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Tables of Contents for Seniors' Housing and Care Facilities
Chapter/Section Title
Page #
Page Count
Table of Illustrations
xxiii
Contents---Volume II: The CD-ROM
xxv
Part I: Elderly Markets and Development Responses
3
54
American Elderly Profile
5
18
Seniors' Housing Fever (Again)
5
2
The Numbers of Older People
7
1
Ages and Lifestyles of the Elderly
8
2
Where the Aging Live
10
1
Senior Wealth and Homeownership
11
4
The Need for Services, Care, and Financial Security
15
8
The Evolution of Seniors' Housing and Care Facilities
23
34
The Essence of a Seniors' Community
23
1
The Four Businesses of Full-Service Seniors' Communities
24
7
Housing
24
1
Convenience Services
25
3
Health Care or Assisted Living
28
2
Insurance
30
1
Traditional Seniors' Community Models
31
8
Overview
31
1
Congregate Housing
32
1
Assisted Living/Board and Care
33
2
Continuing-Care Retirement Communities
35
3
Related Facilities
38
1
Trends in Seniors' Housing Development
39
18
New Participants in the Marketplace
39
2
New Business Structures and Partnerships
41
1
Resident Ownership versus Rental
42
1
Terminable versus Continuing Contracts
42
2
Diversification and Unbundling of Services
44
1
New Payment Mechanisms
45
1
Consumerism, Choice, and Assisted Living
46
3
State-of-the-Industry Surveys
49
8
Part II: Project Planning and Implementation
57
32
Development Team Functions
59
12
In General
59
1
Project Coordination
59
1
Market Feasibility Study
60
1
Financial Feasibility Forecasting
61
1
Legal Consultation
62
1
Experienced Architectural and Construction Services
63
2
Management Expertise
65
1
Financing
65
1
Marketing/Admissions
66
5
Steps in the Development Process
71
10
In General
71
1
Basic Concept Structuring
71
5
Team Selection
71
1
Site Selection
71
5
Formulation of Basic Concept
76
1
Concept Testing and Refinement
76
2
Additional Team Members
76
1
Financial Modeling
76
1
Premarketing
76
2
Exploration of Financing
78
1
Defining the Product
78
1
Initial Implementation
78
1
Site-Related Tasks
78
1
Legal and Management Tasks
78
1
Marketing
79
1
Later Development and Project Opening
79
2
Avoiding Financial Pitfalls
81
8
In General
81
1
Examples of Serious Financial Difficulties
82
1
Causes of Failures
83
1
Developments That May Reduce Some Risks
84
5
Part III: Fee and Occupancy Options
89
56
Entrance Fee Models
93
20
``Nonrefundable'' Entrance Fees
93
7
Marketing and Business Issues
93
1
Fees as Taxable Income
94
5
Resident Tax Considerations
99
1
Refundable Entrance Fees
100
13
Taxation of the Provider
101
1
Resident Tax on Imputed Interest
102
6
Securing the Refund
108
5
Ownership Models
113
24
Condominium Ownership
113
13
In General
113
1
Business Issues
113
2
Developer Control Issues
115
9
Homeowner and Association Tax Issues
124
2
Cooperatives
126
4
Cooperative/Condominium Differences
126
1
Tax Benefits for Cooperative Members
127
2
Taxation of the Cooperative Housing Corporation
129
1
Memberships
130
2
Business Considerations Generally
130
1
Taxation of Sales Proceeds
130
1
Resident Tax Considerations
131
1
Life Estates
132
5
Rentals
137
8
Business Issues
137
1
Treatment of Investors under the Tax Reform Act of 1986
138
3
Passive Loss Rules
138
3
At-Risk Rules
141
1
Conclusion
141
1
Real Estate Reforms under the Revenue Reconciliation Act of 1993
141
4
Part IV: Tax-Exempt Operation
145
56
Federal Tax Exemption
147
34
In General
147
1
Historical Background
147
1
Challenges to Exempt Organizations
147
1
Basic Tests for Tax Exemption
148
2
Organizational Test
149
1
Operational Test
149
1
Home for the Aging Tax Exemption
150
7
Revenue Ruling 72-124
150
3
Implementing Revenue Ruling 72-124
153
4
Homes Operated at less Than Cost
157
1
Low- and Moderate-Income Housing
157
4
Revenue Ruling 70-585
158
1
Safe Harbor
158
2
Hybrid Projects
160
1
Health Facilities and Health Insurance
161
2
Health Facilities
161
1
Insurance
162
1
Application to Seniors' Housing
163
1
