, doctors and families regarding the appropriateness of home and community care alternatives to nursing homes. One respondent noted that these efforts appear to have been successful, given that 95 percent of those receiving CBA waiver services have never been in a nursing facility.
When the CBA waiver program was developed, it was anticipated that 50 percent of waiver clients would be served in personal care facilities, particularly elderly persons who did not need a high level of care. This expectation fueled the development--and some respondents said--the over-development of personal care facilities and other types of residential care settings.
In 1987, Texas had 4,200 beds in personal care facilities. In 2002 there were over 40,000 licensed assisted living beds (including adult foster care homes licensed as Type C assisted living facilities), of which only 67 percent (26,000) were occupied, primarily by private pay residents. The main reason for the low occupancy is that the majority of waiver clients choose to live in their own homes. In 2002, approximately 2,500 CBA waiver clients received services in assisted living facilities through 320 contracts with providers across the state--less than seven percent of the 32,000 clients receiving CBA waiver services.
Adult Foster Care Homes provide a 24-hour living arrangement with supervision for individuals 18 years of age and older who, because of physical or mental limitations, are unable to continue independent functioning in their own homes.
Providers may serve up to three adult clients in a Department of Human Services (DHS) enrolled adult foster home. These homes do not have to be licensed but those accepting Medicaid clients have to meet Medicaid contracting requirements. Homes with four or more residents are called Small Group Homes and must be licensed under the assisted living licensing rules as a Type C facility, in addition to being enrolled with DHS. Providers must serve no more than eight adult clients in an enrolled Small Group Home. The CBA waiver program contracts with both licensed and unlicensed adult foster care homes.
Services reimbursed through the CBA waiver include meal preparation, housekeeping, personal care and nursing tasks, supervision, and the provision or arrangement of transportation. Nursing tasks may be delegated by a registered nurse to a foster care provider based on the provider's abilities and the needs of the participant.
The client pays the provider for room and board from their own income. Texas limits the amount that can be charged for room and board for Medicaid waiver clients in adult foster care to an amount equal to the SSI federal benefit rate minus a personal needs allowance of $85.00 which equals $467. There are no restrictions on the amount adult foster care homes can charge private pay residents.
CBA waiver clients can be served in private or shared rooms depending on availability and the preference of the client. Adult foster care homes cannot have more than two beds in any room and must provide at least 80 square feet of floor space in a single occupancy room, and at least 60 square feet of floor space per client in a double occupancy room.
There are three care levels in adult foster care homes, and as of September 2003, the payment rates are $18.71, $32.27 and $65.52 per day. The level of care required is based on an assessment and the recommendations of a Home and Community Support Services nurse.
Adult foster care providers cannot terminate services to a resident without the prior approval of the adult foster care caseworker or supervisor, unless the resident creates a serious or immediate threat to the health, safety, or welfare of the provider or the other residents of the foster home.
In Texas, assisted living is a service delivery model not an architectural model. It is defined as a housing plus services arrangement for persons who, because of a physical or mental limitation, are unable to live their own homes. Assisted living settings provide food, shelter and personal care services to four or more persons who are unrelated to the proprietor of the establishment.
There are five types of licensed ALFs, but there are two primary licensing designations, which are based on residents' physical and mental ability to evacuate the facility in an emergency, and whether nighttime attendance is necessary.8 They are:
Type A facilities, whose residents must be capable of evacuating the facility unassisted, who must not require routine attendance during night time hours, and who must be capable of following directions under emergency conditions. This may include persons who are non-ambulatory but mobile, such as persons in wheelchairs or who use electric carts, and have the capacity to transfer and evacuate themselves in an emergency.
Type B facilities, whose residents may require staff assistance to evacuate, may not be able to follow directions, who require attendance during the night, and who, while not permanently bedfast, may require assistance in transferring to and from a wheelchair. Facilities that advertise, market, or otherwise promote their capacity to provide personal care services for people with dementia must be certified as a Type B facility.9
Only licensed facilities may use the term assisted living, and the statute requires careful monitoring to detect and report unlicensed facilities. An assisted living facility must be licensed to participate in the CBA waiver program.
The Department of Human Services (DHS) contracts directly with qualified providers on an open enrollment basis. Any provider agency that meets the enrollment or licensing criteria for the service it proposes to provide under the waiver is eligible to apply for a contract with DHS. Providers are required to maintain current certifications or licenses for the applicable services throughout the time period during which waiver services are delivered.
The Medicaid CBA waiver program contracts with six categories of assisted living providers to cover Assisted Living/Residential Care (AL/RC) services:
Licensed adult foster care providers
Licensed assisted living facility (ALF) providers
Licensed emergency response system providers
RNs contracted with DHS and nurses employed by or contracted with licensed home and community support services agencies.
Home and community support services agencies.
In addition to meeting all relevant licensing and regulatory requirements, providers must agree to contractual rules for accepting CBA waiver clients.
The Medicaid contract rules specify three different types of housing options in which waiver clients may be served: assisted living apartments, residential care apartments, and residential care non-apartments. All are considered types of assisted living and all are licensed as assisted living facilities. The three types of housing options are described below.
Assisted Living Apartment
An assisted living apartment--which may be an efficiency or a one-bedroom--is defined as an apartment for single occupancy that is a private space with individual living and sleeping areas, a kitchen, bathroom, and adequate storage space. The bedroom must be single occupancy except when double occupancy is requested by the participant.
The apartment must have a minimum of 220 square feet, not including the bathroom. Apartments in pre-existing structures being remodeled must have a minimum of 160 square feet, not including the bathroom. The bathroom must be a separate room in the individual's living area with a toilet, sink, and an accessible bath.
The kitchen is an area equipped with a sink, refrigerator, a cooking appliance that can be removed or disconnected, adequate space for food preparation, and storage space for utensils and supplies. A cooking appliance may be a stove or microwave.
Residential Care Apartments
Residential care apartments are units with two bedrooms, each with a single occupant, with a shared kitchen and bathroom providing a minimum of 350 square feet per client. Indoor common space used by residents, such as the dining room and entertainment room, may be counted in the square footage requirement by averaging the total square footage of the common areas and dividing by the number of beds in the facility.
Kitchens must be equipped with a sink, refrigerator, cooking appliance (stove, microwave, built-in surface unit) that can be removed or disconnected, and space for food preparation.
