Assisted living operators that provide home- and community-based services to residents who are Medicaid beneficiaries could be affected as states continue to come into compliance with the provisions of the HCBS settings final rule, suggests the results of a KFF survey of state Medicaid HCBS programs.

One expert said that even providers that don’t provide HCBS would benefit from becoming familiar with its provisions.

The HCBS settings final rule in part is meant to protect beneficiaries’ autonomy in making choices and controlling decisions that affect their lives. Senior living industry advocates, however, had warned that the regulation could lead assisted living communities to stop accepting Medicaid as a payment source, causing some residents to need to move to nursing homes or other settings.

In 2023, 47 states provided HCBS through a combination of 1915(c) waivers — used by assisted living operators to provide such services — and 1115 waivers. Currently, 18% of assisted living residents rely on Medicaid to pay for daily services, and 61% of all assisted living communities are Medicaid-certified, according to the National Center for Assisted Living.

In their analysis, the KFF researchers included challenges for states and anticipated effects on those served, and they referenced a white paper released by LeadingAge that was issued this summer and recommended a two-year enforcement moratorium on the rule.

Alice Burns, associate director of the KFF Program on Medicaid and the Uninsured, told McKnight’s Senior Living that the assisted living communities that would be helped the most by the KFF report are those located in states that have not finished implementing the Medicaid HCBS settings final rule.

But even settings that aren’t affected by the final rule might want to become familiar with its provisions, as they could be a preview of what might be coming with an update to Section 504 of the Rehabilitation Act, which Burns calls a “what to watch” rule.

That update could have implications for assisted living providers, she said, because it addresses discrimination and would apply to any provider that takes federal money. So even providers that aren’t paid through a Medicaid waiver could be affected if they provide home health or personal care services. 

The comment period on Section 504 is now closed, but Burns said that the Section 504 rule is so broad that it could affect most assisted living communities. 

“It’s one of those things that if facilities are already in compliance with the HCBS settings rule, the 504 rule probably is not going to add a whole lot more challenges,” Burns said. “But for those who don’t take money from a waiver, or they’re in a state that is not yet in compliance, this rehabilitation rule could be a bigger deal.”

Profile of LTSS users

Another KFF report Burns said would be of interest to both assisted living communities and nursing homes looked at the age distribution of people using long-term services and supports. According to KFF, 6 million people receive Medicaid LTSS.

People aged fewer than 65 years tend not to live in assisted living and are served in their homes or in the greater community. But for adults aged more than 65 years — the assisted living target population — healthcare care plays a much bigger role in long-term care needs fulfillment, Burns said. 

The researchers found that 56% of Medicaid LTSS users are aged fewer than 65 years and are using HCBS, whereas most older adults who use LTSS services are in institutional settings such as nursing homes. Most (62%) of Medicaid enrollees who use LTSS also are enrolled in the Medicare program or are dually eligible for both Medicare and Medicaid. The data, the authors concluded, suggest a consistent unmet need for services, contributing to the risk of unnecessary institutionalization for people with disabilities.

“It points to the fact that one of the barriers to moving more older people into HCBS is that it’s harder to have Medicaid coverage when you’re in assisted living,” Burns said. “You talk about demographics and this interesting age pattern emerges.”

Heightened state regulation, dementia care support, the rise of active adult communities and the increased provision of home- and community-based services to Medicaid beneficiaries are among the top trends that will shape the senior living industry in the coming year, according to a panel of industry experts.

Health Dimensions Group, a management and consulting firm serving senior living and care providers, hosted a panel discussion Tuesday ahead of the release of a white paper on the top trends in aging services for 2024.

State regulation ‘ramping up’

In many states, assisted living has shifted from an apartment setting offering meals and minor assistance into a comprehensive care environment, according to HDG CEO Erin Shvetzoff Hennessey. With the increasing service and care needs of residents, however, comes an increase in state regulations for providers.

“Regulation is ramping up,” Hennessey said, adding that one-third of the states updated their assisted living requirements between 2020 and 2022, and some states are looking at assisted living the way they look at skilled nursing facilities.

“This puts a lot of pressure on providers to continue the lifestyle our assisted living residents desire — that dignity and freedom; we have to balance that with our regulatory requirements,” she said.

Among the strategies Hennessey recommended for addressing residents’ increased needs and resulting regulation in assisted living? Be proactive and conduct third-party mock surveys, implement new technology to monitor and respond to clinical needs, and identify the health-related requirements of residents and staffing levels required to meet them. 

