Medicaid Rules Definition of "Congregate Care"?
December 20, 2017 1:23 PM   Subscribe

Does a HUD subsidized apartment sponsored by a non-profit organization that automatically provides case management services to a disabled tenant qualify as "congregate care" under Medicaid rules? If so, what are the consequences for qualifying for services from Medicaid Waiver Programs such as TBI Waiver?

I have been informed that it does, and that the tenant of such an arrangement would not qualify to receive services from Medicaid Waiver Programs (e.g., TBI Waiver) while living in the apartment. Can anyone point me to an accurate and definitive source of information about (a) the sorts of supportive housing arrangements that would be defined as "congregate care" by Medicaid, and (b) the restrictions placed on residents of such "congregate care" arrangements insofar as receiving benefits from Medicaid Waiver Programs such as OPWDD and TBI Waiver. (The location is Westchester County, New York.)

The HUD apartment sponsored by Turning Point (a non-profit whose mission is housing the homeless) is Westchester County's Department of Social Services' idea of a "special accommodation" for housing for a homeless individual who is cognitively impaired consequent to a severe traumatic brain injury. (The individual is too impaired to cope with a general shelter, and Westchester lacks special needs shelters. The DSS came up with the HUD apartment option after a threat of legal action from legal aide services.)

Support from TBI Waiver is critical for the long term stability and security of this individual; TBI Waiver is standing by to engage once his housing arrangements are resolved. If taking this apartment would involve losing the supports he needs for the long term, he might be better off continuing with business as usual to give OPWDD (currently on the case) time to find a more appropriate residential placement for the long term. It is too long a story, but he spends most nights in a cheap motel so he isn't sleeping rough in the elements.

Note: there is no support of any kind from family or friends. I'm just the former neighbor / "good samaritan" who recognized a train wreck and took action, which is another long story for another day.

For reasons unknown, the determination of facts in the social services universe is a challenge. Many thanks to anyone who can shed a little light on this quandary!
posted by cool breeze to Law & Government (7 answers total)
Hi there. I am a former RN case manager for a different Medicaid waiver program in a different state. Medicaid waiver programs vary from state to state, but generally there is an attempt to avoid duplication of services. In this individual's case, I would try to have a conversation with someone from the TBI waiver program you are trying to help get him qualified for, ideally a case manager who is actively managing clients in that program. S/he would be in the best position to give you insight into what housing in your area would be considered "congregate care."

If there is a wait list for the TBI waiver, ask whether your former neighbor's spot on the wait list would be in jeopardy if he chooses to take the HUD apartment for now.
posted by little mouth at 4:17 PM on December 20, 2017

In IL this would not be an issue provided it is just case management and no in home services such as cleaning, organizing, bathing, things like that.

I'd introduced it as a subsidy with a housing case worker which is what it really is, not a true supportive living which under Medicaid may be defined differently than what HUD defines it as.

(Worked HIV/AIDS waiver tons of them have supportive housing here w/ in home case management services and Ryan white case management.)
posted by AlexiaSky at 6:12 PM on December 20, 2017

Another question is if that caseworker is billing Medicaid. The supportive housing program I worked for (did that too for awhile) did not bill Medicaid for services.

If they aren't billing it cannot be duplication of service. If they are you need to find out the billing codes and talk to someone about how they line up w waiver services.

This is a fairly common situation in my experience so it shouldn't be too difficult to get clarification.
posted by AlexiaSky at 6:19 PM on December 20, 2017

Oh waiver services always require permanent housing though. So he will not get any waiver services until he has a place.

CILAs our other group home arrangements are always congregate care that have staff on site 24 hours a day.
The purpose of waiver services is for independent living only, so if he requires someone more than 16 hours a day he won't qualify. (In this state, unless court ordered)
posted by AlexiaSky at 6:29 PM on December 20, 2017

This varies by location. Waivers are partly negotiated between CMS and the State. For instance, in my [state], DC, there is no need for a particular type of housing in order to receive many of the Medicaid waiver services we provide.

How old is this person? (The below applies from ages 21-64)

The single biggest problem with Medicaid services is that there is something called the Institute for Mental Disease (IMD) exclusion. This exclusion prevents billing Medicaid (unless the state has a different IMD waiver) for services provided in a facility with more than 16 beds (broadly defined) where the majority of the residents are diagnosed with a mental illness. There isn't enough information in your description to know if that's what's going on, but at least where I work, "congregate care" per se is not something that precludes Medicaid services. The IMD exclusion, however, does have a huge impact on what care Medicaid will pay for. And note that the defining issue for determining an IMD is not just size of the facility, it's the diagnosis of the majority of the residents.
posted by OmieWise at 5:51 AM on December 21, 2017

(b) the restrictions placed on residents of such "congregate care" arrangements insofar as receiving benefits from Medicaid Waiver Programs such as OPWDD and TBI Waiver.

Hey, so I don't have any professional standing to discuss this, but I wanted to mention some background that took me a while to understand when in your position (layperson trying to help friends) but which was EXTREMELY helpful once I did.