Residential Care Non-Apartment
A residential care non-apartment setting has living units that do not meet either the definition of an Assisted Living apartment or a Residential Care apartment.
These units may be single or double occupancy units and must be in free standing buildings that are licensed for 16 or fewer beds.
These non-apartments tend to be the older personal care facilities (redefined as assisted living facilities in 1999). Most have dual occupancy rooms and some have rooms with up to four residents in a dormitory style. No more than 50 percent of the beds in a given facility can be shared by three or more persons. Bathrooms are required for every six residents.
A big hurdle in developing the waiver was obtaining consensus among the consumer advocates and providers regarding occupancy rules in assisted living facilities. The consumer advocates wanted single occupancy to be required for waiver clients, while the providers wanted double occupancy to be the standard because existing providers already had double occupancy rooms in many facilities.
CBA waiver provider participation standards require the assisted living facility to provide each client with a choice of a private or semi-private room. The Texas Waiver Handbook also states that the facility must provide each participant with a separate living unit. However, in practice, dual occupancy rooms and apartments are not excluded from the waiver program. Most assisted living facilities serve a predominantly private pay clientele and single occupancy units are not always available
There are no data indicating the percentage of CBA waiver participants typically served in dual occupancy or dormitory units, but respondents did not think that the percentage was that different from the percentage of private pay residents in dual occupancy or dormitory units. As of December 31, 2002, 1787 CBA clients were in single occupancy apartments, and 952 CBA clients were in double occupancy apartments.
The CBA waiver contracts specify which of the three housing options will be available for CBA waiver clients. Providers may not deliver CBA waiver services in a housing option which is not specified in the contract. If the AL/RC provider wishes to limit the types of apartments in a facility that are available to CBA waiver participants, this must be specified in the contract. Without this specification, all types of apartments in the facility must be available to CBA waiver participants.
If the facility limits the type of apartment available for CBA waiver clients and there is no apartment of that type available, they can refuse to accept any CBA waiver client, based on not having space available. This would apply both for a client wanting to move into the facility from the outside, or to a private pay client currently in the facility who has spent down to CBA waiver eligibility. The client would then have to move to another assisted living facility or to an adult foster care home.
Texas limits the amount that can be charged for room and board to Medicaid waiver clients in assisted living facilities. The amount is equal to the SSI federal benefit rate minus a personal needs allowance of $85.00, which equals $467. There are no restrictions on the amount that private pay residents can be charged.
Required services in licensed assisted living facilities include but are not limited to: assistance with activities of daily living (ADLs), 24-hour supervision (periodic checks or visits to a client during each eight-hour shift to ensure that the client is safe), three meals a day and special diets, housekeeping and laundry, transportation and escort for Medicaid-covered medical appointments, and a planned program of social and recreational activities in the community.
Alzheimer's facilities must have a planned and structured program that encourages socialization, cognitive awareness, self-expression and physical activity.
Each of the following services may be provided according to the needs of the participant as authorized on the individual service plan as a waiver or non-waiver service. The case manager will make referrals for the services and coordinate delivery.
All services count towards the client's cost cap, whether they are reimbursed through the state plan or the waiver.
Nursing services consist of the full range of services provided by an RN or LVN within the scope of his/her state licensure. Nursing service can be brought into the assisted living facility for the participant and may be provided by RNs who have contracted with DHS, as well as nurses associated with licensed home and community support services agencies.
In 2001, licensing rules were amended to allow nurse delegation under the Nurse Practice Act in assisted living facilities. However, delegation of nursing tasks by agency RNs to facility attendants is not allowed. The facility must employ its own licensed staff to delegate nursing tasks.
The AL/RC provider is responsible through their contract with DHS for medication administration, which is defined as either the direct administration of all medications or assistance with or supervision of self- medication. This includes injections if needed. Only licensed personnel can give injections.
Home and community support services agencies cannot be authorized to provide--or be reimbursed for providing--medication administration because it is the facility's responsibility to provide this service. The cost must be included in the daily rate that the facility bills CBA. All other nursing tasks and waiver services can be provided by an HCSS agency.
The reimbursement methodology for CBA waiver Assisted Living/Residential Care (AL/RC) services is based on clients' needs as determined by their TILE classification (Texas Index for Level of Effort). The state developed the TILE classification system to group nursing home residents on the basis of the level of effort needed by a licensed nurse to meet their needs and their functional abilities. TILE classifications are numbered TILE 201 through 211, with TILE 201 indicating the highest intensity of care.
Private pay clients are not assessed for TILE levels and facilities are free to charge different rates for private pay residents.
Effective September 2000, the state approved rate increases for CBA waiver AL/RC providers. However, the appropriations for these increases are contingent upon the adoption of agency rules that promote increased wages and benefits for attendants, thereby reducing staff turnover and attrition. Providers have a choice of participating in the Attendant Compensation Rate Enhancement option; those who choose not to will receive a single attendant compensation rate regardless of the client's TILE classification.
Almost half of AL/RC providers have chosen this payment option. State staff reported that participating providers have additional monitoring and reporting requirements, but in return have less recruiting and training costs. In addition, by offering higher rates for attendants, the facility will be more competitive than those offering lower rates. For example, if a participating provider has a client residing in an assisted living single occupancy apartment with a TILE of 210, the client would receive a rate of $47.55 per day. For a nonparticipating provider the rate for this same type of client would be $ 39.69.
There are 11 different TILE levels, 201 to 211, but the CBA waiver decided to combine some of the levels for a total of six payment levels. In 2003, the rates were as follows:
Texas believes that services provided in assisted living facilities should enhance a person's ability to age in place while receiving increasing or decreasing levels of service as the person's needs change.10 The key distinction between nursing homes and assisted living facilities is that the former provides regular nursing care. Licensing rules do not permit assisted living facilities to serve those who require more than intermittent, short-term acute, or terminal nursing services. If an assisted living resident--either private pay or CBA waiver--requires intermittent, short-term or terminal nursing services, the provider has to contract with an agency to provide them.
The regulations specify that assisted living facilities may admit residents who:
If residents have a change in health or conditions related to the amount and type of care required, the case manager, in conjunction with the other members of the Interdisciplinary Team, the provider and the resident or their legal representative, may explore other means to continue serving them in assisted living. CBA waiver participants (and private pay residents) may receive licensed nursing services in an assisted living facility if they are provided through contracts with certified home health agencies. Another option is to have the resident attend a day activity and health services program, which provides some nursing care. In either case, the cost of all services combined may not exceed the waiver cap.
