Ohio Assisted Living Waiver (2026): Eligibility, RCF Participation, Per-Diem, Room and Board

The Ohio Assisted Living Waiver (AL Waiver) is the Medicaid pathway that pays for the service component of assisted living in a licensed Residential Care Facility (RCF) for adults who meet the nursing facility level of care (NF LOC). Authorized under the Ohio Administrative Code (see codes.ohio.gov) and jointly administered by the Ohio Department of Aging (ODA) and the Ohio Department of Medicaid (ODM), the AL Waiver is structurally different from the PASSPORT waiver in one critical way: it does not cover room and board. The resident pays room and board from their own income, retaining only the AL Waiver personal needs allowance. Medicaid pays the facility a defined per-diem rate for services. That per-diem is significantly lower than the private-pay rate most Ohio RCFs charge, which is why only a subset of licensed Ohio RCFs participate in the AL Waiver, and why families considering the AL Waiver need to verify both that a specific desired RCF participates and that a Medicaid bed is available.

This guide is the operational deep-dive on the AL Waiver, distinct from the Ohio HCBS waivers overview, the Ohio assisted living care-types guide, and the Ohio Medicaid application procedural guide. It covers eligibility (age, residency, NF LOC, financial); the service package the AL Waiver pays for inside the RCF; the per-diem rate mechanics and why participation is voluntary at the facility level; how to find Medicaid-participating RCFs in Ohio; the room and board liability calculation and what the resident actually pays each month from their income; the AL personal needs allowance; transition planning from PASSPORT to AL Waiver as community living becomes infeasible, and from AL Waiver to nursing facility Medicaid when assisted living can no longer meet clinical needs; the limited circumstances in which the AL Waiver can fund memory care; appeals; and the operational mistakes that hurt AL Waiver applicants and residents.

By Brevy Care Team · Last verified May 11, 2026

What the AL Waiver Is and What It Is Not

The AL Waiver is the Medicaid funding mechanism for the service component of assisted living when the resident is Medicaid-eligible. It is not a different kind of assisted living, a different licensing category, or a separate building. AL Waiver residents live in the same licensed Residential Care Facilities (RCFs) as private-pay residents, in many cases in the same units, with the same staff providing the same services. The difference is purely on the funding side: Medicaid pays the per-diem to the facility for services, and the resident pays room and board from their income.

What the AL Waiver does:

• Pays a defined per-diem rate to the Medicaid-participating RCF for services delivered inside the facility
• Pays for personal care services (assistance with ADLs)
• Pays for medication oversight (medication administration, reminders, monitoring within the assisted-living scope of practice)
• Pays for limited skilled-nursing oversight within the assisted-living model
• Pays for social activities, programming, and a portion of dining and housekeeping services
• Pays for limited transportation tied to the RCF's transportation program
• Pays for the RCF's overhead and operational structure that supports service delivery

What the AL Waiver does not do:

• Pay for room and board (housing, utilities, food beyond the service-related portion)
• Cover the resident's medical, hospital, pharmacy, or other standard Medicaid-covered services (those are billed under standard Medicaid)
• Pay for skilled nursing facility care (that is institutional Medicaid, a different pathway)
• Pay for community-based services (those are PASSPORT, OHCW, or MyCare)
• Cover assisted living in any setting other than a licensed RCF
• Cover RCFs that have not enrolled in the AL Waiver as Medicaid providers

The split between service payment (Medicaid via AL Waiver) and room and board payment (resident from income) is structurally federal: under the federal HCBS waiver statute and CMS HCBS rules, room and board can only be covered for residents of institutional Medicaid settings (nursing facilities). For HCBS waiver participants, including the AL Waiver, room and board is the resident's responsibility.

Eligibility in Detail

Age

The AL Waiver is open to adults at and above its statutory age threshold; verify the current threshold with ODA. The PASSPORT waiver covers older adults at a higher age threshold; in practice, most AL Waiver participants are older adults parallel to PASSPORT demographics, because RCFs are predominantly older-adult settings. An adult under PASSPORT's age threshold who meets NF LOC may use the AL Waiver if they reside in a Medicaid-participating RCF, while the same person in the community would use the Ohio Home Care Waiver.

