TABLE 4. Details of Rate-Setting Methodology for Services Delivered in Residential Care Settings by State, 2016

State	Medicaid authority	Rate-setting methodology¹	Description
Alabama	Services not covered	N/A	N/A
Alaska	Section 1915(c) HCBS waiver	Flat or cost based, whichever is lower	Providers are reimbursed at the lesser of (1) billed charges or (2) a unit rate based upon an established fee schedule. The fee schedule is revised at least every four years based upon provider-reported costs.² The unit rate varies by facility type (government-owned versus non-government-owned), size of facility (5 or fewer beds, 6–16 beds, 17 or more beds), and geographic region. Providers receive an acuity add-on payment for residents who require one-to-one staffing care 24 hours per day.
Arizona	Section 1115 demonstration waiver	MCO-negotiated	Payments are based on a per diem rate for a 24-hour day that MCOs negotiate with providers. The state enacted a 1.5 percent increase in HCBS-contracted rates, effective October 1, 2015. MCOs are required to pass through this increase to all HCBS providers.
Arkansas	Section 1915(c) HCBS waiver State plan personal care	Tiered Tiered fee-for-service	A four-tiered rate schedule is used to reimburse providers for all direct care services in a participant’s care plan. Tier assignment is based on an assessment process that determines a participant’s level of need for assistance with activities of daily living (ADL) and the participant’s psychosocial or cognitive status. The daily service rate paid for personal care services is determined by beneficiaries’ level of care, which is based on their service plans. The state designates 10 levels of care, each based on the average number of 15-minute units of service per month required to fulfill a beneficiary’s service plan. The reimbursement system has maximum allowable fees.
California	Section 1915(c) HCBS waiver Section 1115 demonstration waiver	Tiered Tiered	Medi-Cal’s reimbursement system has five service levels for residential care facilities for the elderly (RCFEs). Daily rates range from $52 per day for tier 1 to $200 per day for tier 5. RCFEs cannot negotiate the services to be delivered or the payment rate. The reimbursement rate for tier 5, is based on the statewide weighted average skilled nursing facility rate.² Starting in 2015, assisted living waiver program participants who reside in certain counties were required to enroll in a Medi-Cal managed care plan that covers health care services and LTSS. The beneficiaries remain in the waiver program, program providers continue to provide waiver services, and the tiered rates remain the same.
Colorado	Section 1915(c) HCBS waiver	Flat fee-for-service	The state’s Section 1915(c) HCBS waiver program for persons who are elderly, blind, or disabled uses a fee-for-service (FFS) methodology for Medicaid-covered personal care services in alternative care facilities. The total reimbursement is equal to the FFS rate multiplied by the number of units provided. FFS rate schedules are published annually through the Department of Health Care Policy and Financing provider bulletin and posted to the department’s website.
Connecticut	Section 1915(c) HCBS waiver Section 1915(c) HCBS waiver	Case mix Tiered negotiated	The Section 1915(c) personal care waiver program covers services in adult family living/foster care settings. Providers receive a base rate plus additional amounts based on individual participants’ assessed cognitive, functional and behavioral needs. The Section 1915(c) HCBS waiver program for the elderly covers services in residential care homes. For assisted living services, residents are assessed at one of four different service levels based on their nursing or personal care needs. Each service level is reimbursed at a per diem rate established by the state. There may be different per diem rates for each of the assisted living services depending on the negotiated rate by the assisted living service agency with the state.
Delaware	Section 1115 demonstration waiver	MCO-negotiated	Rates are negotiated between MCOs and providers.
District of Columbia	Section 1915(c) HCBS waiver	Flat	The assisted living services rate is a flat per diem all-inclusive rate for all services provided in the setting. Providers cannot bill for individual services.
Florida	Section 1915(b)/(c) waiver State plan personal care	MCO-negotiated Flat	Rates are negotiated between MCOs and providers. The MCOs have the flexibility to determine their payment models. A single daily rate is paid per resident.
Georgia	Section 1915(c) HCBS waiver	Cost based	The state reimburses providers the lesser of (1) the established maximum fee-for-service rate, or (2) the actual amount billed by the provider. Currently, waiver services are reimbursed at an average rate that is 74 percent of comparable private-pay rates.
Hawaii	Section 1115 demonstration waiver	MCO-negotiated	Rates are negotiated between MCOs and providers.
Idaho	Section 1915(c) HCBS waiver State plan personal care	Case mix Tiered	A daily rate is paid based on the number of hours and types of assistance required by the participant as identified in the Uniform Assessment Instrument.³ The rate is based on residents’ care level and assigned one of four levels. Each level is converted to a specific number of hours of personal care services. Reimbursement Level I: 1.25 hours of personal care services per day or 8.75 hours per week. Reimbursement Level II: 1.5 hours of personal care services per day or 10.5 hours per week. Reimbursement Level III: 2.25 hours of personal care services per day or 15.75 hours per week. Reimbursement Level IV: 1.79 hours of personal care services per day or 12.5 hours per week. Level IV is assigned only when there is a documented diagnosis of mental illness, intellectual disability, or Alzheimer’s disease.