Rules regarding retention criteria include:
If participants exhibit behavior that threatens the health or safety of themselves or others, or their needs exceed the licensed capacity of the facility, the AL/RC provider must request the case manager to assess the participant's continued eligibility for CBA waiver services.
If a CBA waiver client is hospitalized or admitted to a nursing facility, the facility must hold their room as long as they pay the daily room and board charge. The facility may not bill for services while the client is residing elsewhere.
An ALF resident may be allowed to stay in a facility as long as the resident and/or the family, a personal physician and the assisted living provider all agree that the residents' needs can be adequately met.
To address concerns regarding the inappropriate retention of residents with a high level of need, the State enacted a requirement, effective September 2002, that facilities conduct a formal assessment of residents' needs annually and whenever there is a significant change in the resident's condition. This requirement is applicable to both Medicaid eligible and private pay residents.
In addition to consulting with ten state staff and policy makers regarding the technical details of the state's programs, we also interviewed four of them. In addition, we interviewed nine stakeholders, including representatives of residential care provider associations, consumer advocates, the state ombudsman program, aging services providers, the state agency that administers the home and community services program, the state office of a national advocacy association for seniors, and a former state administrator (now a long term care policy consultant.)
The interviews focused on respondents' views about several key areas and issues. This section summarizes their views and provides illustrative examples of their responses. These comments are not verbatim quotes, but have been paraphrased to protect the respondents' anonymity and edited for brevity. A list of information sources for the state description and the individuals interviewed can be found at the end of this summary.
Because residential care facilities serve both private pay and Medicaid residents, a few respondents expressed views about the industry as a whole, and about particular issues the long term care system is facing, including a liability insurance crisis.
Litigation has been occurring more and more in the nursing homes and is starting in assisted living facilities. Texas is usually named alongside Florida as being in the same litigation crisis. ALF licensure does not require liability insurance, but nursing facilities will be required to have liability insurance as of September 2003.
Providers will challenge the State on liability issues. The 2003 legislative session is going to address tort reform.
An error in the regulations has led to increased liability for providers. The current regulation states that assisted living providers are responsible for care and services. It is supposed to say that providers are responsible for coordinating all care and services. Often, assisted living facilities do not provide the services themselves, but arrange for them to be provided by outside entities.
Several expressed satisfaction with the state's efforts to involve all stakeholders in the regulatory process and for keeping them informed.
The State was very inclusive in seeking input before it promulgated the assisted living rules. Agencies, providers, and advocates/consumers have always had the opportunity to discuss their concerns about regulations. Consequently, the regulations reflect the intent of the legislation because of the good communication. The State has built a framework for assisted living in terms of regulations and has built in accountability.
The state operates an informative website for providers that is very good at keeping them current on new policy and regulatory changes. Providers also appreciate the availability of training sessions. There are some concerns about the quality of training for CBA wavier case managers.
One respondent expressed concerns about unlicensed assisted living facilities.
There are approximately 3,000 small unlicensed facilities that are receiving SSI payments. Some are operating legally by not providing services, but others are offering and providing substandard services illegally.
Another was very pleased with the state's approach to nurse delegation.
The state has been very progressive in moving towards nurse delegation. This is very important given the nursing shortage, the higher cost of nurses, and the potential for over-medicalization in ALFs.
There was a consensus among all those interviewed that the CBA waiver program was a very good program and that coverage of assisted living was a success for a variety of reasons.
The assisted living program has made extraordinary progress and is considered a model for other states. For example, our mandated disclosure statements are being used by other states.
The state has met its goals of supporting individuals' desires to live in an integrated community setting under the CBA waiver program and in Community Care (which covers those receiving personal care services not under the CBA waiver). For some advocates, living in an ALF is not considered to be a true choice because clients overwhelmingly prefer their own home. However, because some individuals may not have homes, the ALF option is still necessary.
The State and legislature put forth a good effort to meet the Olmstead requirements through Rider 37, which has enabled those in nursing facilities to transition into the community and to receive CBA waiver services. We felt very strongly that efforts to move those in nursing homes into community settings--including ALFs--was critical.
There were fears that the nursing home industry might fight the continuation of Rider 37. However, the state has to support the Olmstead decision, giving some "teeth" to the State agencies' support for the continuance of Rider 37.
The most successful aspect of the program is the ability of individuals to age in place, the stability of the CBA waiver program staff, the ease in managing the CBA waiver program compared with other states, and the willingness of CBA waiver staff to listen to provider concerns and to address them whenever possible.
Two respondents mentioned that the room and board payment for Medicaid waiver clients was not sufficient to cover the costs and needed to be addressed.
Many of the non-profit providers receive supplemental funding and contributions from members of churches, faith-based organizations and foundations. The state has asked for a state supplement for room and board to be funded in recent legislative sessions, but has not been successful. It's not likely to be approved in the next legislative session due to the large budget deficit.
The state should adopt a state supplement for room and board as exists in other states, which could lead to an expansion of providers if additional CBA waiver slots were funded.
There were some issues among those interviewed regarding the content of the state's licensing and regulatory requirements for ALFs, although no one felt that regulations posed a major obstacle to affordable assisted living in Texas.
The legislature has moved to set up a more punitive environment related to the assignment of administrative penalties (fines), in part because the legislature has come under increasing pressure from advocacy groups concerned about care and searching for more complete regulations.
Over the past three legislative sessions, we have advocated for quality standards and enforcement tools.
I am concerned that ALFs are moving too much towards the medical model, with the result that the facilities will turn into nursing homes, much like the old intermediate care facilities we had pre-OBRA 87.
There is a need for regulations that focus on the services people need. The current licensing standards are too focused on life/safety code distinctions.
Many providers do not have well developed and realistic plans for how they would care for someone in an emergency
The consensus among those interviewed was that national standards were not warranted, although some advantages were noted.
Texas is farther ahead than other states in terms of instituting assisted living licensing and regulations.
While federal model guidelines for services could be useful, regulations and licensing should be a state prerogative. Federal regulations might stifle state creativity.
