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GAO. CMS. ACOs. ASPE. National Center for Assisted Living leaders are watching an alphabet soup of policy and regulatory-related issues. Scott Tittle, the organization’s executive director; Lindsay Schwartz, PhD, senior director, workforce and quality improvement; and Meg LaPorte, senior director of policy, detailed them for those attending an Oct. 6 session at the American Health Care Association/NCAL annual convention in San Antonio.

GAO. In July, four U.S. senators asked the Government Accounting Office to review Medicaid spending as well as federal and state oversight of care provided to Medicaid beneficiaries who live in assisted living communities. In an interview with McKnight’s Senior Living, LaPorte said that the request concerns NCAL because of the uncertainty of what will be contained in the GAO’s resulting report.

NCAL has been in communication with the senators’ staff members, she said. “We’ve been told by Sen. [Susan] Collins’ office that they’re just interested in what Medicaid looks like in assisted living across the country,” LaPorte added. “Of course, it varies across the country. There are a number of different waivers that pay for residents to live in assisted living, and they all vary. They’re mostly home- and community-based settings waivers, and I think that the senators really are just interested in what that looks like at the state level.”

CMS. In January 2014, the Centers for Medicare & Medicaid Services issued a final rule related to home- and community-based service waivers for Medicaid beneficiaries. States have until March 2019 to comply.

Since the rule was finalized, LaPorte said, CMS has issued several pieces of guidance to the states regarding how the rule should be implemented and how states should assess providers, including assisted living providers. CMS, however, hasn’t issued policy directives in conjunction with some of that guidance, LaPorte said.

“There’s a concern that CMS will ultimately reject any assisted living [community] that happens to be connected to [or on the same campus as] a nursing home as being ineligible for the home- and community-based settings waiver,” she said.

Also, LaPorte added, the rule might force some assisted living residents—those who have Medicaid waivers and live in memory care settings—to move into more expensive nursing homes, “which is antithetical to what the rule is supposed to do.” The rule and subsequent guidance aren’t clear on the use of waivers in assisted living memory care settings, she said, adding that CMS has indicated that it will issue additional guidance on the matter.

Medicaid managed care. Managed care and alternative payment models in Medicare and Medicaid are affecting assisted living, too, LaPorte said.

“Medicaid managed care is becoming more widespread in the states, and accountable care organizations are prominent in a number of states, too,” she said. “If you’re going to work with them, they’re interested in seeing data from providers, even assisted living. It’s important to bring data to the table about hospitalizations, readmissions, length of stay, staffing turnover and customer satisfaction.”

NCAL’s National Quality Initiative for Assisted Living and AHCA/NCAL’s National Quality Awards program are among efforts to help members gather and analyze such data.

ASPE. In June, the U.S. Department of Health and Human Services’ Office of the Assistant Secretary for Planning and Evaluation issued its “Compendium of Residential Care and Assisted Living Regulations and Policy: 2015 Edition.”

The report notes that the definition of assisted living is “highly varied” among states, LaPorte said. “Twenty-three states have more than one assisted living or resident care facility licensure category, and 44 states actually use the term assisted living, compared with 20 states that still use the term residential care,” she added. Also, the report notes that every state except Mississippi has provisions that address the use of third-party providers, LaPorte said.

Regulation at the state level rather than the federal level makes sense for assisted living, NCAL maintains. Commenting on the report in a statement to McKnight’s Senior Living, Tittle said: “Assisted living communities serve residents and families best by being able to cater to the needs and desires of local community expectations. The diversity of state regulations reflects the diversity of residents’ needs, from coast to coast.”

NCAL will continue to work with its state affiliates, state policy leaders and regulators to ensure that assisted living communities are providing quality care, he added.