Illinois	Section 1915(c) HCBS waiver Section 1915(b) waiver	Flat MCO-negotiated	A flat daily rate is paid. While the rate does not vary by type or frequency of service, it does vary by geographic location. Rates are calculated at 60 percent of the average weighted nursing facility rate in a specific geographic area. The dementia program rates are 72 percent of the average weighted dementia care nursing facility rate in a geographic area. Geographic areas used by the Medicaid agency to determine rates are health service areas developed by the state. Rates are negotiated between MCOs and providers.
Indiana	Section 1915(c) HCBS waiver	Flat or cost based	Providers receive the lesser of (1) a per diem reimbursement of $39.35, and (2) the private pay per diem rate.
Iowa	Section 1915(c) HCBS waiver	Cost based	Fee schedules for the various services are determined by the Department with advice and consultation from appropriate professional groups. Providers are reimbursed the lower of (1) their actual charges, or (2) the maximum allowance under the fee schedule for the service. Fee schedules may be increased or decreased by the Iowa legislature through its Medicaid appropriations.⁴
Kansas	Section 1115(a)/ 1915(c) combination waiver program	MCO-negotiated	The state determines rates and oversees the process to ensure that actuarially sound methods are used, including the use of historical claims data. Under KanCare, the state sets minimum HCBS service rates that MCOs are required to pay providers. Personal care services in assisted living facilities are reimbursed based on the residents’ assessed needs as identified on their care plans.
Kentucky	Not covered	N/A	N/A
Louisiana	Not covered	N/A	N/A
Maine	State plan personal care	Case mix	The state utilizes a case mix-adjusted pricing methodology with three peer groups for medical and remedial services provided in private non-medical institutions, a type of residential care facility.⁵
Maryland	Section 1915(c) HCBS waiver	Tiered	Assisted living facility residents are assessed as requiring one of three levels of service. Reimbursement is not provided for Level I because residents at this level do not meet nursing facility level of care. Only residents who are assessed at Level II or Level III are eligible to receive waiver services.
Massachusetts	Section 1915(c) HCBS waiver State plan personal care	Flat Tiered for foster care; Flat FFS for personal care attendant services	Assisted living service providers are paid at a flat per diem rate that does not account for individual residents. The state developed its rate using a combination of existing rates for comparable service components based on projected units per week, and an analysis of provider cost data. The rate development process started with an analysis of available data, including but not limited to provider costs, labor rates, other economic market information, utilization, and public agency spending. A cost adjustment factor was added to account for projected inflation anticipated during the prospective rate period. Waiver participants can enroll in Senior Care Options, the state’s managed LTSS. Information about rate setting and payment methodology is not available. The state uses a two-tiered rate system for adult foster care providers. The tier is determined by an individual assessment. Personal care attendant services that are part of an individualized care plan are paid on a fee-for-service basis at 15-minute increments ($3.88 per 15-increment in 2015).
Michigan	State plan personal care	Case mix FFS	Rates vary depending on the setting, residents’ needs, and payment levels determined by policy or the legislature. Residents’ care needs are determined by an assessment. Tasks are assigned minute values and the minutes are converted to hours and billed as a total (of hours) at the end of the month. The Medicaid case manager conducting the assessment is permitted to authorize services up to a specified level. If a resident’s needs are extensive or intensive enough to require more or more costly services, designated local agencies can make exceptions to the maximum specified authorization level, with supervisory approval. For cases exceeding the designated local agency’s maximum authorization level, decisions are referred to the single state agency to consider the documented need.⁶
Minnesota	Section 1915(c) HCBS waiver	Case mix	For both the state’s 1915(c) elderly waiver and the 1915(c) waiver program for individuals with disabilities, rates are set using a statewide customized living tool that incorporates case-mix dependency criteria as the basis for determining the rates. For waiver participants enrolled in a managed care plan, the state sets the methodology, and the MCOs review and approve values to calculate the final payment rate for each individual. MCOs must notify the individual and the service provider of the final agreed-upon values and rate.⁷
Mississippi	Section 1915(c) HCBS waiver	Flat	In their waiver application the state adjusted projected service rates for years beyond the initial rate year based on an expected 2 percent annual increase in accordance with the Bureau of Labor Statistics and the Consumer Price Index.
Missouri	State plan personal care	Tiered	The state has tiered rates based on the type and frequency of services required for each resident. The rate paid to providers for each service tier is determined by state appropriations.