Texas has done a good job of addressing licensing and regulatory issues, including aging in place. Our regulations are progressive; we have a special license for facilities that serve clients with Alzheimer's disease (Type B ALF). One company that has several assisted living facilities has gone beyond state standards by always providing private rooms.
The American Association of Homes and Services for the Aging (AAHSA) has formed a workgroup to look at national assisted living standards and is moving towards identifying some commonalities. However, the Texas arm of AAHSA does not have a formal opinion on the issue.
If Medicaid funding is involved, I wouldn't be surprised to see national standards established.
A number of respondents expressed concerns about admission practices and the need to assure that people can age in place.
Fire and safety regulations have made it possible for facilities to deny residence to individuals in wheelchairs. One provider claimed he couldn't admit people in wheelchairs, because they would "knock down" other residents, especially in an emergency.
Some ALFs might be creaming the lesser impaired because they don't want to take care of people with higher levels of care needs.
Some providers are willing to take clients who need higher levels of care, but they don't want to deal with more accountability standards.
Providers are required to make an assessment decision within 72 hours, which is too short a time. Facility managers and staff want to meet a prospective client in person to make decisions, which is difficult to arrange within 72 hours, especially if the client lives in another area. Another problem is that facilities are pressured to take clients that "don't fit" with the current facility population or that have heavier care needs than is desirable for a particular facility at a particular point in time. For example, one facility was pressured to take a 350 pound man prone to falls who also had a very large service dog.
The CBA waiver contract managers recognize that some clients have particularly difficult needs or problem behaviors, but the CBA waiver requirements--not licensing and regulation--require their admittance. I admit, though, that if the requirements were not there, and providers had full choice in admittance decisions, discrimination would likely occur.
With regard to discharge policy, one respondent reported that it was hard to discharge people from assisted living facilities, but noted that the state was getting better about supporting facilities who had really difficult cases.
There is a need for regulatory support for aging in place. I strongly promote the chance for individuals to age in place, but I also recognize that facilities who serve individuals needing higher levels of care are required to pay more attention to fire and safety standards.
CBA waiver clients with Alzheimer's are most at risk for not being able to age in place in assisted living facilities due to extreme problem behaviors and the inability for Medicaid to pay for full-time private sitters that some of the private pay clients have. Caring for these people is so expensive that most facilities don't want them and they wind up in nursing homes.
Respondents felt that the issues related to aging in place were far from settled, with some providers liking the concept and others not. Most supported the concept but had concerns about its implementation.
The state recently instituted new regulations that will allow more people to age in place by allowing short term nursing services to be provided (24 hour skilled nursing is not provided normally). Aging in place is a relatively new concept and providers are still learning the consequences and benefits.
I have concerns that some providers might not have the capacity to really support aging in place.
There have been a few cases of residents inappropriately kept in an ALF, although these were mostly small providers that might not have had a full understanding of how to safely maintain clients.
It's easier to age in place in an ALF that is part of a continuing care retirement community.
CBA waiver case managers fairly often pressure facilities to retain a client even though the client's behaviors or conditions allow the facility to remove that individual under current licensing and regulations.
Several respondents remarked that some providers felt that their facilities would be stigmatized by accepting CBA waiver clients. One has spoken with providers not involved in the program who cited "red tape", financial risks, and fear that the facilities will be known as the "Medicaid house" as reasons for not accepting waiver clients.
Few respondents were familiar with negotiated risk agreements. One noted that although the term "negotiated risk agreement" is not used, there are agreements that must be signed between the facility, the person and the person's attending physician to allow aging in place to occur. Several of those interviewed were aware of these agreements and supported the notion of negotiated risk.
Respondents noted a number of barriers, which are discussed in turn.
The unanimous opinion of all those interviewed was that the number one issue for the CBA waiver program is the lack of funding, and there is pressure from providers to fund more waiver slots.
The large waiting list for CBA waiver slots is preventing access, rather than affordability or provider availability issues. In addition, the number of slots is not uniform across the State. Elderly persons in their own homes can get services through the Frail Elderly Program, but the CBA waiver is the only program that serves elderly persons in assisted living settings.
A disincentive for providers is that the state can not guarantee CBA waiver slots. An additional concern is that facilities are restricted in reducing the number of beds available to CBA waiver clients even when there are no CBA waiver clients in that area to fill the beds. Although it is possible to increase the number of CBA waiver beds in a given facility fairly easily, reducing a slot usually takes three months after the request has been submitted, during which time the facility is losing money on the empty bed.
One respondent felt that there was not much of a demand for assisted living in the waiver program.
Many individuals would rather stay in their own homes and receive services than go to an ALF, thus the pressure might be less on expanding access to assisted living than expanding in-home options.
Some stated that low rates were a barrier to the expansion of assisted living, and one respondent felt that Medicaid rates were low across all settings, not just in ALFs. Another said that Texas is limited in its funding for Medicaid programs, noting that the state ranked 47th in terms of its reimbursement rates. Another disagreed:
The CBA waiver payment rates used to be much lower, but there have been increases to make the rates more competitive with private pay rates. There are now enhanced rates in exchange for the provision of better wages, workers' compensation coverage, and benefits to facility staff. These rates might be at risk though, given the large state budget deficit.
One respondent said that the state's bed hold policy was a major cost problem for providers.
The state requires providers to hold a bed for 120 days when a resident is placed in other care (e.g., hospital or rehabilitation unit). The room and board rate is only about $14.00 a day, much less than the private pay rate. The 120 day rule applies each time a client has an out-of-facility placement, so if a resident returns on the 120th day and stays for 2 days, but then has another emergency, the provider has to hold the bed for another 120 days.
The facility often knows the likelihood of the client's return better than the case managers, who are sometimes resistant to making decisions before the 120 days, even if it seems obvious that the resident can't return. The state should lower the number of days (it used to be 90 days) or limit it to one 120-day period per year per client.
The amount of paperwork involved in accepting CBA waiver clients and the difficulties in dealing with a state agency keep some providers from serving these clients. For example, when a CBA waiver client is involved in an incident in an ALF, the facility has to go through two different report processes, one with the regulatory agency and the other with the CBA waiver program agency.
The audit process done by the CBA waiver program, which looks at ledger receipts and daily census record, and the potential fines and vendor/client holds for what are essentially "clerical errors" are a disincentive for some providers to take CBA waiver clients.
