Long-term care facilities, such as nursing homes and assisted living facility, are typically quite expensive for families. Unfortunately, most private health insurance policies do not cover services at nursing homes. To make matters worse, Medicare coverage for nursing home care is very restricted. Most people do not have insurance policies that include coverage for private long-term care. The most common financial resources for California residents in need of long-term or nursing home care is Medi-Cal. Indeed, Medi-Cal provides coverage for nursing home expenses for close to 65% of California nursing homes residents. Experienced and qualified elder law attorneys are available to help you plan and apply for the Medi-Cal benefits you need.
Understanding how Medi-Cal works
Medi-Cal is California’s version of the national Medicaid program, which is funded the federal and state government. The California Department of Health Care Services (DHCS) administers long-term care programs in California. Becoming eligible for nursing home services through Medi-Cal can be accomplished in several different ways, all of which Medi-Cal lawyers can guide you through.
Medi-Cal coverage for nursing home residents
Nursing homes are residential health care facilities which offer skilled nursing care in addition to other supportive services to resident round-the-clock. The average cost of nursing home care in California is at least $8,000 per month. Many families cannot afford to pay nursing home expenses on their own.
Medi-Cal coverage for “medically necessary” nursing home services
Medi-Cal will only pay for nursing home services when those services are determined to be “medically necessary.” In California services are medically necessary “when it is reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain.” The potential patient’s health care provider needs to prescribe nursing home care before Medi-Cal will pay for that care. More specifically, the health care provider must establish the need for continual, round-the-clock availability of skilled nursing care or what’s called “intermediate care.”
Services included in skilled nursing care
Many clients and their families are often confused about what type of care is included in skilled nursing care. Generally, this type of care includes treating bed sores, changing wound dressings, feeding through a gastric tube, giving injections, and inserting or replacing catheters. The term “intermediate care” refers to providing a protective and supportive environment, including “observation on an ongoing intermittent basis to abate health deterioration.” In effect, your physician must find that a patient’s health would be at risk if you do not have access to skilled nursing care.
Qualifying for Medi-Cal
Patients already receiving Medicaid coverage through Medi-Cal will automatically qualify for nursing home services. Recipients of SSI benefits, participants in the California’s Temporary Assistance to Needy Families program (CalWORKs), and individuals enrolled in California’s refugee programs automatically qualify for Medi-Cal, and therefore, qualify for nursing home care.
Medi-Cal limits on income and assets
Patients can also qualify for Medi-Cal based on limited income. Currently, the income limit for Medi-Cal is 138% of the Federal Poverty Level (FPL), which equates to approximately $16,100 for an individual and $32,900 for a family of four. The limitations on assets are $2,000 for an individual and $3,000 for a couple if both spouses need Medi-Cal long term care benefits. Not all types of assets are counted towards this limit. For example, your residence is not counted as long as either your spouse still lives there or you intend to return to the residence once you’re done receiving nursing care. Additionally, one vehicle, your personal belongings, and small burial or life insurance policies are typically not counted.
You may be allowed to “spend down” your assets in order to qualify
In most cases, you will be allowed to “spend down” your assets in order to qualify for Medi-Cal. Spending down means you use your countable assets to pay off certain debts or expenses. Before patients attempt to spend down their assets, it is wise to obtain advice from an experienced and qualified elder law attorney in order to avoid a penalty period being imposed their benefits.
Share of Cost – a Medi-Cal Program
In some cases, if you have too much income to qualify for Medi-Cal but your health care expenses are still higher than you can afford, you may be able to qualify for a program called Share of Cost (SOC) Medi-Cal. With this program, you may be able to pay a set portion of your income each month towards your health care expenses, while Medi-Cal covers the remainder of your expenses. This portion is called your “Share of Cost.” This program can be a tremendous help for patients who may not normally qualify, but who still cannot afford the high costs of long-term care.
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