Montana	Section 1915(c) HCBS waiver	Cost based	The state reimburses providers the lesser of (1) the provider’s usual and customary charge, and (2) the negotiated rate up to the Department’s maximum allowable fee.
Nebraska	Section 1915(c) HCBS waiver	Flat FFS	The state pays providers fixed fee-for-service rates for assisted living services. Rates vary to account for rural and urban cost differences and differences in costs for single and multiple occupancy units.
Nevada	Section 1915(c) HCBS waiver Section 1915(c) HCBS waiver	Flat Tiered	Under the waiver program for persons with physical disabilities, providers receive a flat per diem rate of $105 per day. For the frail elderly waiver program, the state uses a tiered rate system based on three levels of care for each individual that range from minimal assistance with an ADL to maximum assistance with four or more ADLs.
New Hampshire	Section 1915(c) HCBS waiver	Flat for residential care; tiered for adult family care	Residential care facility providers are paid a flat per diem rate. Adult family care providers are paid using a two-tiered rate system for two levels of care.
New Jersey	Section 1115 demonstration waiver	MCO-negotiated	MCOs negotiate per diem rates with providers. Additional information about rate setting and payment methodology is not available.
New Mexico	Section 1115 demonstration waiver	MCO-negotiated	MCOs negotiate daily rates with providers. Additional information about rate setting and payment methodology is not available.
New York	State plan personal care	Tiered	Providers are paid rates based on 16 classification groups. The rate is related to an average residential health care facility rate consisting of a direct component and an other-than-direct component. The direct component of the rate for each classification group is determined by a statewide mean direct case mix neutral cost multiplied by a case mix index for the classification group; this amount is divided by a regional direct input price adjustment factor for the patient classification group and trended by the applicable weighted average regional roll factor.
North Carolina	State plan personal care	Flat FFS	Providers are paid for each 15 minute unit of care at a rate of $3.58 per unit up to a maximum number of hours.
North Dakota	Section 1915(c) HCBS waiver State plan personal care	Case mix Case mix FFS	Provider rates are determined based on a formula and factor-based system that considers the tasks required to care for specific residents. Each allowable task has an identified point factor. The total points are multiplied by a factor unique to the specific service. The factor formula then calculates a daily rate. If the rate is at or lower than a state-specified limit, the provider is notified of the assigned rate. If the rate is greater than the limit, the rate is reduced and the provider is notified of the rate. Providers are paid a prospective per diem rate. The maximum per diem rate for an individual or agency provider is established using the provider’s allowable hourly rate multiplied by the number of hours per month authorized in a client’s care plan multiplied by twelve and divided by 365. Providers may bill only for days in which at least 15 minutes of personal care service were provided to a resident. The maximum per diem rate for an individual or agency may not exceed the maximum per diem rate for a residential care provider.
Ohio	Section 1915(c) HCBS waiver Section 1915(b)/(c) HCBS waiver	Tiered MCO-negotiated	The state uses an acuity-based rate setting methodology. The payment rate is based on a three tier model with the tier assignment reflecting the level of services a resident requires. Assignment to a tier is based on an assessment of the degree of need for supervision to prevent self-harm and the amount of direct care service. One unit of assisted living service equals one calendar day.⁸ MCOs negotiate rates with providers based on the demand for services, the availability of qualified providers, clinical priority or best clinical practices, and estimated provider service cost. Additional information about rate setting and payment methodology is not available.
Oklahoma	Section 1915(c) HCBS waiver	Tiered	Providers are reimbursed through a three level tiered system. Residents are assessed to determine their level of need. The state used several guidelines when developing the provider rates, including: The rate needs to be attractive enough to encourage providers to participate; The rate needs to reimburse assisted living services providers at a level adequate to support staffing capacity required to provide quality care and 24 hour staffing; and The rate needs to take into consideration varying needs for assistance with ADLs and instrumental ADLs, as well as specialized care related to daily medical needs.
Oregon	Section 1915(k) Community First Choice program	Tiered negotiated	The state has five rate levels for assisted living facilities. The level is based on residents’ assessed needs, including the need for assistance with ADLs. Rates for adult foster home providers are collectively bargained through the Department of Administrative Services on behalf of the Department of Human Services with the Service Employees International Union. These rates are set based on a bargaining agreement at two year intervals. The collective bargaining process is a public process.
Pennsylvania	Not covered	N/A	N/A