A few respondents did not make specific suggestions about Medicaid, but instead noted that there were general areas that the state needed to pay more attention to.
With increased emphasis on aging in place, more attention to quality might be needed in ALFs. There have been some reports that the quality issues in ALFs--regarding food, activities, and staffing--are similar to those in nursing homes.
Others had very specific recommendations.
CBA waiver cost-neutrality should be determined on an aggregate rather than individual basis. Therefore, if one individual's cost for remaining in the community in an integrated setting was higher than the nursing home payment, that individual could remain eligible because overall cost neutrality would be upheld.
More education is needed for discharge planners so they will present the full range of options for living in an integrated community setting. While assisted living services should be part of the CBA waiver program, they should be alternatives to nursing homes, not the wing of a nursing home.
More staff are needed in ALFs. Greater attention to quality and oversight is given to nursing homes than assisted living facilities due to resource constraints and the need to give priority to clients in higher levels of care.
The state needs to improve the screening process to make sure that clients are set up for the most appropriate services based on their needs. It also needs to increase coordination to support a streamlined point of access into the CBA waiver program. Administrative and contracting processes should be simplified so that the grandmother seeking and receiving CBA waiver services and the child and mother seeking and receiving TANF assistance could go into the "same door" to seek and receive services.
The state needs to do a better job marketing and promoting the CBA waiver program to providers. It also needs to reduce the duplication of effort that results from multiple agencies being involved (licensing/regulation and CBA waiver program staff). The state could also be more flexible in its paperwork requirements. For example, the state requires hand-written ledger forms whereas a company may operate a computerized form. Similarly, the state requires a daily service delivery record whereas a company authorizes a service plan for each client that identifies the service and how many times a week it will be provided.
The state should develop an extensive comprehensive assessment process that all providers would use. Some providers do not know what they are looking for when conducting pre-admission assessments. This is more an issue for private pay clients, because for CBA waiver clients, the DHS managers and home health nurses are involved in the admission decision process with the providers.
A number of respondents mentioned ongoing activities related to the Olmstead decision.
There are many advisory boards operating at the state level that are discussing long term care and Olmstead issues, with providers, consumers and advocates working together.
The appropriations Rider 37 has supported the Olmstead decision and allowed more than 900 nursing home residents to move into their own homes and ALFs. The state is asking for more CBA waiver slots in this next legislative session a continuation of Rider 37.
There is a pilot study using Olmstead relocation specialists to provide individuals in nursing homes with information on the full range of community options.
A number of respondents mentioned regulatory issues that the state is planning to address.
The state is aware of provider concerns with the 120 day bed hold rule and draft new rules are coming out shortly. Stakeholders are appreciative that the state shares draft rules to obtain input.
Draft CBA waiver rules were due to be circulated to providers months ago. The focus of these regulations is to increase the ability of assisted living residents to age in place, and to develop a monitoring process that involves more site visits and interviews rather than just fiscal and process reviews. While more operationally difficult, this type of review would yield more information on service outcomes. The licensing staff are more used to surveying facilities, but the State CBA waiver program staff are less familiar with this type of review. Both they and the providers are going to need training on the review process.
The state is developing a standardized care assessment process.
Another mentioned the state's ongoing data monitoring activities.
The state is tracking individuals transitioning out of nursing facilities into the CBA waiver program. Because their funding is supported by the nursing home budget, the state wants to see if there are cost savings, or whether those leaving the nursing facilities are merely replaced by new Medicaid clients.
Only one respondent had a specific recommendation for other states interested in using Medicaid to pay for services in residential care.
It's important to have good lines of communication between the program and licensing staff when developing the licensing requirements for assisted living and establishing program operating procedures. The Texas Department of Human Services now houses both program and licensing staff, which has facilitated communication.
I also recommend that a state reach a consensus on what population will be served (specific client characteristics) and secure buy-in from providers (including nursing home providers) and advocates. A state may have to convince advocates that assisted living is a valid option under community care.
Gibson, M. J. and Gregory, S. R., Across the States 2002: Profiles of Long-Term Care, AARP, 2002.
Kassner, E. and Williams, L., Taking Care of their Own: State-funded Home and Community-based Care Programs for Older Persons, AARP, September 1997.
Kassner, E. and Shirley, L., Medicaid Financial Eligibility for Older People: State Variations in Access to Home and Community-Based Waiver and Nursing Home Services, AARP, April 2000.
Mollica, R.L., State Assisted Living Policy: 1998, Report (ASPE and RTI) June 1998. [Full Report]
Mollica, R.L., State Assisted Living Policy: 2000, National Academy for State Health Policy; funded by The Retirement Research Foundation (LTC13). August 2000.
Mollica, R.L., State Assisted Living Policy: 2002, National Academy for State Health Policy, November 2002.
Mollica, R.L., and Jenkens, R., State Assisted Living Practices and Options: A Guide for State Policy Makers, A publication of the Coming Home Program, funded under a grant from The Robert Wood Johnson Foundation, September 2001.
O'Keeffe, J., People with Dementia: Can They Meet Medicaid Level-of-Care Criteria for Admission to Nursing Homes and Home and Community-Based Waiver Programs?, AARP, August 1999.
Smith, G. et. al., Understanding Medicaid Home and Community Services: A Primer, U.S. Department of Health and Human Services, Office of the Assistant secretary for Planning and Evaluation, October 2000. [Full Report]
State Assistance Programs for SSI Recipients, January 2001, Social Security Administration, Office Of Policy, Office Of Research, Evaluation, and Statistics, Division Of SSI Statistics and Analysis.
Stone, J.L., Medicaid: Eligibility for the Aged and Disabled, Congressional Research Service Report for Congress, updated July 5, 2002.