With the increasing number of people living with Alzheimer’s disease and related dementias, she added, some assisted living operators might consider specializing in providing memory care and services.

She suggested that providers evaluate the financial feasibility of using the Guiding an Improved Dementia Experience (GUIDE) Model initiated by the Center for Medicare & Medicaid Services to improve quality of life for residents living with dementia, reduce strain in their unpaid caregivers and enable individuals to remain in their senior living communities or homes.  

The rise of active adult

On the other end of the spectrum is the active adult category, which was defined by the National Investment Center for Seniors Housing & Care in 2022. The definition, Hennessey said, triggered a turning point for the rental property type, moving it from a trend to a sustainable product.

The active adult community type, she said, represents an opportunity for operators to extend stays in the continuum of care while meeting consumer demand for communities that support an active lifestyle. A surge of development of active adult communities, she said, has been created by those already immersed in the model, senior housing providers eager to offer housing options earlier in the continuum and housing owners not traditionally associated with senior living. Some operators are repurposing existing housing and independent living units into active adult communities, she said.

“Significant changes in the later average age of entry and subsequent shorter length of stay [on other parts of the continuum] is driving the move to active adult for senior living providers,” Hennessey said, adding that operators need to tailor active adult environments to younger, more active individuals looking for social and physical engagement in a maintenance-free setting with resort-style amenities.

“I think consumer demand, mixed with developer, owner and industry interest, will combine to see a lot of growth in this space in 2024,” she said.

Medicaid HCBS increasing

The movement from care in institutional settings to HCBS settings, including assisted living communities, has been a trend over the past 20 years that escalated with the COVID-19 pandemic, according to panelist John Capasso, HDG executive adviser of senior care.

Several factors have converged to lead to the increase in HCBS, including increased Medicaid funding, decreases in labor availability, changing consumer preferences and increased Medicare Advantage plan use. 

The American Rescue Plan Act of 2021 devoted $37 billion to states, which used the funding to transition care from institutions to the home. Many states also are implementing managed long-term services and supports, which aim to improve care coordination, enhance beneficiary choice and promote community integration through case management, personal care assistance and home health services. 

In response to the shifting funding to HCBS, Capasso said, long-term care providers must educate themselves on the national and state level changes to HCBS funding and conduct demand and feasibility studies to understand how that shift in funding will affect occupancy. He also suggested that providers partner with Medicaid managed care programs to provide services.

“Take stock of the services you can provide, and approach a Medicaid managed care organization to see if you can contract with them for those services,” Capasso said. 

HDG will release its white paper later this week.

He was one of the experts who during a webinar shared predictions of trends that will shape aging services providers in the coming year.

The decline in the number of long-term care deals is “most likely due to the Fed policy of having raised rates continuously since March of 2022 in an effort to curb inflation, though a slower recovery in occupancy, increased operating costs and challenging labor markets have added to seniors becoming a less desirable commodity,” Branin said.

Higher capitalization rates are partly to blame as well, he added.

“As capital becomes constrained, the potential to invest resources, whether they be financial or human, into turnarounds becomes limited,” Branin said.

It might be a good time to divest of assets that have been a drain on resources and have had a negative effect on a provider’s bottom line, according to Branin.

“Regional team alignment can provide growth opportunities as well as ensuring that you have the right person in the right seat,” he said.

Funds move away from nursing homes

Another trend affecting aging services providers is “the transformation of Medicaid funding for home- and community-based services,” HDG CEO and Principal Erin Shvetzoff Hennessey said. 

The shift of Medicaid funding from institutional settings such as nursing homes to HCBS settings such as the home and assisted living communities is not new, according to John Capasso, executive adviser of senior care at HDG. 

“I think it’s important to note that this has been a trend over the past 20 years or so … [and] has continued to escalate” since the pandemic, he said. Additionally, he said, there has been an increase in Medicaid funding directed toward HCBS.

“The convergence of factors resulting in increased home- and community-based services has … decreased the occupancies of nursing homes,” Capasso said. “There are a lot of factors that could contribute to declines in occupancy, but the transition to patients being cared for in their homes rather than in institutions is an important factor and related to this Medicaid funding that’s occurring.”

He also noted that many states used American Rescue Plan Act of 2021 funds to transition care from institutions such as nursing homes to HCBS settings.

