Long-term care facilities, like a nursing home or assisted living facility, are often very expensive. Unfortunately, private health insurance policies usually do not cover these services. Medicare coverage for long-term care is limited and most people do not have private long-term care insurance policies. For California residents who require long-term care services, Medi-Cal is the source of funding most often used. In fact, Medi-Cal covers the nursing home expenses of nearly 65% of California residents in nursing homes.
What is Medi-Cal?
Medi-Cal, California’s state Medi-Cal program, is funded by both federal and state funds. There are several different methods for obtaining eligibility for Medi-Cal. There are also eligibility rules specifically for long-term care services like nursing homes, assisted living facilities, and home health care services. The California Department of Health Care Services (DHCS) administers long-term care programs in California.
Medi-Cal for Nursing Home Residents
Skilled nursing facilities are residential facilities that offer round-the-clock skilled nursing care in addition to other supportive services. These nursing homes are expensive, averaging approximately $7,000 per month in California in 2012. Most people cannot afford to pay their own nursing home expenses.
Payment for “medically necessary” nursing home services
Medi-Cal pays for nursing home services only when those services are deemed “medically necessary.” California defines that term as “when it is reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain.” In order for Medi-Cal to pay for a nursing home stay, it is necessary for the patient’s treating physician to prescribe a nursing home, based on the need for continual, round-the-clock availability of skilled nursing care or what’s called “intermediate care.”
What does skilled nursing care include?
Skilled nursing care basically includes things like giving injections, inserting or replacing catheters, changing wound dressings, feeding through a gastric tube, and treating bed sores. Intermediate care refers to a protective and supportive environment, with “observation on an ongoing intermittent basis to abate health deterioration.” Essentially, your doctor must find that your health would be at risk if you do not have access to skilled nursing or intermediate care.
Qualifying for Medi-Cal
If you already qualify for Medi-Cal, then your Medi-Cal coverage includes nursing home care if you need it. Groups of people who automatically qualify for Medi-Cal include SSI recipients, participants in the CalWORKs (California’s Temporary Assistance to Needy Families) program, individuals enrolled in California’s refugee programs, and children in its foster care system.
Medi-Cal Limitations on Income and Assets
Another way to qualify for Medi-Cal is based on limited income. According to the Affordable Care Act, the income limit for Medi-Cal is 138% of the Federal Poverty Level (FPL). That is about $16,100 for an individual and $32,900 for a family of four. While the Affordable Care Act has eliminated the asset test for most Medi-Cal applicants, if you are elderly or disabled, you will still need to have few assets to qualify for Medi-Cal. The limits are $2,000 for an individual and $3,000 for a couple. Not all of your assets are counted towards that limit. Your residence will not be counted if either your spouse still lives there, or if you intend to return to that residence. Also one vehicle, personal belongings, and small burial or life insurance policies are generally not counted.
The opportunity to “spend down” your assets
You are also allowed to “spend down” your assets in order to qualify for Medi-Cal. This means you can use your assets to pay off certain kinds of debts or expenses. If you are trying to spend down your assets, get advice from a Medi-Cal lawyer first, in order to avoid a penalty period affecting your benefits.
Sharing the cost Medi-Cal
If you have excess income that prevents you from qualifying for Medi-Cal, but you have high health care expenses, such as nursing home fees, then you may qualify for a program called Share of Cost (SOC) Medi-Cal. SOC Medi-Cal allows recipients to pay a certain portion of their income every month towards their medical expenses, and Medi-Cal pays the remainder of the expenses incurred. The portion that the Medi-Cal recipient pays is called his or her share of cost. This program is a very valuable resource for individuals who may have higher incomes, but who find that they cannot afford the cost of long-term care.
If you have questions regarding nursing home care, or any other Medi-Cal planning needs, please contact the Schomer Law Group either online or by calling us at (301) 337-7696. Join us for a free seminar!