Aged, Blind and Disabled Medicaid Eligibility Survey http://www.masterpiecepublishers.com/eligibility/
Case Manager Community Based Alternatives Handbook http://www.dhs.state.tx.us/handbooks/cm-cba-hb/appendix/XIV/index.htm
Community Care for the Aged and Disabled Handbook http://www.dhs.state.tx.us/handbooks/ccad/
Community Based Alternatives/Community Care for the Aged and Disabled Policy Clarifications http://www.dhs.state.tx.us/programs/communitycare/policyletters/PolicyCBACCAD.html
Department on Aging http://www.tdoa.state.tx.us/
Elder Options of Texas, Assisted Living Communities http://www.elderoptionsoftexas.com/tbh_excerpts/assisted_living_communities.htm
Gaps in services for older Texans, a survey report http://www.tdoa.state.tx.us/OAPIpubs/Gaps&Coordination.pdf
Home and Community Based Services network http://www.hcbs.org/states/texas.htm
Information Letter No.2000-17, Change in Reimbursement Methodology for Community Based Alternatives Assisted Living/Residential Care Providers http://www.dhs.state.tx.us/programs/communitycare/infoletters/cbaccad/2000/
Spousal Impoverishment http://www.dhs.state.tx.us/programs/Elderly/MedicaidNursing/impoverishment.html
Texas Administrative Code, Title 25, Health Services http://info.sos.state.tx.us/pub/plsql/readtac$ext.ViewTAC?tac_view=2&ti=25
Texas Administrative Code, Title 40, Social Services and Assistance: Chapter 92, Licensing Standards for Assisted Living Facilities http://info.sos.state.tx.us/pub/plsql/readtac$ext.ViewTAC?tac_view=4&ti=40&pt=1&ch=92
Texas Department of Human Services, Community Care Programs for Elderly and Disabled http://www.dhs.state.tx.us/programs/Elderly/CommunityCare.html
Texas Health and Human Services Commission, STAR+PLUS Background Information http://www.hhsc.state.tx.us/starplus/background_page.htm
Texas Statutes, Health and Safety, Chapter 247, Assisted Living Facilities, http://www.capitol.state.tx.us/statutes/he/he0024700toc.html
Texas Statutes, Health and Safety, Chapter 242, Convalescent And Nursing Homes And Related Institutions, http://www.capitol.state.tx.us/statutes/he/he0024200toc.html
Kerry Adair, Provider Funding and Contracting
Pine Tree Lodge, a Veranda Living Assisted Living Facility
Gerardo Cantu, Director,
CBA Waiver Program
Texas Department of Human Services
Candice A. Carter
Texas AARP, State Affairs
Dee Church, Section Director for Client Eligibility,
Long Term Care Services
Texas Department of Human Services
Pam Coleman, Project Manager,
STAR+PLUS Managed Care Project
Skip Comsia, President
Veranda Living
Cheryl Cordell, Ombudsman
Texas Department on Aging
Frank Genco, Program Analyst
State Medicaid Office
Marc Gold, Director,
Long Term Care Policy
Texas Department of Human Services
Becky Grantham, Contract Manger
Assisted Living Concepts
Rose Ireland, Director of Clinical Services
Texas Association of Home and Services for the Aged
Bob Kafka, National Organizer
Richard Ladd, Long Term Care Policy Consultant
Ladd & Associates
George Linial, President
Texas Association of Home and Services for the Aged
Susan Moellinger, Executive Director
Covenant Place of Abilene
Mary Ann Ramirez, Supervisor
Unit 54, Long term Care Services
Texas Department of Human Services
Jeannie Williams, Benefits Counselor
West Texas Council of Governments Area Agency on Aging
John Willis, Ombudsman,
Texas Department on Aging
Jeanoyce Wilson, Unit Director
Long Term Care Regulatory Policy
Texas Department of Human Services
Gibson, M. J. and Gregory, S. R., Across the States 2002: Profiles of Long-Term Care, AARP, 2002.
When SSI recipients enter a nursing home, SSI provides only $30 for personal needs. For these individuals, the state provides a supplement of $30 per month.
The provisions of Rider 28 were originally contained in Rider 37 in the 76th legislative session. The number was changed during the 78th legislative session.
Although the AFDC program no longer exists, allowable maintenance costs are still tied to the basic monthly grant when it did exist.
"Support and maintenance are not counted as income if eligibility is being tested for a waiver program; for example, Community Living Assistance and Support Services (CLASS), the Community Based Alternatives (CBA), Home and Community-Based Services (HCS), and Medically Dependent Children's Program (MDCP). The 1929(b) program is not a waiver program." Texas Administrative Code, Title 40, Part I, Chapter 15, Subchapter E, Rule 15.455.
The TILE classification system was developed by the Department of Human Services to group nursing home residents on the basis of their clinical conditions and functional abilities.
The respondent who provided this figure stated that it is a conservative estimate based on incomplete data, and that a larger number is probably being served in these settings.
Type C facilities are Adult Foster Care Homes with four or more beds. In 1999, when personal care facilities were renamed assisted living facilities, the state required AFC homes with four or more beds to be licensed as an assisted living facility. Type D facilities are operated by the Department of Mental Health and Mental Retardation for persons with serious mental illness and developmental disabilities. Type E facility residents are the same as Type A except that they do not require assistance with ADLs, but only with medication administration.
Use of advertising terms such as "medication reminders or assistance," "meal and activity reminders," "escort service," or "short-term memory loss, confusion, or forgetfulness" will not trigger a requirement for certification as an Alzheimer's facility. (Source: Texas Administrative Code, Title 40, Chapter 92)
Texas Administrative Code, Title 40, Social Services and Assistance, Chapter 92, Licensing Standards for Assisted Living Facilities, Subchapter A, Rule 92.2,a.
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text:
Gonzalo Higuain criticizes state of pitch in New Jersey
Nov 16, 2013, 1:35 PM EDT
Argentina and Ecuador played out a drab 0-0 draw on Friday night in New Jersey, but Gonzalo Higuaín is more concerned about the pitch at MetLife Stadium. The venue normally plays host to American football games, including the home games of the New York Giants and Jets. But that, according to Higuaín, made it unacceptable for a soccer match that, despite lacking Lionel Messi, included some of the world's brightest talents.
Higuaín, quoted in Argentina sports outlet Olè, was upset with the conditions in New Jersey, where chunks of turf had been laid over the artificial playing surface. The Napoli forward, who went down with a knee injury but appeared to shake it off, stated that conditions made the players' feet sink more than normal, creating hazardous playing conditions. The field was, Higuaín said, in no condition to play on.
Ezequiel Lavezzi agreed with his Argentina teammate, saying that the turf was irregular, which caused the ball to slow down. The PSG attacker felt both sides were lucky not to have anyone seriously injured.