Residency

Ohio resident status under federal Medicaid residency rules (see the federal Medicaid eligibility regulations on eCFR).

Setting

The participant must reside in (or be in the process of moving to) a Medicaid-participating, licensed Residential Care Facility in Ohio. RCFs are licensed by the Ohio Department of Health under the RCF chapter of the Ohio Administrative Code. An RCF differs from a nursing facility in that the RCF model provides assistance with ADLs, medication oversight, and supervision but not the comprehensive skilled-nursing care a nursing facility provides. RCFs are licensed for a specific number of beds and may also hold endorsements (such as the Memory Care Endorsement) that authorize specialized programming.

Critical operational fact: Licensure as an RCF does not mean participation in the AL Waiver. Participation is voluntary, and many Ohio RCFs do not participate. Some that participate limit Medicaid beds to a small fraction of total beds. The participating-RCF list is much shorter than the list of licensed RCFs.

Clinical Eligibility: Nursing Facility Level of Care

The AL Waiver requires that the applicant meet NF LOC, determined through the Adult Comprehensive Assessment Tool (ACAT) administered by AAA assessors. The same ACAT framework used for PASSPORT applies here: ADLs, IADLs, cognitive function, behavioral health, medical complexity, and informal support are evaluated to determine whether the applicant would qualify for nursing facility placement absent waiver services.

For AL Waiver specifically, the clinical reality is that residents typically need more support than community PASSPORT can provide but less than nursing facility level. The combination of supportive housing, medication oversight, prepared meals, and on-site personal care available in an RCF is the right fit for many older adults whose families cannot provide 24-hour informal support and whose home environment is not safe for solo residence.

Financial Eligibility

The AL Waiver uses the same Ohio Medicaid financial eligibility framework as PASSPORT and nursing facility Medicaid:

• Income at or below the federal Special Income Limit. Applicants over the limit can use a Miller Trust (Qualifying Income Trust) for the over-income amount.
• Countable resources at or below the SSI-aligned LTC resource limit for an individual. For married couples with one spouse applying, federal spousal-impoverishment rules protect the community-spouse resource allowance (CSRA).
• No improper transfers in the federal LTC lookback period (see the transfer-penalty lookback guide).
• Home equity below the federal home-equity cap. For an AL Waiver applicant who owns a home but no longer resides in it (because they have moved or will move to the RCF), the home is exempt only if the applicant intends to return, or a community spouse, blind or disabled child, or qualifying sibling resides there. Without an applicable exception, the home becomes a countable resource and must be addressed in financial planning.

For the broader financial eligibility framework, see /medicaid/ohio/eligibility-income-limits. For the application procedural pipeline, see /medicaid/ohio/how-to-apply.

How the Per-Diem Rate Works

The AL Waiver pays Medicaid-participating RCFs a per-diem rate for each AL Waiver resident-day. The per-diem covers the bundled service package authorized in the resident's plan of care. The rate is set by the Ohio Department of Medicaid and is updated periodically; verify the current rate with ODM or the local AAA.

Why the per-diem is well below private-pay assisted living rates: The Medicaid per-diem is intentionally set below the typical private-pay rate. Federal cost-neutrality for HCBS waivers requires that waiver costs average below the institutional alternative (nursing facility). The AL Waiver per-diem reflects that constraint. The result, predictably, is that RCFs participating in the AL Waiver typically face a financial gap between the Medicaid per-diem and their full cost of care. Some RCFs absorb this gap as a community benefit or to maintain operational flexibility. Others price private-pay residents above market to cross-subsidize Medicaid beds. Many do not participate at all.

Why this matters for families: A common family experience is to identify a desired RCF, tour it, get along with the admissions team, and then learn either that the facility does not participate in the AL Waiver at all, or that it participates but currently has no Medicaid bed available. Verify before committing.

