02/08/2024

Confused About AL Waiver Memory Care Billing Guidance? You’re Not Alone

Some assisted living providers may have received confusing guidance from their Area Agencies on Aging on how to bill for the new memory care rate under the waiver. LeadingAge Ohio is working with the Department of Aging and our AAA partners to resolve misinformation. 

In the meantime, providers should ensure they are compliant with the rules for memory care before billing to circumvent later recoupments.

The memory care rate should be authorized and billed only for residents who meet all of the following criteria:

1. Residents are eligible for ALW as determined by the PAA.
2. Residents have a diagnosis of dementia as verified by the PAA and included in their service plan.
3. Residents reside in a memory care unit that meets the certification standards specified in paragraph (D) of OAC rule 173-39-02.16.

Paragraph (D) of OAC 173-39-02.16 lists the requirements for memory care certification, including: “The provider designates the single-occupancy resident unit in paragraph (C)(2)(c) of this rule to be a stand-alone memory care unit, a memory care unit in a memory care section of the RCF, or a memory care unit in an RCF of a provider that provides only memory care.” 

The rule also outlines staffing requirements that must be demonstrated for memory care which can be either:

• 20 percent higher than the non-memory care part of the facility
• 20 percent higher than a representative sample of waiver providers or, 
• A staff-to-resident ratio of 1:10 if neither of these are available (as in the case of assisted living communities specifically designed for memory care).

LeadingAge Ohio is concerned that the staffing thresholds would be very challenging to document in dispersed / stand-alone memory care rooms, and encourages members NOT to bill for these rooms. LeadingAge Ohio is working with the Ohio Department of Aging to evaluate the reopening of the AL memory care rule for corrections, which could occur in the first half of this year. 

Any questions regarding the AL memory care rules and provided billing guidance can be sent to LeadingAge Ohio’s Policy Director, Tiffany Bukoffsky at tbukoffsky@leadingageohio.org.