It's now on to St. Louis for Argentina, where they will face Bosnia and Hercegovina on Tuesday. Higuaín, Lavezzi and their teammates will be hoping that the biggest issue there will be faint traces of lines left over from baseball season. The same goes for the fans of their clubs, most of whom are already fed up with what seem to be pointless friendlies. Putting players at risk won't endear FIFA to anyone.
- mikeevergreen - Nov 16, 2013 at 1:42 PM
The Argies are just laying out the excuses for Tuesday when BIH busts them in the chops. BIH second-leading scorer Vedad Ibisevic grew up there, so it's going to hav a Sarajevo feel to it..
- bear06 - Nov 17, 2013 at 10:34 AM
It doesn't matter if it's going to have a Sarajevo feel to it, because Argentina who are one of the best football nations in the world will still win easily.
- mvktr2 - Nov 16, 2013 at 5:39 PM
"The same goes for the fans of their clubs, most of whom are already fed up with what seem to be pointless friendlies. Putting players at risk won't endear FIFA to anyone."
I hate to be Dr Obvious but aside from that statement being a matter of opinion rather than fact (even if I generally agree with it) the reality is that the players are to blame, not FIFA, as it is they whom choose to play for their national teams. There are instances of players refusing call-ups and no player has to play for anyone aside from their club, fifa is simply a facilitator of what most players and fans desire. Personally I think nationalism is disgusting but I still follow my national team simply because it's there and it's compelling.
- wyrm1 - Nov 17, 2013 at 11:41 AM
Of course the field at MetLife was a disaster, since they had to lay sod over a turf field in the middle of the fall. If the national federations cared about their players, they would not schedule games for venues where you KNOW there aren't going to be good field conditions (domes, sod fields over turf with no prep time, etc…).
However, the money is more important then the safety of the players or the quality of play. Until that changes you will hear these same complaints.
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subset: commoncrawl


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Just letting you guys know that I've moved all the GIF stuff to MLB GIFS, basically because I wanted this site to mainly focus on Dodgers news and analysis.
I gave a slightly longer explanation of things over there, and the link to the site is now in the main navigation bar here.
GIFS are fun. Baseball is fun. I figured combining the two should be fun.
Go over there and lol.


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Microsoft's Windows 10 Enterprise makes Windows 8 seem like a distant memory. But should CIOs wait or take the bait? Also in Searchlight, Google uses sensors to fight pollution; Intel's new memory chip breakthrough.
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Expert Karen Scarfone examines the top wireless intrusion prevention systems (WIPS) to help readers determine which may be best for them.
News of government surveillance programs is appearing almost daily. Enterprises need to do what they can to protect corporate data from potential eavesdropping -- but how? Expert Kevin Beaver offers some best practices.
Security pros are too stretched to digest actionable intelligence on a continuous basis. Dedicated appliances may help ease their load.
From large-scale Agile news to how science impacts Agile, presenters discuss the topics that will be included in Agile2015.
An expert walks you through two Agile software testing methods so you can choose an Agile testing strategy that best fits your needs.
There is no step-by-step recipe for scaling Agile, but with solid principles the software development team will have the ingredients to create high-quality enterprise software.
IoFabric Vicinity enables storage admins to apply separate storage service policies to applications individually or as a group.
SimpliVity CEO clarifies differentiators among hyper-convergence vendors, outlines company's OmniCube product roadmap, issues technology predictions.
When RAID restores require more skills than can be found in-house, a RAID recovery service provider could be the answer -- as long as the right one is chosen.


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4 SWiSH Templates and counting!
Politic SWiSH Templates
If you're in charge of your candidate's website, we know you have plenty to worry about to begin with, creating a website design shouldn't be something else to fret over. Start with one of these politics swish templates. Not on the staff? Setup a website supporting your favorite candidate anyways, every bit helps! No matter what office your candidate is running for, President, City Council, Mayor, or even a local Home Owners Association chair. Show your colors and support your candidates and yourself, starting here! SWiSH templates are similiar to our regular website templates except that the template's Flash portions are constructed using SWiSHmax. Once the website is ready the Flash portions are compiled into a .SWF file just like our Adobe Flash templates. Each of our SWiSH templates will come with the .SWI source file so that you can edit and make changes using SWiSHmax. Our politic SWiSH templates have awesome textual animation effects which can be easily customized with your own text.
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Omar Becerra and his brother Javier's film "Shoreline Drive" is one of 10 movies chosen for the Where I'm From contest, Texas Monthly magazine's first film competition, and will be shown this weekend in Austin.
Kippy Edge of Robstown made one of two local films chosen for the first Texas Monthly magazine film contest. In his short film, "Why Not Robstown?" he gives a tour of the town on his unicycle. Here he rides in the 59th annual Aransas Pass Shrimporee.
Javier Becerra and his brother made a film about Corpus Christi and family.
Omar Becerra and his brother's film will be screened Saturday.


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Mad Max Summary
Latest news
E3 2015: More than 10 minutes of Mad Max gameplay shows open world exploration, combat
Avalanche is building two large open worlds and one of those is Mad Max. There's a good 14 minutes worth of interview with the developer accompanied by gameplay teasing us all the way through.
Combat is shown off and is very Batman-like, and we also see there's plenty to explore and collect in the vast wasteland. Avalanche built the world pre-apocalypse, and then destroyed it.
E3 2015: Warner release 'Eye of the Storm' story trailer for Mad Max
Avalanche Studios is working on another sandbox (literally) open world to play in called Mad Max, in case you forgot. It's not all island dictator-toppling, fighter jet surfing and grappling hooks. A new story trailer has been released.
The video we see is all in-engine and has gameplay footage too, so no CGI trickery. We get to see the "merciless Wasteland tyrant" Scrotus again, who Max must defeat to escape The Wasteland madness.
Mad Max Savage Road trailer released, features Wasteland tyrant Scrotus
WB Games has just released a new trailer for Avalcnhe Studios' upcoming Mad Max which will be out in early September on PC and console.
This new trailer introduces the Wasteland tyrant Scrotus who leads his warboys and steals Max's Interceptor, leaving him for dead. The rest is Max tearing up the Wasteland taking them on.
Gameplay overview trailer offers "glimpse into the desperate struggle" of Mad Max, on PC September 4th
Warner Bros. IE has just released a gameplay overview for Avalanche Studios' Mad Max, which looks at the "deep car customization," vehicular combat, melee action and a "wide range of other activities".