Finding a Medicaid-Participating RCF

There is no single comprehensive consumer-facing directory of Medicaid-participating Ohio RCFs that is consistently maintained. Practical approaches:

1. Call the local AAA at 1-866-243-5678 and ask for a list of Medicaid-participating RCFs in the county or service area
2. Call individual RCFs directly and ask: "Do you participate in the Ohio Medicaid Assisted Living Waiver?" If yes, follow up with: "How many Medicaid-licensed beds do you have? Is one currently available? What is your waitlist policy?"
3. Search the Ohio Department of Aging consumer resources for any current statewide assisted living locator that flags AL Waiver participation
4. Work with a geriatric care manager who specializes in placement; they typically maintain current participation lists for their region
5. Use the Ohio LTC Consumer Guide maintained by ODA for licensed facility information; cross-reference participation separately
6. Check with LeadingAge Ohio and the Ohio Health Care Association, the major industry associations, for member RCFs that report AL Waiver participation

Families starting AL Waiver search should expect this step to take time. Most counties have a manageable number of participating RCFs, but the right fit (location, programming, memory care if needed, Medicaid bed availability) often requires touring several facilities.

Room and Board: What the Resident Actually Pays

The AL Waiver does not pay for room and board. The resident pays room and board to the RCF from their income, retaining only the AL Waiver personal needs allowance. The calculation works approximately as follows (verify current figures with the AAA or CDJFS):

1. Total monthly income: Add up Social Security, pension, IRA distributions, any other income.
2. Subtract the AL Waiver personal needs allowance (the amount the resident retains for personal expenses). Ohio's AL Waiver PNA is higher than the institutional nursing facility PNA because AL residents have more personal expenses (haircuts, clothing, personal items, outings, gifts). For the current AL Waiver PNA amount, see /medicaid/ohio or verify with the AAA.
3. Subtract any allowable income deductions such as Medicare Part B premiums, supplemental health insurance premiums, and certain medical expenses.
4. The remaining income is the resident's room and board contribution to the RCF.

For married couples, the community-spouse monthly income allowance (CSMIA) under federal spousal impoverishment rules may divert a portion of the institutionalized spouse's income to the community spouse before the room and board calculation. This can substantially affect the math for couples and is one of the most common sources of confusion in AL Waiver financial planning.

What this means in practice: An AL Waiver resident with a typical Social Security check, retaining the published AL Waiver personal needs allowance and paying their Medicare Part B premium, contributes the balance to the RCF as room and board. The RCF receives this room and board contribution plus the AL Waiver per-diem for services from Medicaid. The combined total typically falls below the RCF's full private-pay rate, which is the gap the facility absorbs or cross-subsidizes.

The AL Waiver Personal Needs Allowance

Ohio sets a specific personal needs allowance for AL Waiver residents that is higher than the institutional nursing facility PNA. The AL Waiver PNA reflects the greater range of personal expenses an assisted-living resident incurs: clothing, personal care items beyond what the RCF provides, hair care, gifts, outings, telephone, internet, and small purchases. For the current AL Waiver PNA amount, verify with the AAA, ODA, or CDJFS, or see /medicaid/ohio. The PNA is updated periodically.

The PNA is the resident's money. It cannot be taken by the RCF for room and board or any other purpose. RCFs are required by federal law and Ohio regulation to maintain a resident-funds account or comparable mechanism for residents who wish to deposit PNA dollars with the facility for safekeeping; the resident retains full ownership and access.

The Service Plan and Case Management

The AL Waiver service plan is developed by the AAA case manager in coordination with the RCF, the resident, and family or representative. It documents:

• The resident's goals for community living within the assisted-living setting
• The personal care services the resident needs (ADLs, medication oversight, transferring, supervision)
• The RCF's role in delivering those services
• Any external services that supplement the RCF (such as Medicare home health for short-term skilled needs)
• The schedule for reassessment and plan revision

The AAA case manager remains the resident's primary external point of contact and advocate. The RCF staff handles day-to-day care delivery within the facility. The case manager monitors quality, responds to complaints, coordinates with external providers, and conducts annual reassessments.

For dual eligibles in MyCare Ohio counties, the AL Waiver services may be delivered through the MyCare FIDE-SNP plan under Ohio's MyCare OAC chapter on codes.ohio.gov; see the MyCare Ohio waiver guide.

When Memory Care Is Part of the Picture

Some Ohio RCFs hold the Memory Care Endorsement under OAC 3701-16-21, authorizing them to operate specialized memory care programming for residents with Alzheimer's disease or related dementias. The AL Waiver per-diem may include a memory care add-on for endorsed facilities, though specific rate detail and authorization requirements vary; verify with the AAA and ODM.