Religious Organizations
163
1
Government Facilities
164
1
Exempt Services
164
1
Homeowners' Associations
165
1
Avoidance of Private Foundation Status
166
1
Unrelated Business Taxable Income
167
3
Unrelated Trades or Businesses
167
2
Dividend, Interest, or Rental Income
169
1
Debt-Financed Property
169
1
Deduction of Payments to Exempt Facilities
170
1
Reporting and Technical Requirements
171
1
Intermediate Sanctions
172
9
State Tax Exemption
181
20
In General
181
1
Survey of State Laws and Cases
182
19
Alaska
182
1
Arkansas
182
1
Arizona
182
1
California
182
1
Colorado
183
1
Connecticut
183
1
Delaware
183
1
Florida
183
1
Hawaii
184
1
Idaho
184
1
Illinois
185
1
Indiana
185
1
Iowa
185
1
Kansas
186
1
Maine
186
1
Maryland
187
1
Michigan
187
1
Minnesota
187
1
Mississippi
188
1
Missouri
188
1
Montana
188
1
Nebraska
189
1
Nevada
189
1
New Hampshire
189
1
New Jersey
189
1
New Mexico
189
1
New York
190
1
North Carolina
190
1
North Dakota
190
1
Ohio
190
1
Oklahoma
191
1
Oregon
191
1
Pennsylvania
191
1
Rhode Island
192
1
South Carolina
192
1
South Dakota
192
1
Tennessee
192
1
Texas
192
1
Utah
193
1
Vermont
193
1
Virginia
194
1
Washington
194
1
West Virginia
194
1
Wisconsin
194
1
Wyoming
194
7
Part V: Multiparty Ventures
201
42
Multiplay Relationships
203
12
What Others Have to Offer
203
1
Expertise, Staffing, and Resources
203
1
Constituency
204
1
Tax Advantages
204
1
Capital, Land, or Other Assets
204
1
Partner Goals and Approaches
204
4
Hospitals
204
3
Religiously Affiliated Organizations
207
1
For-Profit Developers
207
1
Other Possible Partners
208
1
Multiparty Roles and Structure
208
7
Alternative Roles and Relationships and Their Impact on Development Issues
208
1
Formation of New Entities
209
6
Tax Implications of For-Profit/Nonprofit Ventures
215
18
Preservation of Tax-Exempt Status
215
10
In General
215
1
Equity Joint Ventures
216
5
Use of a Subsidiary Corporation
221
1
Nonprofit Vendor Contracts
222
1
For-Profit Vendor Contracts
223
2
Preserving For-Profit Tax Advantages
225
1
ACRS after the Tax Reform Act of 1986
225
1
Tax-Exempt Use Property
225
1
Example of a For-Profit/Nonprofit Joint Venture
226
7
Benefits of the Venture
226
2
Venture Legal Issues
228
5
Other Joint Venture Considerations
233
10
In General
233
1
Medicare/Medicaid Issues
233
2
Reimbursement
233
1
Fraud and Abuse
234
1
Antitrust Issues
235
1
Employment-Related Issues
236
7
Workers as Employees
236
1
Employment Retirement Income Security (ERISA)
237
1
Labor Laws
238
5
Part VI: Financing Seniors' Facilities
243
84
HUD Financing Programs
245
22
In General
245
2
Mortgage Insurance
247
9
General Procedural Requirements
247
1
HUD Evaluations
247
1
Closing and Funding Procedures
248
1
Specific HUD Mortgage Insurance Programs
249
6
Secondary Financing
255
1
Direct Loans
256
2
Section 202/8 Program
256
1
Section 312 Rehabilitation Loans
257
1
Grants
258
9
Capital Advances and Rental Assistance under Section 202
258
1
Urban Development Action Grants
259
1
Community Development Block Grants
260
1
Housing Development Grants
261
1
Rental Rehabilitation
262
5
Tax-Exempt Financing
267
18
In General
267
1
Qualified 501(c)(3) Bonds
267
4
The GAO Report
271
1
Limits on Section 501(c)(3) Residential Rental Projects
271
1
Residential Rental Projects
271
1
Limitations on All Tax-Exempt Bonds
271
3
Arbitrage
271
1
Relationship of Bond Maturity to Life of Assets
272
1
Public Approval Requirement
272
1
Restriction on Issuance Costs
272
1
Reimbursement of Prior Expenditures
272
1
Advance Refundings
273
1
Change in Use
273
1
Use of Bond Proceeds for Religious Purposes
274
1
The Issuer and Form of Tax-Exempt Bonds
274
3
State Authorities
275
1
Local Authorities
275
1
City of County Bonds
275
1
Certificates of Participation
276
1
63-20 Bonds
276
1
Issuer Requirements
276
1
Participants and Documents in a Tax-Exempt Bond Issue
277
8
Structure and Participants
277
2
Basic Bond Documents
279
6
Conventional Financing
285
6
In General
285
1
