We have had hundreds of clients over the years who have gone to nursing homes to provide for their care as they aged. Some of them lived full, rich, engaged lives in the nursing home until the very end. Others suffered from severe physical disabilities or dementia that prevented them from actively interacting with the world as meaningfully as they would have liked. Clients often are confused by the different types of long-term care options available to them. Today we’ll describe the differences between each of the main types of long-term care facilities available in Hawaii.

There are three main categories of long-term care facilities you can go to are: 1) ARCH, 2) Adult Foster Home, and 3) Nursing Home. Each are distinct and serve a slightly different purpose.

ARCH stands for Adult Residential Care Home. These homes are licensed and regulated by the Hawaii State Department of Health, Office of Health Care Assurance. ARCH type I homes are limited to 1-5 long-term residents, while ARCH type II homes can have 6 or more residents. Both ARCH I and ARCH II homes could be regular—serving residents requiring minimal assistance with Activities of Daily Living, (such as bathing, changing, walking, eating, getting out of bed); or they could be expanded—able to accept residents who require 24-hour assistance or skilled nursing services. Only the Expanded ARCH homes (either Type I or Type II) may choose to accept Medicaid patients, but they are not required to.

Adult Foster Homes are licensed and regulated by the Hawaii State Department of Human Services. Although commonly referred to as Adult Foster Homes, the official name of the program they are under is called the Community Care Foster Family Homes (CCFFH) program. Foster Homes are designed to be a less expensive, family-home setting alternative to an institutional nursing home. They will be licensed for one, two, or three long-term residents. Residents in Foster Homes must be at the Intermediate Care Facility (ICF) level of care or Skilled Nursing Facility (SNF) level of care (equivalent to Expanded ARCH). Foster Homes must have at least one Medicaid resident, but those homes licensed for 2-3 residents may have one of their residents be a private-pay, non-Medicaid eligible individual. All residents in a Foster Home must have a Case Management Agency licensed by the Department of Human Services to coordinate their health care requirements.

Finally, full-fledged nursing homes are generally licensed under the Hawaii State Department of Health, Office of Health Care Assurance as Intermediate Care Facilities and/or Skilled Nursing Facilities. These are what most people think of as typical nursing home institutions. They may have only a mere handful or a few dozen beds, but some of them have the capacity for several hundred residents. Most ICF and SNF nursing homes have most or all of their beds Medicaid eligible, but some institutions have a limited number of Medicaid-eligible beds, with all the rest being private pay only.

Contrary to the myths, Medicaid does not tell you where to go. Rather, Medicaid recipients get to choose which long-term care facility they would like to live in, as long as there is availability there, and the resident is accepted into that facility. Also contrary to myth, the quality of care you receive is not generally better or worse based on whether you are privately paying or on Medicaid—rather, the quality of care depends primarily on other factors such as how much the nursing staff care, and how often family members visit and are involved in monitoring the resident’s care. Next month, we’ll look at how to select the right facility for you.



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Ethan R. Okura received his Doctor of Jurisprudence Degree from Columbia University in 2002.  He specializes in Estate Planning to protect assets from nursing home costs, probate, estate taxes, and creditors.

This written advice was not intended or written to be used, and it cannot be used by any taxpayer, for the purpose of avoiding penalties that may be imposed on the taxpayer.  (The foregoing legend has been affixed pursuant to U.S. Treasury Regulations governing tax practice.)

This column is for general information only.  The facts of your case may change the advice given.  Do not rely on the information in this column without consulting an estate planning specialist.