All the footage in the trailer is in-engine and from in-game cinematics, teases Warner. The sandbox wasteland of Mad Max will be arriving on PC and console September 4th.
Mad Max Burns his way onto PC in September, new Screenshots Released
Avalanche Studios has released several new screenshots for the video game release of Mad Max, which is coming to the PC in September.


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It's a sport you've probably never heard of – rabbit racing.
A 13-year-old girl from La Porte, Iowa, which is located about an hour north of Iowa City, was featured on Good Morning America on Sunday, October 27th, 2013 to teach ABC's Ron Claiborne how to train for the wackiest competition you'll ever see.
Click the video up above to see it yourself.


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A severed cable line resulted in a 6-hour Comcast outage in parts of Charleston County on Monday, an official said today.
A tree-trimming crew accidently cut a fiber optic cable on Fort Johnson Road in James Island late Monday afternoon, said Shannon Dulin, Comcast's senior manager for government and regulatory affairs.
The incident downed Internet, phone and cable services for some customers in James Island, Folly Beach and part of West Ashley, she said.
The outage lasted roughly six hours before crews were able to begin restoring service to affected customers, Dulin added.
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Techniques for managing user identities in Linux
Smart Access
Maybe password security isn't perfect, but most networks depend on it. This month we examine some tools for smarter, more versatile authentication.
Despite years of constant high-tech innovation, the password remains a fundamental feature of most networks. Various tools let you consolidate, encrypt, sanitize, and synchronize passwords, but unless your company invests heavily in smart cards or other new age technologies, you'll eventually have to log in somewhere. This month we look at some techniques for supporting, securing, and simplifying user authentication in Linux.
Our first article examines some tools for authenticating users with one-time passwords. You'll learn why many organizations prefer passwords that change with every login. We then zero in for a look at OPIE and OTPW – a pair of open source solutions for one-time password authentication.
Many Linux users would rather not even think about Microsoft, but part of our mission has always been to let readers know about free, open source tools for easy integration with proprietary technologies. Our next article describes how Samba's Windbind service lets Linux clients participate in Microsoft's Active Directory environments.
We'll also discuss some options for creating password-protected pages for your website. We'll look at how the Apache web server handles authentication, we'll examine authentication alternatives based on SQL and LDAP, we'll show you how to create a custom authentication solution in Perl.
The final article describes how to use the OpenID service as a single authentication system for multiple web accounts. Read on for more on some great techniques for managing user identities in Linux.
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Qemu Flaw Lets the Guest Escape
Xen project announces a privilege escalation problem for Qemu host systems
Android Bug Threatens Millions of Users
Attackers can compromise an Android phone just by sending a text message
Lenovo and Canonical Announce Laptop Deal
PC vendor will pre-install Ubuntu on portables in India.
Mozilla Firefox Blocks Flash
More embarrassment for Adobe's embattled multimedia tool
Security Problem in Firefox's NoScript Add-On
Mozilla's script blocker add-on could be putting malware sites on the whitelist.
RIP SSLv3
The Internet community officially banishes the notoriously unsafe Secure Sockets Layer protocol.
Mate 1.1 Arrives
Popular desktop environment continues the Gnome 2 legacy – with new support for the Gnome 3 toolkit.
US Government Requires HTTPS
The Obama White House has issued a memorandum telling all US government agencies they must use HTTPS for all websites and web communication.
Mozilla Signs Firefox Add-Ons
New program will dial up security for the Firefox browser.
Fedora 22 Arrives
Red Hat's community distro embraces the cloud.


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Sorry this is a really basic question but I just can't figure it out. I have a scene that I have hit "Build and Run" on. I didn't have the Unity Web Player installed so nothing happened. Now I have installed it I'm not sure what I have to do to see my scene in the web player. I'm using firefox if that helps.
(My actual problem is that Screen.lockCursor is causing the mouse to jump out of the "game" panel and into my project folder when I click in game which I don't want to happen so I wanted to test it out of the Unity application so I thought I would use the web player to see if the problem fixes itself.)
Thanks for any information!
asked Aug 08, 2013 at 09:24 PM
Did you restarted your Web Browser? Can you try with another Web Browser? Please try this common troubleshooting tasks first. Since your problem since to be more of a Web Player installation/Compatibility issue. :)
Aug 08, 2013 at 09:43 PM CodeAssembler
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The answer is simple, you dont have to hit, build and run, just build settings(the option upwards), then you specify the option web player. After that you can upload it to any website, and anybody that has installed the web player of unity can play it. :)
answered Aug 08, 2013 at 09:39 PM
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The #1 Blind Item Site in the World!
Prince: As in "Fresh Prince of Bel-Air" Will Smith
Wife: Jada Pinkett-Smith
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Model: Float-30 Up to: 30gal (114L) Glass / Thickness: 3/16" (5mm) Dimensions: 2 3/8" x 1 3/8" x 1" The Mag-Float's Powerful rare earth neodymium magnets enable the easy removal of algae. By dragging the Mag-Float on the outside ...
Replacement Pad for the Mag-Float 125 Magnet Cleaner for Glass
Replacement Pad for the Mag-Float 130A Magnet Cleaner for Acrylic
Replacement Glass Scraper for the Mag-Flip Aquarium Cleaner. Fits Flip-100 (medium) and the Flip-200 (large).


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Rocky Patel The Edge Lite Double Corona
7 1/2 x 52 - Natural - Box of 20
Rocky Patel Edge Lite Double Corona cigars have a robust blend of high-priming, 5-year-aged Nicaraguan & Honduran ligero tobaccos tamed by a mild Ecuadorian Connecticut wrapper. These medium-bodied cigars are rich, creamy, perfectly-balanced, and brimming with earthy, complex flavors. A must-smoke!
As I am new to cigars I tried a box of the RPs. I found these smokes to extremely tasteful, easy draw and no bitterness anywhere in the smoke. Have purchased my second box now. will keep these in my Humidor from now on.
My wife bought me one for Fathers Day 3 years ago. Found it to be one of my favorites. Great taste, smooth draw. The type of cigar I could smoke for 90 minute and light another. One of Rocky's Finest.
a definite favorite. smooth and mild yet full of flavor. You wont regret this purchase!