"Waiver" is a shorthand that refers to several disparate state-level programs. When states want to spend federal Medicaid money in ways otherwise prohibited by CMS (the federal Medicaid agency), the states apply for a waiver from the requirements they don't wish to follow. Usually they are asking for permission to pay for services not otherwise covered under medical insurance for specific groups of at-risk patients. The states have to submit complicated applications that define the patient group, eligibility, ensuing services, etc.

The ensuing programs are then ALL referred to as "waiver" even though (as in your example of OPWDD and TBI) they have very different requirements and eligibility criteria. Waiver services are state and program specific, so what is covered in New York may not be covered elsewhere and vice versa. It's entirely possible that OPWDD and TBI wavier programs in New York have different definitions of "congregate care" and that such care affects eligibility in different ways for each program.

With that knowledge, my first instinct when reading your question was to make the TBI waiver people and HUD people talk to each other about what housing is acceptable. But that may or may not be feasible.
posted by Snarl Furillo at 10:20 AM on December 21, 2017


Thank you all for your input!

A little more relevant background:

The individual is a 48 year old male with significant cognitive impairment consequent to a severe traumatic brain injury (TBI) incurred in a motorcycle accident 27 years ago. He has an orthopedic disability and other co-morbidities, but it is the brain damage that precludes living a responsible, independent life and the issue upon which the successful appeal for a resumption of Social Security disability benefits turned. His impairment presents like a form of dementia with problems with comprehension, memory, judgment, etc. His mother was his caregiver until mid-2015, and made a godawful mess of it (i.e., didn’t understand or want to face the extent of his impairment; failed to plan for the future; etc.).

He was accepted into the TBI Waiver Program in late 2016, but because of his lack of income and homelessness (the latter seemingly the bigger problem), service coordination did not commence. Once housed, TBI Waiver says we can transfer him back to its program provided his housing isn’t congregate care.

Note: Because of a NYS Dept. of Health freeze on housing supports for the TBI community, TBI Waiver cannot help find a housing solution. As a result, we are starting with the OPWDD Medicaid Waiver Program, which claims to be able to help with this and does not have a requirement of either an income or a current residence. Once housed, it would almost certainly make sense to transition the individual back to TBI Waiver as TBI is a specialty and not quite in OPWDD’s “wheel house” of expertise.

Note: The HUD apartment only came up following a legal services request to Westchester Department of Social Services for an emergency special accommodation for temporary housing until OPWDD finds the appropriate long term placement.

@little mouth: The TBI Waiver Program office called my attention to the problem initially. OPWDD staff seem clueless; I’m playing phone tag with someone in the local OPWDD “Front Door” office in an effort to get clarity. One of the frustrating aspects of advocating for a disabled individual at least in this part of the country is that the employees of the various government agencies and participating non-profit service providers are generally ignorant of their own employer’s mandates and requirements, and even more clueless with respect to the rest of the social services system of which they are a part.

@AlexiaSky: Bingo Number 1! Your point about the possible inclusion of in-home services including cleaning, organizing, etc. may be the issue on which the answer to the question ultimately turns. Turning Point has been vague when queried on this, but while this individual does not need much support with the activities of daily living, he does need help with organization, staying on top of paperwork, money management, and cleaning. Turning Point claims – without justifying its claims as to how and when – that it will deal with this. And the provision of the needed services could indeed make this HUD apartment equal “congregate care.”

Bingo Number 2! Will Turning Point be billing Medicaid? If not, the apartment may not equal “congregate care.”

Bingo Number 3! How many hours of service does Turning Point claim to be intending to provide? Good question, and it may be another relevant factor.

As to the residency requirement, as noted above, TBI Waiver has one; OPWDD does not (and has been enlisted explicitly because it claims to be able to help solve the homeless problem).

@Snarl Furillo: Yes, I would bet that TBI Waiver and OPWDD Waiver Programs have different definitions of “congregate care.” It is one of the things I am trying to ascertain because I fear that, if this individual takes this HUD apartment as a short term fix, he could wind up cut off from both OPWDD for the short term benefit we are looking to it to fill (i.e., the right housing placement for the long term) and TBI Waiver for the long term (i.e., for TBI focused supports). This is a particular worry as nothing Turning Point staff have done or said so far implies that they either grasp the nature of TBI or would be able to transition the individual out of the HUD apartment into more appropriate care when and if they ever came recognize the need to do so (and the need for a more appropriate solution for the long term is very real now).

The fact that I cannot remain engaged this intensively for much longer adds a degree of urgency to the situation than might be the case if there was caregiving participation by family or friends, but there is none of this. This individual is completely alone and reliant on the “kindness of strangers” for his survival.

As I distill your comments collectively, the answer to whether or not this HUD apartment constitutes a form of “congregate care” may turn on:

The specific services Turning Point plans to deliver to this individual in the HUD apartment;
Whether Turning Point bills Medicaid for any of its services regardless of what they are.

Many thanks again for all your input; it has been enormously helpful!
posted by cool breeze at 7:18 AM on December 22, 2017 [1 favorite]

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