Sources of Conventional Financing
285
1
Structure of the Transction
286
1
Securitized Loans
287
4
Ratings and Credit Enhancement
291
10
In General
291
1
Unrated Debt
291
1
Rated Debt
291
1
Bond Insurance
292
1
Letters of Credit
292
5
Guarantees
297
1
Underwriting Considerations
297
4
Debt Terms and Covenants
301
14
Variable-Rate Versus Fixed-Rate Debt
301
2
Publicly Offered Variable-Rate Debt
301
1
Institutional Variable-Rate Debt
302
1
When Variable-Rate Debt Should Be Used
302
1
Conditions Precedent to Closing
303
1
Conditions Relating to the Financing Transaction
303
1
Presales
304
1
Construction Contract
304
1
Business Covenants
304
5
Limits on Consolidations, Mergers, Sales, or Transfers
305
1
Limitation on Encumbrances
306
1
Limits on Indebtedness
307
1
Debt Service Coverage Ratios
307
1
Limitation on Disposition of Properties
308
1
Other Financial Covenants
308
1
Insurance and Condemnation
308
1
Disposition of Insurance and Condemnation Proceeds
309
1
Timing, Funding, and Disbursements
309
1
Timing
309
1
Construction Financing and Permanent Financing
310
1
Lender Control of Construction
310
1
Call Protection and Prepayment Premium
310
5
Equity Financing
315
12
In General
315
1
Owner Contribution
316
1
Corporate Stock
316
1
General Partnerships
317
1
Limited Partnerships
318
1
Real Estate Investment Trusts
319
1
For-Profit/Nonprofit Joint Ventures
319
1
Low-Income Housing Tax Credits
320
3
Generally
320
1
Use of Tax Credits for Retirement Facilities
321
1
Time Limitations and Allocation Issues
322
1
Use of Low-Income Housing Tax Credits
323
1
Equity Leases
323
1
Charitable Constributions
323
1
Cooperatives and Condominiums
324
3
Part VII: Regulation of Seniors' Housing and Care Facilities
327
144
Licensing of Care Programs
329
44
In General
329
1
Certificate of Need
329
2
Evolution of the Process
329
1
State Programs since Repeal of the Federal Law
330
1
Exemptions for Continuing-Care Retirement Communities
331
1
Nursing Facility Licensure
331
8
The Omnibus Budget Reconciliation Act of 1987
332
5
Transfers in Multilevel Facilities
337
2
Construction Standards
339
1
Assisted-Living Facility Licensure
339
25
A Patchwork of State Laws
340
19
The Subtle Boundaries of Licensure
359
2
The Prospect for Adoption of Federal Standards
361
1
Enhanced Building Standards for Assisted-Living Facilities
362
2
The American Seniors' Housing Association Model Assisted Living Act
364
1
Home Health Care Regulation
364
2
Regulation of Health Maintenance Organizations
366
7
Regulation of Continuing-Care Retirement Communities
373
30
Regulatory Definition
373
1
Applications and Disclosures
374
1
Escrow of Resident Deposits
375
16
Presales Thresholds as a Condition of Ongoing Development
391
1
Reserves
392
1
Resident Contracts and Related Documents
393
3
Disclosure of Basic Information and Policies
394
1
Contract Termination
394
1
Refunds
395
1
Advertising
396
1
Resident Rights
397
1
Resident Protection and Enforcement
398
1
Accereditation
398
1
Similar Regulated Industries
399
4
HUD Operational Regulations
403
18
In General
403
1
Retirement Service Centers (suspended program)
403
3
Section 221(d)(4)
403
2
Section 223(f)
405
1
Section 232 Board-and-Care Homes and Assisted-Living Facilities (Active)
406
1
Board-and-Care Homes
406
1
Assisted-Living Facilities
407
1
Section 202
407
4
Section 202 Capital Advances and Rental Assistance Program
407
2
The Section 202/8 Direct Loan Program (superseded)
409
1
Congregate Housing Services Program
409
2
Other Federal Housing Programs for the Elderly
411
1
Section 231 Mortgage Insurance for Elderly Housing
411
1
Section 236 Mortgage Insurance and Interest Reduction Payments
411
1
Regulations Generally Applicable to HUD Programs for the Elderly
411
10
Rent Control
411
1
Eviction Procedures
411
1
Pet Regulations
412
1
Mandatory Meals
413
2
Service Coordinators
415
6
Discrimination
421
40
In General
421
1
Age
421
7
Age Discrimination Act of 1975
421
3
Familial Status Provisions of the Fair Housing Act