Older adults, particularly the baby boomers — those born between 1946 and 1964 — prefer to age in place in their own homes until it is medically necessary to move to a care setting, Hennessey stated. They tend to wait until they have chronic health issues or difficulty with activities of daily living, she added.

“What we have seen from that is assisted living really shifting from a safe apartment with some meals and minor assistance to a really comprehensive care environment that’s taking care of the whole person,” Hennessey said.

Half of assisted living residents have three or more chronic conditions, and more than 40% have Alzheimer’s disease or dementia, she said.

‘We really recommend watching’ active adult

Hennessey noted that 2022 was a turning point for the relatively new active adult segment. That’s when the National Investment Center for Seniors Housing & Care developed a definition for the community type. And the trend is not going away, she said.

“This is an area that we really recommend watching in the year ahead. While we’re seeing increased acuity in other settings, this is really a place for younger seniors to age and enjoy life,” Hennessey said. “This is also a great option as you’re balancing out how to provide care with much less staffing. So this setting really lends itself to a younger, healthier group of seniors.”

Among other long-term care industry trends discussed by the panelists were the changing aging services employment landscape in light of CMS’ proposed minimum staffing rule for nursing homes, growth in Programs of All-Inclusive Care for the Elderly, skilled nursing facilities challenges and the evolution of hospitals’ post-acute strategies.

For more coverage of the webinar, see McKnight’s Senior Living and McKnight’s Long-Term Care News.

The majority of those funds are being used to help providers retain, recruit and train care workers as well as to provide bonuses and pay increases for such workers.

The provision for HCBS “has ended up being the most significant down payment on the efforts to our vision of quality home- and community-based care for all Americans,” White House American Rescue Coordinator Gene Sperling said Tuesday during a panel discussion.

Not everyone has the financial means to provide the best in HCBS for their loved ones, Health and Human Services Secretary Xavier Becerra noted.

“That’s what this American Rescue Plan initiative is all about. It is elevating those we care about most so they can spend their last years, or maybe it’s last decades, in comfort with those they love most at home or in a community-based setting,” he said. 

Regarding direct care workers, Becerra said, “We want you to make more money than the folks that are flipping burgers in that hamburger joint down the street. But we know that we have to do better, and that’s why it’s so important that we do the work together.”

At the state level, for example, according to the White House, Colorado is using ARP funds to substantially raise base wages for as many as 60,000 HCBS workers. The state not only raised wages for those workers; it also has provided grants to boost training.

And Maine’s government provided bonuses to more than 24,000 direct care workers in every county in the state, at $3,429 per worker.

North Carolina used 80% of its ARP funds to give raises to direct caregivers and to establish a Direct Care Jobs Innovation Fund to support initiatives that improve recruitment and retention among the direct care workforce.

The Centers for Medicare & Medicaid Services also released new guidance outlining how states can use worker registries for Medicaid-funded HCBS “to ensure beneficiaries have awareness of and access to qualified workers to deliver these critical services,” Vice President Kamala Harris said in a related press release.  

“The registry will help families locate that excellent caregiver without having to go through all the headaches and not know where to navigate,” Beccera said. “This registry will help so many people understand who is out there and qualify.”

A recent study seeking to uncover the largely “hidden circumstances” preceding and following older adults’ transition into residential care settings called out the need to strengthen long-term services and supports.

Assisted living and nursing home residents experienced severe disabilities and escalating help at home, usually from unpaid caregivers, in the year leading up to a move into a long-term care setting. That’s according to an examination of 10 years of data from the National Health and Aging Trends Study, said researchers from the University of California, San Francisco; the San Francisco VA Health Care System, University of Colorado School of Medicine, Rocky Mountain Regional VA Medical Center and the VA Eastern Colorado Geriatrics Research Education and Clinical Center. 

Along with improving LTSS for older adults and their families, the authors also suggested the data would help clinicians understand when home supports approach a breaking point.

The study, published in JAMA Internal Medicine, found assisted living residents, who reportedly received 18 hours of caregiving per week, move when they are less disabled. But they approach disability levels similar to nursing home entrants within two years of admission. 

The average nursing home entrant received 27 hours of caregiving per week before moving, and only one-third of those individuals had paid caregivers, leaving the burden to unpaid caregivers. The authors said the data help inform decisions on how much HCBS may be needed to facilitate aging in place with dignity. 