Rhode Island	Section 1115 demonstration waiver	Flat	Providers are paid a flat per diem rate through both the Medicaid fee-for-service system and the managed LTSS program. Additional information about rate setting and payment methodology is not available.
South Carolina	State plan personal care	Flat FFS	The rate is calculated on an hourly basis and services are billed in six-minute units; 10 units equal an hour of care.⁹
South Dakota	Section 1915(c) HCBS waiver	Cost based	Rates are determined using a standard provider cost report submitted after the close of their fiscal year. The cost reports summarize expenses associated with the provision of waiver services and corresponding revenue. Aggregation and analysis of data submitted in cost reports by providers from across the state allows the Office of Provider Reimbursements and Audits to establish rates reflective of actual costs. The Department of Social Services uses a financial workgroup to develop rate-setting methodologies.
Tennessee	Section 1115 demonstration waiver	Cost based	In 2016, the capped rate for covered services is $1,089 per month.40 For covered services and services that exceed the specified benefit limit, MCOs must reimburse providers at the rate specified by the state.
Texas	Section 1115 demonstration waiver	MCO-negotiated or flat rates	MCOs can establish fixed rates for each service or can negotiate rates with providers. MCOs are required to have a process in place to administer Attendant Compensation Rate Enhancement (i.e., a program developed by the Texas Health and Human Services Commission to increase compensation for attendants). MCOs must submit their rate methodologies to the Health and Human Services Commission Rate Analysis office.
Utah	Section 1915(c) HCBS waiver	Flat fee-for-service	Providers are paid on a fee-for-service basis. Payment is based on a statewide fee schedule.
Vermont	Section 1115 demonstration waiver State plan personal care	Tiered Flat	The state has a three-tiered daily rate and residents are assessed to determine their service tier. An additional $5 a day is given to providers to compensate for the cost of regulations requiring additional personal space, safety standards, and “aging in place” care standards. Providers are paid a uniform per diem rate, paid monthly.
Virginia	Section 1915(c) HCBS waiver	Flat	The state pays providers an established rate. When the rate was initially established, the rates for similar services and the estimated cost of services were considered. Rates are not increased automatically for inflation, but may be increased if authorized by the state budget. Rates vary by region; providers in the same geographic regions receive the same rate.
Washington	Section 1915(k) Community First Choice program State plan personal care	Tiered negotiated	Tiered rates are determined by assessing beneficiaries with the Comprehensive Assessment Reporting Evaluation (CARE) tool. Seventeen levels of care classifications determine rates. Reimbursement rates are also determined by the location of the facility. Facilities in King County or other counties determined to be Metropolitan or Non-Metropolitan receive different rates. Facilities that retain a Medicaid occupancy percentage of sixty percent or higher also receive a higher rate. Adult Family Homes also can negotiate different rates than are set forth in the fee schedule. The rate for personal care provided in an adult family home is based on a per day unit and is determined by the state legislature, based on negotiations between the Governor’s Office and the union representing adult family homes.
West Virginia	Not covered	N/A	N/A
Wisconsin	State plan personal care Section 1915(c) HCBS waiver Section 1915(c) HCBS waiver Section 1915(b)/(c) HCBS waiver	Unknown Resident-negotiated County-negotiated MCO-negotiated	The Medicaid state plan covers personal care services in certified residential care apartment complexes and community-based residential facilities with 20 or fewer beds. Under the Section 1915(c) Include, Respect, I Self-Direct (IRIS) waiver program, waiver participants negotiate rates with providers, including adult family homes and residential care apartment complexes. The state establishes guidelines for a suggested payment range based on market and geographic complexities of providers and analysis of historical costs per unit and trending program expenditures. These guidelines are shared with the waiver participants’ consulting agencies, who in turn educate participants on these historical costs and trending. Under the 1915(c) Community Options waiver program, the state sets a maximum reimbursement rate for community-based residential care facilities that may not exceed 85% of the Medicaid reimbursement for nursing homes. The payment rate to the provider is the amount negotiated and contracted by a county with a particular facility for a particular individual according to the individual’s service needs. This payment includes assisted living services provided by the facility and other waiver costs such as county care management, transportation, and therapies. The managed care plan is responsible for establishing service provider rates for waiver services for which it contracts. The incentive to negotiate and establish competitive rates that result in cost effective services to meet identified member outcomes is critical to the financial viability of the managed care plan.
Wyoming	Section 1915(c) HCBS waiver	Tiered	Assignment to the established rate tier is based on functional needs and the potential intensity of services, as assessed by the state’s nursing home level-of-care determination process.

