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 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. 

Background

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.[1]

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.  AB 50 (Kalra), introduced in the 2019-2020 legislative session, is currently moving through committees and seeks to increase the number of waiver slots to 18,500.

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 April 2019, statewide there are 335 assisted living facilities out of 7,320 designated as open for enrollment

Program Details

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. 

Table I: 2017 ALWP Levels of Care, Reimbursement Rates & Participation
Tier Level Daily Reimbursement Rate Percentage of ALWP Enrollees in Tier Level
1 $55/day 33%
2 $66/day 17%
3 $75/day 28%
4 $87/day 22%

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).

Table II: 2017 ALWP Plus SSI Monthly Reimbursement Rates
Tier Level Monthly ALWP Rate Monthly SSI Rate Total Monthly Reimbursement
1 $1,673 $1,102 $2,775
2 $2,008 $1,102 $3,009
3 $2,281 $1,102 $3,383
4 $2,646 $1,102 $3,748

San Diego

Since 2014, California has received approval from the Centers for Medicare and Medicaid Services (CMS) to operate ALWP in San Diego.  Currently, there are 42 facilities out of 595 enrolled in the program.  

CARR did a quick review of San Diego's ALW facilities' compliance histories:

  • 57% of facilities have fewer than 5 citations since 2014. In contrast, almost 24% of facilities have more than 10 citations.
  • 2 facilities are on probation with the Department of Social Services, Community Care Licensing Division (CDSS/CCLD) for failing to properly care for their residents.
  • The largest number of citations for a San Diego ALW provider is 51; the lowest is 0.

The number of citations is important, but it does not tell you about why the citations were given.  Older adults and their families can check an ALW provider's compliance history at CCLD's Transparency Website.  For a list of facilities enrolled in California's ALW program, click here.

 

Works Cited

 

California Department of Health Care Services. (2019, 2017). C. Selder.

California Department of Social Services. (2019, 2017). 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

 

 

 

 

 

 

 

 

 

 

 

 

 


[1] 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. 

 

Data & Research

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