California’s Medicaid program is known as Medi-Cal. It provides free or low-cost health care coverage for adults who are 65 or older, blind, disabled, pregnant or residing in a long-term facility. Medi-Cal also provides benefits for non-disabled, non-elderly adults aged 19-64 who qualify based on their income levels. To qualify based on income, their level must be at or below 138% the Federal Poverty Level. For Sacramento residents, it is important to know the requirements imposed by Medi-Cal law.
What is “Medi-Cal” exactly?
Medi-Cal, like Medicaid programs in other states, is funded in part by the federal government but are run independently by each state. For that reason, Medi-Cal eligibility and benefits are not consistent from one state to the next. Usually, Medi-Cal recipients only pay a small co-pay, if anything. The program pays for various medical services for qualified individuals with limited income and financial resources. Similar to other states, Medi-Cal offers waivers that can be used for additional services not typically available under the standard program.
How do Medicaid waivers work?
Medi-Cal waivers are used to allow specific groups of people to receive additional medical services, when they may not otherwise qualify. For example, there are waiver programs that provide family planning services, home and community-based medical services, managed care and mental health services.
Medi-Cal waiver programs
Under Medi-Cal law, there are numerous Medi-Cal waiver programs available through California’s Department of Health Care Services. Some of the current waiver programs include:
- Section 1115 Medicaid Waiver
- 1915(b) Medi-Cal Specialty Mental Health Services Waiver
- Assisted Living Waiver (ALW)
- Developmentally Disabled – Continuous Nursing Care (DD-CNC)
- Family Planning, Access, Care and Treatment Program (Family PACT)
- Home and Community-Based Services Waiver for the Developmentally Disabled (HCBS-DD)
- In-Home Operations (IHO)
- Multipurpose Senior Services Program (MSSP)
- Nursing Facility/Acute Hospital (NF/AH Waiver)
- Pediatric Palliative Care Waiver (PPC)
- Superior Systems Waiver (SSW)
There are other waivers that are under development. You can find more information at the California Department of Health Care Services website.
How to obtain Medicaid waiver services
Typically, the first step in obtaining health benefits through a Medi-Cal waiver program is to contact your local county human services office. Some programs may require an initial assessment to determine eligibility for those services.
Will Medi-Cal cover nursing home care?
Nursing homes, assisted living facilities and other long-term care facilities can be very expensive. Many private health insurance policies do not cover these types of services and Medicare benefits usually offer limited coverage for long-term care. If you require nursing home care, Medi-Cal is probably your best bet. In fact, Medi-Cal pays the nursing home expenses of nearly 65% of California residents receiving care in nursing homes.
Benefits available for “medically necessary” services at a nursing home
Although Medi-Cal covers nursing home services, it is only those services that are considered “medically necessary.” Under California Medi-Cal law, the term medically necessary means “it is reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain.” A doctor has to prescribe nursing home care for a Medi-Cal patient based on the medical need for “intermediate care.” Intermediate care is considered as continuous, around-the-clock, skilled nursing care. Medi-Cal only pays for nursing home services when they have been prescribed as medically necessary.
Services involved in skilled nursing care
The medical services involved in skilled nursing care include changing wound dressings, treating bed sores, giving injections, inserting or replacing catheters, and gastric tube feedings. Intermediate care involves to a protective and supportive environment, with “observation on an ongoing intermittent basis to abate health deterioration.” In the end, a physician needs to determine that the patient’s health would be at risk if skilled nursing or intermediate care is not provided.
Those who cannot qualify can share the cost of Medi-Cal
For those individuals who earn too much to qualify for Medi-Cal but cannot afford the expense of nursing home care, there may be another option. Share of Cost (SOC) is a Medi-Cal program that allows you to pay only a portion of your income each month towards your medical costs. The rest of the cost is paid by Medi-Cal, which can be very helpful for those who have higher incomes but cannot afford the costs of long-term care without assistance.
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