Notes: HCBS is home- and community-based services. LTSS is long-term services and supports. MCO is managed care organization. N/A is not applicable, as the state does not provide Medicaid coverage for services delivered in residential care settings.

¹ Medicaid rate-setting methodology definitions:

Flat rates: The facility receives the same payment regardless of its individual facility costs and regardless of the type and amount of services actually provided. These rates may vary by factors such as urban/rural location or single/multiple occupancy unit.
Tiered: Reimbursement system is based on state-defined levels of care for the facility level or at the individual level. At the individual level, individuals are slotted into tiers based on their assessment or needs and there is a payment level associated with each category. At the facility level, the entire facility is slotted into a tier, which could be by licensure category that varies by the level of service they provide or the disability level of the residents that they serve.
Case mix: Reimbursement rates vary by the case mix of the facilities or individuals. Case mix only applies when there are no tiers or categories and the payment rate is determined along a continuum based on the individual’s assessment. Providers are paid based on the number of hours and level of assistance needed by the resident. The case-mix adjusted rate for a facility is calculated by averaging the assessment levels for all residents and multiplying that index by the standard rate set by the state.
Cost based: The reimbursement rate of each facility varies with the costs of each facility.
Fee-for-service: Payment is made for each separate service provided. Payment amounts are determined by the number of units of specific types of service(s) used by a Medicaid beneficiary, which are identified from the resident’s service plan.

² California’s 1915(c) San Francisco Community Living Support Benefit waiver program, which covers community living support benefits in RCS, only applies to Medicaid beneficiaries living in the city and county of San Francisco who would otherwise be homeless, living in shelters, or institutionalized. RTI did not include this waiver program in our review.

³ Idaho’s Medicare-Medicaid Coordination Plan is a fully-integrated dual eligible special needs plan that provides managed LTSS to voluntarily enrolled dual-eligible individuals. Medicaid-only service providers, including providers of personal care and adult residential care services are reimbursed according to the state reimbursement methodology for such services.

⁴ Enrollment for Iowa’s Health Link managed care program, which includes residents of assisted living programs in the 1915(c) HCBS Elderly waiver program, begins April 1, 2016.

⁵ Please note that payment methodology for Maine’s1915(c) waiver is not included because the state uses the waiver to cover services for waiver participants in a residential care setting only on a respite basis.

⁶ Under the financial alignment demonstration—MI Health Link—managed care plans can enroll dually eligible residents and cover personal care services provided in adult foster care homes and homes for the aged. The flat monthly rate established for Medicaid residents in adult foster care facilities and homes for the aged is included in the integrated care organization (ICO) rates, and the ICOs must pay this rate to adult foster care homes and homes for the aged providers for individuals enrolled in MI Health Link.

⁷ Medical Assistance beneficiaries age 65 and over are required to receive their Medical Assistance benefits through MCOs, with two exceptions: beneficiaries who are required to pay a medical spend down; and, certain people served by American Indian tribes. These beneficiaries and those who are not yet enrolled in managed care may receive waiver services through the fee-for-service system.

