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Why is cause Medicaid for NH is dedicated funding (so is required & will be consistent in coverage) BUT a state can decide to move $ earmarked for Medicaid to go into waiver programs like AL. Medicaid is a joint federal & state program (there's a formula on the $) but each state administers its Medicaid uniquely and interdependent on its state laws & administrative codes. But within overall federal guidelines. So a state can decide if waivers will happen & will set requirements for the waiver. If your state wanted to fund AL, & make it encouraging for participation by facilities, they could. Some states are very pro-elderly on AL waivers, like AZ.
Then facilities have to determine IF they will participate in a waiver program. Waivers tend to be limiting period of time (like 5 years) and then could or could not be renewed & have narrow eligibility. If a AL can easily fill butts in beds by private pay then no reason to ever participate in waivers & state oversight on a program that could end. Just lots of uncertainty so not worth it. What happened when waivers started years ago is that facilities just didn't participate, so those states ceased any AL waivers. Most states do NOT have AL waivers now or have waiver programs so narrow that facility just aren't interested.
Then add in that the current trend is for waivers now to go to programs that are more community based & serve bigger #'s. Like PACE type of day programs where they go 2 -4 days a week, get on site health care, meals, transportation to/from but still living at home so much more cost effective use of the limited Medicaid $ than state paying for 1 on 1 care.
What you often hear is that AL requires 2 years of private pay first. It's a fairly safe determination by the AL that a lot of the residents are going to need a higher level of care so move out to a NH or die before the 2 year mark. So there's good probability that a Medicaid bed will be available 2 years from now. If a AL tells you this, you may want to ask for a guarantee of Medicaid bed from the AL after 2 years private pay before you sign an admissions contract.
Ok I realize this may be way WAY more info than you asked for but with facilities costing 6 figures a year, to me, it's important to understand the backstory.