I am asked this question a few times each year and continually expand my understanding as to how to make it work.
Most Assisted Living Facilities (ALF) we are familiar with provide information for 3rd party recommended doctors/nurses who visit a patient at the facility. The expectation is a patient pays the provider directly from their insurance, separate from monthly costs of the facility.
DOL will consider direct reimbursement for an ALF if the facility is 1) enrolled in the OWCP/EEOICPA program, and 2) the facility provides RN/LPN (skilled) or CNA/Personal Care Attendant (non-skilled) services.
Below is a Q & A email exchange between AtomicWorkers® and a DOL EEOICPA Medical Benefits Unit Senior Staffer. The gist is that some ALFs could work, and some will not work.
Can a worker have their Assisted Living Facility expenses covered under the program?
Yes
Can an Assisted Living Facility and Home Health Care provider coexist under this program, and both be covered?
Yes, the program can potentially authorize multiple levels of Home Health Care services simultaneously. Common example where this may occur is as follows: The claimant is in an ALF. The ALF only provides non-skilled nursing services. However, the claimant also requires skill nursing services as it relates to their accepted condition. We can potentially authorize the ALF with the non-skilled services, and the Home Health Care provider for the skilled services, if medical documentation establishes the need for both.
Who writes the Letter of Medical Necessity (LMN)? Doctor and Facility?
All orders for any prescribed medical services, equipment, supplies, etc. must be prescribed by a doctor (M.D./ D.O.), along with medical rationale establishing patient needs, and specification as to the frequency and duration of skilled/non-skilled services. A Letter of Medical Necessity is the typical method for providing this information.
I presume the worker would have to be deemed incapable of driving, going to the store, managing money, etc., whether they had a spouse/partner or not.
These are not requirement(s) for authorization. The medical reasons for a claimant to be referred to ALF will vary from patient to patient and are dependent on their individual needs as it relates to their accepted condition. The doctor would be the one to describe the medical necessity in their LMN as it relates to that patient’s accepted condition.
If the ALF provides non-skilled services as part of their “package” I presume such services would have to be delineated in LMN from the doctor or facility. And their monthly billing would have to document daily provision of those services as delivered, for the approved days/hours.
ALF is billed and paid as an all-inclusive. Meaning it covers room and board, and the medical services they provide. It is not billed separately. Prior to authorizing ALF, the treating physician will need to describe in the LMN what medical services the claimant will be receiving in the ALF. The claimant must be receiving some type of medical assistance from the facility, whether that be in the form of skilled or non-skilled care, or both. Please note this program does not pay for “Senior Living” facilities.
If the ALF does not provide any services beyond meals/meal prep, can a Home Health Care provider deliver services skilled/non-skilled as per a normal residential home?
Yes, however in this case, the cost of the ALF is not covered by the program.
If the ALF provides non-skilled services such as dressing, bathing, laundry, and the Home Health Care provider provides other non-skilled services, I presume those would have to be spelled out so there was no overlap in duties, correct?
We cannot authorize duplicative services. One or the other would need to provide ALL non-skilled services. In my experience, I have never come across a situation where a provider would need to split the duties of non-skilled (or skilled services) with another provider. Spilt hours, yes, but not duties. Additionally, I have never known an ALF that is not capable of providing all typical non-skilled services. The claimant and their family will need to ensure they choose a facility that will adequately meet the claimant’s needs, as with any medical service provider.
Where would medication dispense versus medication management fall?
Medication dispensation must be performed by someone who is licensed to do so, which would be a nurse (RN/LPN) or above. A CNA/Personal Care Attendant cannot dispense medication. They can remind the patient to take their medication, but they cannot administer/dispense it. Medication management is a little different. Ultimately, it is the doctor, or a medical professional, who has the license to prescribe medication, “manages” the patient’s medication regimen.
How is this handled when there are shared facilities, a married couple in one apartment, or two non-related tenants sharing a two-bedroom apartment?
The program only covers the cost for the claimant. The facility would need to separate the cost for the claimant from all other expenses.
Can you outline the criteria for qualification and approval for Assisted Living Facility coverage? I presume there must be a medical opinion (LMN) outlining the rationale, supporting medical, with discussion as to ADLs, limitation of the worker, and then spelling out what “services” the ALF facility is to provide.
We require a letter of medical necessity which describes the need for ALF as it relates to the claimant’s accepted condition(s) and the expected medical services the claimant will receive in the facility. There is no one size fits all kind of an approach. It is really a case-by-case situation and every patient’s situation is different. The doctor that is familiar with the patient, their medical condition(s), and their needs should have no trouble providing a clear letter of medical necessity with a well rationalized opinion. For additional information, please refer to Chapter 30 of our Procedure Manual located on our website. https://www.dol.gov/agencies/owcp/energy .
Our services at AtomicWorkers® do NOT include identification of potential Assisted Living Facilities, coordinating care for a patient/client, explaining billing practices, nor setting up a facility to enroll in the EEOICPA program. Please contact any DOL Resource Center for assistance in these areas.