For a fuller picture of Ohio memory care, including the two structural pathways (ODH RCF Memory Care Endorsement vs. ODA AL Waiver memory care certification), see /care-types/ohio/memory-care. For families navigating dementia at the AL Waiver stage, the case manager and the RCF's memory care team are the primary operational contacts.

Transitioning From PASSPORT to AL Waiver

A common scenario in Ohio LTSS: a PASSPORT participant's needs grow beyond what community living and PASSPORT services can safely support, and the family is considering assisted living. The transition from PASSPORT to AL Waiver involves:

1. The case manager evaluates whether AL Waiver is clinically appropriate (continued NF LOC, but now the right setting is RCF rather than community)
2. The family identifies a Medicaid-participating RCF with an available bed; the case manager can help identify options
3. The RCF conducts pre-admission screening and confirms it can meet the resident's needs
4. The financial application is updated to reflect the new setting; income, resources, and home status may need re-evaluation
5. The service plan is revised to authorize the AL Waiver service package within the RCF rather than the PASSPORT service package in the community
6. The move happens, often coordinated with hospital discharge or a brief rehab stay
7. PASSPORT enrollment ends and AL Waiver enrollment begins; the case manager continues or a new case manager is assigned depending on AAA staffing

The financial transition has implications: the resident moves from PASSPORT (no room and board obligation because they live in their own home) to AL Waiver (substantial room and board obligation paid from income). The home may shift from exempt to countable depending on whether the resident intends to return, whether a community spouse remains there, or whether other exceptions apply. Estate recovery exposure changes correspondingly; see /medicaid/ohio/estate-recovery.

Transitioning From AL Waiver to Nursing Facility

When an AL Waiver resident's clinical needs exceed what the RCF can safely provide, transition to nursing facility Medicaid is often the next step. Triggers include:

• Substantial decline in mobility requiring more transfers than the RCF can safely provide
• Behavioral symptoms (in dementia) that exceed the RCF's training or staffing
• Skilled-nursing needs (complex wound care, IV therapy, ventilator support) that are beyond the RCF scope
• Falls and safety incidents that the RCF cannot prevent at its staffing model
• Hospice not available at the RCF or hospice + RCF not a workable combination

The transition is administratively straightforward from a Medicaid standpoint: the resident's financial eligibility continues, the per-diem source changes from AL Waiver to institutional Medicaid, and the personal needs allowance changes (the nursing facility PNA is lower than the AL Waiver PNA in Ohio, so the resident's income contribution to the facility increases). The clinical transition typically involves nursing facility pre-admission screening, often coordinated by hospital discharge planning when the transition follows an acute event.

For nursing facility coverage details, see /care-types/ohio/nursing-homes.

Appeals

AL Waiver applicants and residents who are denied initial eligibility, denied a service plan request, or terminated have State Hearing appeal rights at the Ohio Department of Job and Family Services Bureau of State Hearings.

• State Hearing filing window: Ohio's published filing window from the date of the adverse notice (verify on the State Hearings page)
• Aid pending hearing: for service-reduction or termination notices, filing promptly within the published aid-pending window preserves continued benefits at the prior level during the appeal
• File by: calling 1-866-635-3748, online at jfs.ohio.gov, in writing, or in person at CDJFS

For complex cases (memory care disputes, behavioral-acuity-related discharges from the RCF, transfer-penalty issues), retaining an Ohio elder law attorney or contacting Pro Seniors Cincinnati, the Ohio Legal Aid network, or Disability Rights Ohio for free legal help is often worthwhile.