⁸ Under the Financial Alignment Initiative demonstration—Integrated Care Delivery System—managed care plans can enroll dually eligible individuals living in one of 29 counties participating in the demonstration. These managed care plans must cover assisted living services in residential care facilities. The plans must maintain current provider rates that the state set for the duration of the demonstration.

⁹ In South Carolina, HCBS waiver participants may receive personal care in RCS; however, RTI was unable to find any information about the rate-setting methodology used to pay for personal care in RCS.

Sources: § 208.151.1, RSMo 2016. 105 Mass. Code Regs. 357.03 (2013). 105 Mass. Code Regs. 351.03 (2013). 105 Mass. Code Regs. 309.03 (2013). 455 Ind. Admin. Code IAC 1-3-3 (2016). Alaska Department of Health and Social Services (DHHS), 2015, Department of Health and Social Services chart of personal care attendant and waiver service rates, Juneau, AK: DHSS, http://dhss.alaska.gov/dsds/Documents/pca/PCA-waiver-service-rates201507.pdf. Arizona Health Care Cost Containment System (AHCCCS), 2013, AHCCCS medical policy manual, chapter 1200 ALTCS services/settings for the elderly and/or disabled, policy 1230 home and community-based services settings, Phoenix, AZ: AHCCCS, https://www.azahcccs.gov/shared/Downloads/MedicalPolicyManual/Chap1200.pdf. AHCCCS, 2015, AHCCCS contract renewal request for proposals, Phoenix, AZ: AHCCCS, https://www.azahcccs.gov/Resources/Downloads/ContractAmendments/ALTCS/ALTCSCYE2015/ALTCSEPD10-1RenewalFinal.pdf. Arkansas Medicaid, 2012, Arkansas Medicaid personal care provider manual, Section II: Program policy, Little Rock, AR: Arkansas Medicaid, https://www.medicaid.state.ar.us/download/provider/provdocs/manuals/perscare/perscare_ii.doc. California Department of Health Care Services (DHCS), 2014, The Coordinated Care Initiative and beneficiaries in the Assisted Living Waiver Program and Medicare and/or Medi-Cal, Sacramento, CA: DHCS, http://www.calduals.org/wp-content/uploads/2014/05/CCI-ALW-Fact-Sheet.pdf. Centers for Medicare & Medicaid Services (CMS), 2016, North Dakota Medicaid state plan, Baltimore, MD: CMS, https://www.medicaid.gov/State-resource-center/Medicaid-State-Plan-Amendments/Downloads/ND/ND-15-0013.pdf. Centers for Medicare & Medicaid Services (CMS), 2016, Ohio contract for the Financial Alignment Initiative demonstration, Baltimore, MD: CMS. https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/OhioContract.pdf. Connecticut Department of Social Services (DSS), 2016, Connecticut home care program for elders, standards for access agencies and assisted living service agency program requirements, Hartford, CT: DSS, http://www.ct.gov/sots/lib/sots/regulations/title_17b/342.pdf. Delaware Department of Health and Social Services (DHSS), 2011, Diamond State Health Plan Plus program FAQ document, Providence, RI: DHHS, http://dhss.delaware.gov/dhss/dmma/files/dshpplus_qa.pdf. Department of Vermont Health Access, 2011, Medicaid state plan, Attachment 4.19-B, Montpelier, VA: DVHA, http://dvha.vermont.gov/administration/36attachment-4.19-b.pdf. Florida Agency for Health Care Administration (AHCA), 2016, Telephone conversation with RTI International and MACPAC staff, March 3. Florida AHCA, 2016, Medicaid state plan, Tallahassee, FL: AHCA, http://ahca.myflorida.com/Medicaid/Stateplanpdf/attachment_4-19-B.pdf. Hawaii Department of Human Services (DHS), 2013, Request for proposal: QUEST integration (QI) managed care to cover Medicaid and other eligible individuals, Honolulu, HI: DHS, https://web.archive.org/web/20170207234556/http:/gpcprod.spo.hawaii.gov/spo2/health/rfp103f/attachments/rfp10091375755966.pdf. Idaho Admin. Code r. 16.03.01 (2017). Idaho Admin. Code r. 16.03.17 (2017). Illinois Department of Healthcare and Family Services (HFS), 2016, Managed care manual for Medicaid providers, Springfield, IL: HFS, http://www.illinois.gov/hfs/SiteCollectionDocuments/1.14.16%20Managed%20Care%20Manual%20for%20Medicaid%20Providers.pdf. Iowa Department of Human Services (DHS), 2015, Section 1915(c) waiver proposal for MCO, PIHP, PAHP, PCCM programs & FFS selective contracting programs: The Iowa high quality healthcare initiative, Des Moines, IA: DHS, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/Downloads/Iowas-High-Quality-Healthcare-Initiative-appvl-app-02232016.pdf. Maine Department of Health and Human Services (DHHS), 2016, MaineCare benefits manual, Chapter III, Section 97: Private non-medical institutions, Appendix C, Principles of reimbursement for medical and remedial service facilities, Augusta, ME: DHHS, https://www1.maine.gov/sos/cec/rules/10/ch101.htm. Michigan Department of Health and Human Services (DHHS), 2017, Medicaid state plan, Lansing, MI: DHHS, http://www.mdch.State.mi.us/dch-medicaid/manuals/MichiganStatePlan/MichiganStatePlan.pdf. Michigan Department of Health and Human Services (DHHS), 2015, Medicaid provider manual: MI Health Link, Lansing, MI: DHS, http://www.michigan.gov/documents/mdhhs/MSA_15-41_504786_7.pdf. Laws