“If HCBS programs cannot support 27 or more hours of care per week per person, we must acknowledge long-term care facilities provide substantial relief for caregivers and ensure nursing homes and assisted livings are staffed to support and maintain quality of life in severely disabled residents,” the authors wrote.

The researchers noted that residents and family caregivers want healthcare professionals to provide more guidance around disability and long-term care planning during later stages of life, with specific information on when more care is needed and how circumstances will change for both residents and caregivers once someone transitions to long-term care. 

Conversely, healthcare professionals admitted to lacking evidence to make unbiased and evidence-based recommendations for care settings for older adults. 

“We hope these findings help clinicians better understand ‘who lives where’ to inform long-term care facility decision-making and estimate when home supports are critically strained,” the authors wrote. 

They also hoped their findings inform policy, noting that with only one-third of nursing home and assisted living entrants having any paid caregiver, home- and community-based services programs may be underutilized. 

A window into disability, caregiving dynamics

In commentary on the study, researchers from the Johns Hopkins Bloomberg School of Public Health and the University of Michigan said the study is important because understanding of the dynamics of late-life function, care needs and transitions across residential settings is limited. 

In fact, they said, less than 2% of older adults move to residential care each year. And in 2020, roughly 80% of the 7.5 million adults aged 70 and older receiving help with self-care or mobility activities were living in the community. State strategies to rebalance Medicaid spending away from institutional settings and into HCBS likely will shift even more care into community settings.

They said the study provides a window into the disability and caregiving dynamics of older adults transitioning from the community to a residential care setting, including “precipitating care needs, limited use of paid help, and extensive hours of uncompensated care.” 

“Understanding the high levels of family caregiving to older adults, regardless of whether a residential transition is imminent, is an important step to establishing policies and practices that promote person- and family-centered care,” they wrote.

Item: Report: Alternative approaches to senior living, LTSS needed for growing older adult population

The gist: A recent story highlighted a report from the Harvard Joint Center for Housing Studies, revealing that only 13% of adults aged 75 or more years, living alone across 97 metro areas, can afford to move into an assisted living community without depleting their assets.

Why this matters: We’re hearing a lot these days about the need to serve the so-called middle market. (I say “so-called” because industry views on the meaning of that range can vary considerably.) What this report makes clear is that the senior living sector more than has its work cut out here. Success is not just going to be a matter of paring options and operating costs to the bone — although that, too, likely will need to be a part of the equation. Essentially, those findings suggest operators will need to re-imagine how to reach this market. And that, my friends, is going to be a very heavy lift.

Item: CCRCs continue to report higher occupancy than other senior living segments

The gist: Continuing care retirement / life plan communities continued to outpace non-CCRCs in senior living occupancy in the third quarter, according to a data analysis from specialty investment bank Ziegler.

Why this matters: At first glance, the implication is obvious: These are good times to be running CCRC / life plan communities. Part of the advantage is that CCRCs often can charge higher entry fees and monthly rates. So everyone should want to become a CCRC, right? Not so fast. Many of these campuses have a 60-acre or larger footprint, which can be a substantial barrier to entry. Moreover, the full-service aspect of CCRCs can backfire, especially if one component of the portfolio — such as skilled care — hits hard times. Then what? It’s worth noting that the things that make CCRCs formidable also can hamper them when times are tough.

In case you didn’t notice, there is no single silver bullet when it comes to ensuring success in senior living.

Probably best to focus on finding many good bullets instead.

John O’Connor is editorial director for McKnight’s Senior Living and its sister media brands, McKnight’s Long-Term Care News, which focuses on skilled nursing, and McKnight’s Home Care. Read more of his columns here.

Expanding access to home- and community-based services is the recommendation from a new report from the Schwartz Center for Economic Policy Analysis on unmet care needs among the nation’s older adults.

Using data from the 2020 Health and Retirement Study, the policy note released Tuesday reported that nearly 20% of adults 55 and older — some 20 million people — had difficulty with one or more activities of daily living (ADLs) or instrumental activities of daily living (IADLs). Roughly 8.3 million of those individuals do not receive the help they need. 

Only 23% of adults 55 and older who had difficulty with ADLs or IADLs receive care from a paid professional, including assisted living, home care or skilled nursing facility care. But the report noted that professional care is “prohibitively expensive” for many. The average cost of assisted living in 2016 ranged from about $3,600 to $6,800 monthly, depending on accommodations, while hourly rates of home-based care were roughly $20 per hour. 

