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California's Assisted Living Waiver Program (ALWP) Facts + Figures
With the median cost of assisted living care estimated at around $4,000 per month, and dementia care costing two to three times this amount, statewide advocacy to expand California's (Medicaid) Assisted Living Waiver Program (ALWP) is essential for low and middle income seniors who need this form of care. The ALWP waiver is up for renewal in 2019. CARR has compiled current ALWP facts and figures to facilitate discussions among policymakers, advocates, professionals and consumers aimed at (1) increasing the number of ALWP waiver slots and (2) increasing Supplemental Security Income (SSI) rates and/or ALWP reimbursement rates to more closely align with the cost of care.
In 1983, Congress added section 1915(c) to the Social Security Act giving states the option to receive a waiver of Medicaid rules governing institutional care. The intent was to increase care services provided in the community versus in institutions (i.e. nursing homes). The Assisted Living Waiver Program (ALWP) is a 1915(c) Home and Community-Based Services (HCBS) waiver in affect in California since 2009. HCBS waivers allow the state’s Medicaid plan to offer HCBS, like assisted living, to Medicaid eligible persons at risk of nursing home placement, provided the cost of services delivered in the community does not exceed the cost of providing similar care in a nursing home.
States choose the maximum number of persons served under a HCBS wavier and, in California, as of 2017, the ALWP program had 3,744 slots authorized. In early 2018, Governor Brown proposed California apply for a waiver amendment to add 2,000 slots to the ALWP. This addition, when approved by CMS, will bring the total number of authorized slots in the state to 5,744. Throughout 2018, there was continued advocacy to expand the number of slots using California’s budgetary process to 18,000 slots. Governor Brown, however, vetoed AB 2233. The growing ALWP waitlist currently has 2,620 persons.
When no more ALWP slots are available in a local area, ALWP enrollees are placed in one of the available slots in other counties (Alameda, Contra Costa, Fresno, Kern, Los Angeles, Organ, Riverside, Sacramento, San Bernardino, San Francisco, San Joaquin, San Mateo, Santa Clara and Sonoma) or enrollees are placed on a wait list.
While there is a limit to the number of persons who can enroll in ALWP, there is no limit on the number of facilities that can participate in the program. As of December 2017, statewide there are 298 assisted living facilities designated as open for enrollment and 11 as “closed enrollment” due to poor compliance. Of the facilities enrolled, 50% are licensed for 6 beds, 23% are licensed for 100+, with the remain 27% evenly disbursed among the three other licensed bed categories (8% 7-15 beds, 8% 16-49 beds, 11% 50-99 beds).
Under ALWP, care services are provided by either staff at an ALWP-enrolled assisted living facility or by an enrolled home health agency for persons residing in publically subsidized housing. The location (a facility or public housing) is determined by the enrollee’s acuity. California’s Department of Health Care Services (DHCS) reports the majority of enrollees reside in assisted living facilities.
To enroll in ALWP, eligible persons must demonstrate the need for a level of care that would meet California’s eligibility requirements for services in a nursing home. Reimbursement rates are associated with the level of care needed (Table I). Tier 1 services are assigned to persons with the lowest level of support needs, with Tiers 2 through 4 assigned to persons with more significant support needs, respectively.
|Tier Level||Daily Reimbursement Rate||Percentage of ALWP Enrollees in Tier Level|
ALWP enrollees use SSI (Supplement Security Income) to pay for room and board in a facility. In 2017, SSI payments range from $1,026 to $1,178 per month (SSA, 2017). Facilities accepting SSI residents must accept the monthly SSI benefit as payment in full, unless the resident is an ALWP-enrollee and the facility is an ALWP-enrolled facility. If both are ALWP participants, then ALWP reimbursements pay for the care an SSI resident receives in the facility.
The median cost of assisted living care in California is $4,275 per month (Genworth, 2017). However, the actual cost of care can vary significantly depending upon a resident’s specific care needs. For example, dementia care costs are closer to $8,000/month (SeniorHomes.com, 2017). When ALWP monthly reimbursement rates are coupled with the average monthly SSI payment ($1,102), ALWP-facilities total monthly reimbursement for providing care to a Medicaid-eligible resident are closer, but not equivalent, to the median cost of care (Table II).
|Tier Level||Monthly ALWP Rate||Monthly SSI Rate||Total Monthly Reimbursement|
Since 2014, California has received approval from the Centers for Medicare and Medicaid Services (CMS) to operate ALWP in San Diego. As of May 2017, 34 of the 611 (6%) assisted living facilities in San Diego County were enrolled in ALWP. 174 (5%) of the 3,744 waiver slots available statewide are in use in San Diego County ((DHCS), 2017). It is unknown which of the 34 ALWP-enrolled facilities are caring for the 174 enrollees. Additionally, less than 25% of San Diego County’s assisted living facilities accept at least one SSI resident. (DSS, 2017).
California Department of Health Care Services. (2017, July 26). C. Selder, Interviewer
California Department of Social Services. (2017, July 31). California Department of Social Services, Compiler
Genworth. (2017). Retrieved April 6, 2017, from Genworth Cost of Care Survey: https://www.genworth.com/about-us/industry-expertise/cost-of-care.html
SeniorHomes.com. (2017). Alzheimer's and Dementia Care Costs: Facts & Figures. Retrieved July 17, 2017, from https://www.seniorhomes.com/p/alzheimers-care-costs/
Social Security Administration. (2017). Retrieved September 2017, from Social Security Administration: https://www.ssa.gov/pubs/EN-05-11125.pdf
Selder, Christina and Christine Murphy (2017). Long-Term Housing for an Age-Friendly San Diego: A Review and Assessment of Assisted Living Accessibility
 In California, as of 2017, the amount is set not to exceed the annual nursing home rate of $51,804, plus the estimated state plan costs of $5,258.