of Minnesota 2013, chapter 108, article 1233, section 12. Mollica, R, 2009, State Medicaid reimbursement policies and practices in assisted living, Washington, DC: National Center for Assisted Living and American Health Care Association, https://www.ahcancal.org/ncal/advocacy/Documents/MedicaidAssistedLivingReport.pdf. Mont. Admin. R. 37.40.145 (2011). Nevada Division of Health Care Financing and Policy (DHCFP), 2017, Provider type 58 waiver for people with physical disabilities, Reno, NV: DHCFP, http://dhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/Rates/PT58WINWaiver-04012016.pdf. N.Y. Comp. Codes R. & Regs. Tit. 10, §86-7.2 (2017). Neighborhood Health Plan of Rhode Island (Neighborhood), 2013, RHODY Health Options (RHO) implementation, Smithfield, RI: Neighborhood, http://www.nhpri.org/Portals/0/Uploads/Documents/RHO%20111313/RHO%208.27.13%20Assisted%20Living%20Facility%20.pdf. New Jersey Department of Human Services, 2015, Contract between State of New Jersey, Department of Human Services, Division of Medical Assistance and Health Services and contractor, Trenton, NJ: DHS, http://www.nj.gov/humanservices/dmahs/info/resources/care/hmo-contract.pdf. New Hampshire Department of Health and Human Services (DHHS), 2013, New Hampshire Medicaid fee schedule—covered services (that are not manually priced), Concord, NH: DHHS, https://nhmmis.nh.gov/portals/wps/wcm/connect/0bcc01804ec4b91580c8a2054277da38/covered%2bprocedures%2b2013.xlsx?mod=ajperes. New Mexico Human Services Department (HSD), 2015, Medical assistance division managed care policy manual, Sante Fe, NM: HSD, http://www.hsd.State.nm.us/uploads/files/Providers/Manuals%20and%20Guides/Managed%20Care%20Policy%20Manual/MCO%20Policy%20Manual%20update%203_16%20FINAL.pdf. North Carolina Division of Medical Assistance (DMA), 2014, Medicaid state plan, Raleigh, NC: DMA. https://ncdma.s3.amazonaws.com/s3fs-public/documents/files/NC_State_Plan_Medical_Assistance_Program.pdf. Oregon Department of Human Services (DHS), 2013, State plan amendment for Community First Choice state plan option, Salem, OR: DHS, http://www.oregon.gov/DHS/SENIORS-DISABILITIES/KPLAN/Documents/1915-K-Option-State-Plan-Amendment.pdf. Rhode Island Executive Office of Health and Human Services (EOHHS), 2015, RI Medicaid waiver services provider reference manual, Providence, RI: EOHHS, https://web.archive.org/web/20170107154127/http://www.eohhs.ri.gov/Portals/0/Uploads/Documents/MA%20Providers/MA%20Reference%20Guides/Waiver/waiver_services_manual.pdf. RTI International, 2016, analysis of Centers for Medicare & Medicaid Services (CMS), 2016, approved demonstration and waiver applications, Baltimore, MD: CMS, https://www.medicaid.gov/medicaid-chip-program-information/by-topics/waivers/waivers_faceted.html. South Carolina Department of Health and Human Services (DHHS), 2012, South Carolina Medicaid state plan, Columbia, SC: DHHS, https://www.scdhhs.gov/sites/default/files/ATTACHMENT%204.19-B_4.pdf. South Carolina Community Residential Care Facilities (CRCF) Committee, 2013, Assisted living and community residential care facilities: A practical guide for consumers, Columbia, SC: CRCF Committee, http://www.State.sc.us/dmh/crcf/crcf_guide.pdf. State of Washington, 2016, Medicaid rates for contracted home and community residential care services, Olympia, WA: Washington State Legislature, http://apps.leg.wa.gov/wac/default.aspx?cite=388-105&full=true467. State of Washington, 2016, Establishment of capital add-on rate—determination of Medicaid occupancy percentage, Olympia, WA: Washington State Legislature, http://app.leg.wa.gov/rcw/default.aspx?cite=74.39A.320. State of Wisconsin, 2017, Long-term support community options program, Madison, WI: Wisconsin State Legislature, https://docs.legis.wisconsin.gov/statutes/statutes/46/27/11/c/7. Tennessee Division of Health Care Finance & Administration (HCFA), 2016, 2016 maximum room and board charges for persons receiving assisted care living facility services in the CHOICES program, Nashville, TN: HCFA, https://web.archive.org/web/20171016215537/https://www.tn.gov/assets/entities/tenncare/attachments/ACLFMemoMaximumRoomBoard.pdf. Tennessee Division of Health Care Finance & Administration (HCFA), 2016, MCO statewide contract, Nashville, TN: HCFA, https://web.archive.org/web/20160528174049/https://www.tn.gov/assets/entities/tenncare/attachments/MCOStatewideContract.pdf. Texas Health and Human Services Commission (HHSC), 2014, STAR+PLUS provider training, Austin, TX: HHSC, https://hhs.texas.gov/sites/default/files/documents/services/health/medicaid-chip/provider-information/expansion-managed-care/starplus-provider-training.pdf. Vermont Department of Disabilities, Aging and Independent Living (DAIL), 2016, Report on rate setting: Medicaid , Montpelier, VA: DAIL. http://dail.vermont.gov/sites/dail/files//documents/Rate_Setting_Report_2-2016.pdf. Washington State Department of Social and Health Services, 2016, Telephone conversation with RTI International and MACPAC staff, March 9.