424
1
Significant Facilities and Services Rule (repealed)
425
2
State Laws
427
1
Disability
428
17
Fair Housing Amendments Act of 1988
428
5
Americans with Disabilities Act
433
4
HUD Projects
437
4
Section 504
441
4
Due Process Issues
445
1
State and Local Laws
445
1
Religion
445
1
Income Discrimination
446
3
Fair Housing Laws
446
1
Medicaid
446
3
Race, Color, National Origin, Sex, and Marital Status
449
12
Securities Registration
461
4
In General
461
1
Application to Seniors' Housing
462
3
Local Laws
465
6
Zoning
465
2
Assessments; Rent Controls
467
4
Part VIII: Financing Health Care
471
40
Government Funding of Health Care
473
8
In General
473
1
Hospital Orientation of Medicare
473
1
Medicare Copayments and Deductibles for Acute Hospitalization
474
1
Minimal Medicare Coverage for Long-Term Care
474
1
Home Health Limited
474
1
Medicaid: Long-Term Care for the Poor
474
3
Generally
474
1
Eligibility of Recipients
475
1
Medicaid Waivers
476
1
Miscellaneous Federal Programs
477
4
Supplemental Security Income
477
1
Older Americans Act
478
1
Social Services Block Grants
478
3
Private Funding of Health Care
481
14
Medigap Insurance
481
1
Long-Term-Care Insurance
481
5
Historical Unavailability; Increasing Demand
481
1
Confusing Array of Benefits
482
1
Long-Term-Care Insurance Innovations
483
3
Self-Insurance Methods
486
2
Continuing Care
486
1
Home Equity Conversion
487
1
Medical Savings Accounts
488
1
Use of Transferable Memberships, Refunds, and Equity Loans as a Health Care Reserve
488
1
Managed Care and Retirement Communities
488
7
Generally
488
1
Residents Enrolled in Managed-Care Organizations
488
2
Responding to Managed-Care Challenges
490
5
Health Care Reform
495
16
In General
495
1
Harvard Medicare Project
495
1
The Catastrophic Coverage Act
495
2
The Push for a Long-Term-Care Solution
495
1
The Act as Adopted and Repealed
496
1
Brookings Institution Long-Term-Care Finance Study
497
1
Consumers Union Long-Term-Care Proposal
498
1
Extra-Low-Budget Option
498
1
Low-Budget Option
499
1
Medium-Budget Option
499
1
High-Budget Option
499
1
Pepper Commission Proposal
499
1
Congressional Proposals for the 1990s
499
2
Employer-Mandated Health Insurance
499
1
Public Health Insurance
500
1
Public/Private Incentive Programs
500
1
The Clinton Health Care Reform Proposal
501
2
The Goals of Health Care Reform
501
1
Guaranteed National Benefits Package
501
1
Medicare and Medicaid
502
1
Home- and Community-Based Services
502
1
Health Care Reform and Communities for Seniors
502
1
Aftermath of the Clinton Proposal
503
1
The 1995 White House Conference on Aging
504
1
The Health Insurance Portability and Accountability Act of 1996
504
2
Long-Term-Care Insurance Benefits
504
1
Long-Term-Care Expenses
505
1
Accelerated Death Benefits
505
1
Insurance Discrimination; Portability
505
1
Medical Savings Accounts
505
1
The Balanced Budget Act of 1997
506
1
Medicare + Choice Program
506
1
PACE Program
506
1
Skilled-Nursing Facility Reimbursement
506
1
Repeal of the Boren Amendment
507
1
Public Policy, Long-Term Care, and Retirement Communities
507
4
Part IX: Operations
511
10
Civil Liability for Operations
513
8
Increased Exposure to Operational Liability
513
1
General Rules of Civil Liability
514
1
Foreseeable Harm
514
1
Employee Conduct
514
1
Regulatory Violations
514
1
Volunteers
515
1
Areas of Exposure
515
2
Unmet Care Needs
515
1
Confused or Combative Residents
516
1
Private-Duty Aides
516
1
Risk Reduction
517
4
Regulatory Compliance Plans
517
1
Policies for Staff and Private Aides
517
1
Assessment and Handling of Claims
517
1
Negotiated Risk Agreements
518
3
Part X: Case Studies
521
42
The Fountains at La Cholla
522
8
Tucson, Arizona
Franciscan Village
530
10
Lemont, Illinois
Newbury Court
540
8
Concord, Massachusetts
Peninsula Regent
548
8
San Mateo, California
Seasons at Redondo Beach
556
7
Redondo Beach, California
Appendix
563
2
Bibliography
565
14
Table of Authorities
579
28
Index
607