The nation’s long-term care system, the report authors noted, puts these individuals at greater risk of injuries and harm.

“Seniors who do not get the care they need are more prone to accidents and have more negative health outcomes, such as more emergency department visits and increased risk of mortality,” the report read. “Research shows that unmet long-term care needs of older adults are associated with higher disability levels.”

Stuck in the middle

The report also found that access to care is not entirely based on wealth. Significant shares of people in all wealth quartiles don’t receive the care they need. Lower-income adults qualify for public assistance through Medicare, Medicaid or other insurance, while wealthier adults can afford professional care — including private pay assisted living, home care or skilled nursing facility care — through private funds. That leaves the middle class most unable to access care. 

Between 42% and 48% of people across all wealth quartiles do not receive any care despite having difficulties with ADLs or IADLs. The authors noted this lack of a wealth gradient was explained in part by different family structures and caregiving behavior across communities. 

Many lower- and middle-income families, for example, provide unpaid family care to older loved ones, while higher income households either pay for professional care, reduce their work hours or quit their jobs to care for older loved ones.

“The gaps in care across the wealth distribution underscore the necessity of universal care for all elderly people,” according to the authors. 

State variances complicate matters

The SCEPA report recommended expanding access to Community Medicaid to help older adults access the care they need while relieving the burden on unpaid family caregivers. Community Medicaid provides financial subsidies to Medicaid beneficiaries through two programs — home- and community-based services waivers, and Aged, Blind and Disabled Medicaid.

But the authors noted that access to these programs varies significantly across states. Even meeting eligibility requirements does not ensure access to Community Medicaid due to additional enrollment caps and years-long waiting lists in some states. Thirty-eight states have HCBS waiting lists, with a combined nearly 700,000 people waiting for services, according to a recent KFF analysis of state Medicaid HCBS programs. 

Expanding access and raising enrollment caps in all states, but especially in states with long waiting lists or low-income and asset-eligibility caps, can help remove the disproportionate burden from family caregivers to ensure access to care for everyone, the authors concluded.

“We are specifically focused on adults ages 55 and older, because we are interested in individuals who are facing disabilities and difficulties due to conditions related to aging,” Forden said. “We use 55 and older instead of a higher cutoff like 65+ as some other analyses do, because the higher age cutoff ignores an important group of adults who also have difficulties but are not likely to qualify for Medicare or assistance through Medicaid.” 

Forden added that if the needs of this population go unmet, then there is a potential need for greater services as they age. Although those adults may not need nursing home or other care of that nature, they may need some form of day-to-day assistance.

“We wanted to make sure that we were capturing these gaps in addition to folks who might need a more intense level of long-term care as well,” she said.

Single people have a harder time accessing the care they need. According to SCEPA, 60% of adults aged 55 or more years who have a spouse or children receive some form of care, compared with only 42% of those without a spouse or children. 

“Now, this is because eldercare in the US is just so heavily dependent on the often unpaid labor of family caregivers,” Forden said. “In fact, family care is the most common source of eldercare, and in our report, you’ll see that in 2020, over half of adults who needed care got it from an adult child or grandchild, and 44% received care from a spouse. That’s compared to only 23% of adults receiving care from a paid professional.” 

Additionally, the data show that health demographics affect the level of care for those 55+. 

“When we look at professional care specifically, a wealth pattern is very apparent,” Forden said.

The least wealthy and the wealthiest among us are most likely to get taken care of, she said, as higher-income adults are more able to afford professional care, and those with the least means are most likely to qualify for public programs that will subsidize the cost of or outright pay for care.

“And what this means is that policies like Medicaid, community Medicaid, miss those in the middle class who likely still can’t afford the increasingly expensive professional care options on the private market and will otherwise have to depend on family care if they have folks who can provide that care,” Forden observed.

For additional coverage of the SCEPA report, visit McKnight’s Senior Living.

Certification of a class-action lawsuit against New Hampshire’s home- and community-based services waiver program could be the catalyst for elevating assisted living as a viable Medicaid option, according to one senior living organization.

A federal judge certified a class-action lawsuit last week against the New Hampshire Department of Health and Human Services for placing recipients of its HCBS waiver program at “serious risk of unjustified institutionalization” by failing to ensure those services are provided.

Choices for Independence, New Hampshire’s Medicaid waiver program, provides HCBS to nearly 3,800 adults who would otherwise be Medicaid-eligible for nursing home care. Some assisted living providers provide HCBS to residents under the waiver program. 