Notes: HCBS is home- and community-based services. LTSS is long-term services and supports. MCO is managed care organization. N/A is not applicable, as the state does not provide Medicaid coverage for services delivered in residential care settings.

1 Medicaid rate-setting methodology definitions:

Flat rates: The facility receives the same payment regardless of its individual facility costs and regardless of the type and amount of services actually provided. These rates may vary by factors such as urban/rural location or single/multiple occupancy unit.

Cost based: The reimbursement rate of each facility varies with the costs of each facility.

Fee-for-service: Payment is made for each separate service provided. Payment amounts are determined by the number of units of specific types of service(s) used by a Medicaid beneficiary, which are identified from the resident’s service plan.

4 Enrollment for Iowa’s Health Link managed care program, which includes residents of assisted living programs in the 1915(c) HCBS Elderly waiver program, begins April 1, 2016.

5 Please note that payment methodology for Maine’s1915(c) waiver is not included because the state uses the waiver to cover services for waiver participants in a residential care setting only on a respite basis.

9 In South Carolina, HCBS waiver participants may receive personal care in RCS; however, RTI was unable to find any information about the rate-setting methodology used to pay for personal care in RCS.

¹ Medicaid rate-setting methodology definitions:

⁴ Enrollment for Iowa’s Health Link managed care program, which includes residents of assisted living programs in the 1915(c) HCBS Elderly waiver program, begins April 1, 2016.

⁵ Please note that payment methodology for Maine’s1915(c) waiver is not included because the state uses the waiver to cover services for waiver participants in a residential care setting only on a respite basis.

⁹ In South Carolina, HCBS waiver participants may receive personal care in RCS; however, RTI was unable to find any information about the rate-setting methodology used to pay for personal care in RCS.