Medi-Cal, California’s Medicaid program, provides, among other benefits, no-cost or low-cost health insurance for adults age 65 years or older, blind, disabled, pregnant, or in a long-term facility. The program also provides benefits for non-disabled, non-elderly and qualifying adults aged 19-64 whose income levels are at or below 138% the Federal Poverty Level. For Sacramento residents, it is important to know that the Medi-Cal benefits are available if you qualify or you have a loved one who qualifies.
What is “Medi-Cal?”
Medicaid programs, while partially funded by the federal government, are independently run by each state. Therefore, Medicaid benefits and eligibility requirements may be different from state to state. In most cases, Medicaid patients are only required to pay a small co-pay, if anything at all.
Sacramento residents are typically familiar with California’s Medicaid program – Medi-Cal. The program provides payment for a variety of medical services for those with limited income and resources. Like in many other states, Medi-Cal provides waivers for additional services, which may not specifically be available under the standard Medicaid programs within the state.
What are Medicaid waivers?
The purpose of Medicaid waivers is to provide additional services to certain groups of people, certain geographic locations, or individuals who may not otherwise qualify for Medicaid. For instance, there are waiver programs that will provide family planning services, home and community-based medical services, managed care and specialty mental health services.
Medi-Cal waiver programs
California’s Department of Health Care Services has several Medi-Cal waiver programs available. Following is a list of current waiver programs. There are often programs that expire and programs that are still under development, so this list is in no way exhaustive.
- Acquired Immune Deficiency Syndrome (AIDS) Waiver
- Home and Community-Based Services Waiver for the Developmentally Disabled
- Family Planning, Access, Care and Treatment Program (Family PACT)
- Developmentally Disabled – Continuous Nursing Care (DD-CNC)
- Multipurpose Senior Services Program (MSSP)
- Nursing Facility/Acute Hospital (NF/AH)
- Specialty Mental Health Consolidation Program (SMHC)
- Pediatric Palliative Care Waiver (PPC)
How to obtain Medicaid waiver services
In many cases, the first step in obtaining benefits through waiver programs is to simply contact the local social services office. In Sacramento, that would be the California Department of Developmental Services. Other programs may require an initial assessment through that program’s administrator, in order to determine eligibility for those services.
Paying for Sacramento nursing home care through Medi-Cal
Long-term care facilities, such as nursing homes are quite expensive, averaging over $8,000 per month in California. Unfortunately, most private health insurance policies do not cover these services. Medicare coverage for long-term care is limited. For Sacramento residents who require nursing home care, Medi-Cal is a very common source of funding. Overall, Medi-Cal pays the nursing home expenses of nearly 65% of California residents receiving care in nursing homes.
Benefits for “medically necessary” nursing home services
Medi-Cal pays for nursing home services if those services are deemed “medically necessary.” In California that term means “it is reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain.” A physician must prescribe nursing home care for the patient, based on the medical need for “intermediate care.” Intermediate care is basically continuous, around-the-clock skilled nursing care. Medi-Cal will only pay for the nursing home care if it has been prescribed as medically necessary.
What is involved in skilled nursing care?
Skilled nursing care includes services such as changing wound dressings, treating bed sores, giving injections, inserting or replacing catheters, and feeding through a gastric tube. Intermediate care refers to a protective and supportive environment, with “observation on an ongoing intermittent basis to abate health deterioration.” Ultimately, a physician must determine that the patient’s health would be at risk if skilled nursing or intermediate care is not provided.
Sharing the cost Medi-Cal if you can’t qualify
Some people may have too much income to qualify for Medi-Cal, but still cannot afford the huge costs of nursing home care. If that is the case, there is another program called Share of Cost (SOC) Medi-Cal. If you qualify for SOC Medi-Cal, you can pay only a portion of your income every month towards your medical expenses. Medi-Cal then pays the remainder of the expenses. The share that you pay for your medical expenses is your share of cost. This program can be a very helpful resource for those individuals who have higher incomes, but who still cannot afford the cost of long-term care.
If you have questions regarding Medi-Cal, or any other Medicaid planning needs, contact the Northern California Center for Estate Planning and Elder Law for a consultation, either online or by calling us at (916) 437-3500. Join us for a free seminar!