A lawsuit against the program was filed in January 2021 in US District Court in New Hampshire by New Hampshire Legal Assistance, the Disability Rights Center-New Hampshire and the AARP Foundation. After initially denying a motion for class certification, Judge Paul J. Barbadoro ruled on Nov. 27 that there was evidence that hundreds of people could face “unjustified institutionalization” due to CFIs failure to ensure eligible individuals received eligible community-based long-term services and supports.

Earlier this year, agencies that provide HCBS services through the CFI program — including assisted living providers — told lawmakers they could no longer afford to participate in the program without significant rate increases. 

State legislators passed a state budget in June that gave providers a 3% increase in Medicaid payments in July, with additional raises coming in January. But the groups filing the lawsuit said the increase would address only workforce shortage issues, and would not correct the program’s shortcomings, including its failure to ensure CFI recipients receive approved services. 

The suit could shine a light on assisted living as a viable HCBS option, according to Brendan Williams, president and CEO of the New Hampshire Health Care Association. He told McKnight’s Senior Living that too few providers are willing to take on Medicaid contracts because the “rates are just so terrible.”

“Too often, assisted living is treated as a middle child when it comes to home care and nursing homes — it’s the Jan Brady of long-term care,” Williams said.

And while the state made “solid progress” in the last legislative session on funding in home care, it only made “marginal progress” in improving funding for assisted living. 

“We really do need a game-changer when it comes to placing a greater priority on making assisted living an option for Medicaid residents,” Williams said. “I hope that will emerge from this litigation.”

The state recently embarked on a gap analysis of its HCBS system to improve and promote community integration, independence and a robust system of LTSS for older adults and people living with disabilities.

As the state of New Hampshire embarks on a gap analysis of its home- and  community-based services system, one senior living organization leader is cautioning against a “Hunger Games” scenario that pits one setting over another.

The nonprofit Human Services Research Institute and the University of New Hampshire’s Center on Aging and Community Living are conducting an assessment and gap analysis of the state’s HCBS system, with a goal of providing recommendations for improvements that promote community integration, independence and a robust system of long-term services and supports for older adults and people living with disabilities. 

Through public forums, the organizations will look at the availability of HCBS services across the state, use rates for those services, HCBS provider capacity, nursing facility usage, and the experiences and preferences of those using HCBS services. 

Brendan Williams, president and CEO of the New Hampshire Health Care Association, said that the COVID-19 pandemic led to historic federal and state resources for Medicaid programs, including providing that care in assisted living communities through HCBS waivers. But assisted living’s role in the state’s “fragile long-term care system” must be recognized, he added.

“While the influx of funding for in-home care has been a positive, assisted living is a very rare Medicaid option, given low state payments,” Williams said. “If assisted living is to be a meaningful Medicaid option, as much attention must be paid to it as is being paid to in-home care.”

He added that although NHHCA supports HCBS, he’s wary of any “Hunger Games” scenario where any long-term care setting could be disadvantaged over another.

“We view the system as fragile and interdependent,” Williams said. 

New Hampshire passed a state budget in June that gave providers a 3% increase in Medicaid payments. It began in July, with additional raises coming in January. A portion of those increases were targeted at the Choices For Independence, or CFI, waiver program, which provides almost 3,800 individuals from the Granite State with help at home or in a small community setting, according to the New Hampshire Bulletin. 

Chris Kelliher, the administrator at the Villager Assisted Living Home in Goffstown, NH, said that assisted living operators are looking for an increase in CFI rates that comes closer to covering their costs. Those rates will be announced by the state in December and will go into effect in January.

The operator of the small assisted living community said all residents move into the community as paying with private funds, but once they run out of resources and turn to Medicaid or the CFI waiver, he accepts that payment, knowing he will lose approximately $500 every month per resident.

“It does put places in a precarious position,” he said, adding that he has an almost two-year waiting list. “It’s a big gamble that a lot of facilities take when they do CFI. A lot of facilities aren’t willing to gamble, because they’re gambling on their future.”

Assisted living operators, Kelliher said, aren’t asking for an “astronomical” rate increase, just something closer to the private-pay rates.

Using funding from the Centers for Medicare & Medicaid Services’ Money Follows the Person Demonstration Expansion award, the state plans to evaluate its long-term services and supports system, including the CFI waiver. A final report is expected in June.