What the AL Waiver Does Not Cover

To set expectations clearly, the AL Waiver does not pay for:

• Room and board in the RCF (resident pays from income)
• Private-pay assisted living facilities that have not enrolled as Medicaid providers
• Independent living facilities (those are not licensed RCFs)
• Adult family homes or board-and-care homes not licensed as RCFs
• Continuing Care Retirement Communities (CCRCs) as a single payment structure (though some CCRC's licensed RCF assisted-living units may participate)
• Custodial nursing facility care (that is institutional Medicaid)
• Community-based services delivered outside the RCF (those are PASSPORT, OHCW, or MyCare)
• Acute medical care, prescription drugs, or physician services (those are standard Medicaid)
• Family caregiver wages within the AL Waiver structure (the AL Waiver pays the facility, not individual caregivers; the consumer-direction model that pays family caregivers is on the PASSPORT and OHCW side, under the relevant OAC chapter on codes.ohio.gov)

Operational Mistakes Families Make

The most common AL Waiver application and participation failures:

1. Assuming all licensed RCFs participate. Most do not. Verify participation and Medicaid-bed availability before committing to a facility.
2. Underestimating the room and board liability. Many families discover after the move that the room and board contribution from income is close to or equal to total Social Security, leaving minimal disposable income for the resident beyond the personal needs allowance.
3. Misunderstanding the home as a resource. When the resident moves into the RCF and no longer intends to return home, the home becomes countable unless a community spouse or other qualifying person resides there. Many families do not address the home in advance planning and face complications later.
4. Missing the spousal income allowance. For couples, the CSMIA can divert a portion of the institutionalized spouse's income to the community spouse, reducing the room and board contribution. Couples who miss this leave money on the table.
5. Not coordinating with the RCF on Medicaid timing. The RCF needs to know the AL Waiver enrollment is in process and the expected start date so it can transition the resident from private-pay to Medicaid at the right time. Misalignment leads to billing disputes.
6. Confusing AL Waiver with private-pay assisted living LTC insurance reimbursement. LTC insurance reimbursement and Medicaid AL Waiver are different funding sources with different rules. Some families try to use both simultaneously and create administrative complexity.
7. Not exploring memory care endorsement. If the resident has dementia, the RCF's memory care endorsement status matters. Endorsed memory care environments have specific programming and staffing requirements that unendorsed RCFs may not provide.
8. Not appealing adverse decisions. State Hearing appeals are free and frequently successful when the family presents clear evidence. Adverse-acuity discharges from the RCF, in particular, often have appealable due-process issues.

Frequently Asked Questions

Next Steps for Ohio Families

For families considering the AL Waiver:

1. Confirm clinical fit. Assisted living is the right setting for residents who need more support than community living can safely provide but less than nursing facility level. Discuss with the resident's physician, geriatric care manager, or AAA case manager.
2. Begin the AAA conversation. Call 1-866-243-5678 to reach the local AAA. The AAA can begin the ACAT process, refer the financial application to CDJFS, and provide initial guidance on Medicaid-participating RCFs in the area.
3. Tour Medicaid-participating RCFs. Visit several. Ask about Medicaid bed availability, waiting lists, memory care endorsement if needed, room and board rates, what the facility includes in the bundled per-diem, and what is billed separately.
4. Run the room and board math. Calculate what the resident will actually pay each month from income, taking into account spousal income allowance for couples, Medicare premiums, and the AL Waiver personal needs allowance. Verify the math with the AAA, CDJFS, or an Ohio elder law attorney.
5. Address the home. If the resident owns a home and is moving permanently to the RCF, work with an Ohio elder law attorney on home equity, exemption, transfer-penalty, and estate recovery considerations before the move.
6. Coordinate the financial application and the move. The AL Waiver enrollment, the financial application at CDJFS, and the move-in date should be aligned so the resident transitions cleanly from private-pay (if applicable) to Medicaid.
7. Engage with the service plan. Once enrolled, the AAA case manager and the RCF develop the service plan together; participate actively in service-plan reviews and request revisions when needs change.

For broader context on Ohio Medicaid and HCBS waivers, see /medicaid/ohio and /medicaid/ohio/hcbs-waivers. For the application procedural guide, see /medicaid/ohio/how-to-apply. For the PASSPORT pathway as the most common alternative, see /medicaid/ohio/passport-waiver.

This guide is for general informational purposes and is not a substitute for legal, tax, or financial advice. Ohio AL Waiver rules, per-diem rates, RCF participation, and personal needs allowance amounts change; verify current information with the local AAA, ODA, ODM, the specific RCF, or an Ohio elder law attorney before acting.

Find personalized help navigating the Ohio Assisted Living Waiver at brevy.com.