The type and level of assistance a senior may need can vary greatly. Some seniors only need help around the house a few times a week while others require around the clock medical care and monitoring. For seniors who need more extensive care, the options are an assisted living facility or nursing home care. Not only is assisted living a more attractive option, it is usually the more economical option as well. If you are relying on Medi-Cal to cover the cost of care though, will it pay for assisted living? Let’s explore when Medi-Cal will pay for assisted living for those who qualify.
Nursing Home Care vs. Assisted Living
Skilled nursing facilities are residential facilities that offer round-the-clock skilled nursing care in addition to other supportive services. Assisted living is part of a continuum of long-term care services that provides a combination of housing, personal care services, and health care. The primary difference between the two is that a nursing home typically offers more extensive medical care but the residents have less personal freedom whereas at an assisted living facility the residents have a considerable amount of personal space and independence with less extensive medical care. An assisted living community is often like an apartment community with services geared toward seniors and a medical care component that isn’t found at a basic apartment community.
Another noticeable difference between a nursing home and an assisted living facility is the cost. For a senior who needs some assistance, but who does not truly need the level of care offered at a nursing home, an assisted living community is the obvious choice. The fact that assisted living is almost half the cost of nursing home care would seem to make it a win-win for seniors and Medi-Cal if assisted living is an option.
Will Medi-Cal Pay for Assisted Living?
The high cost of long-term care caused many seniors to turn to Medi-Cal (California’s Medicaid program) for help paying for care. Medi-Cal will pay for a nursing home only when it is “medically necessary.” California defines medically necessary as “when it is reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain.” For Medi-Cal to pay for a nursing home stay, your treating physician must prescribe a nursing home for you because you either need the continual, round-the-clock availability of skilled nursing care or what’s called “intermediate care.” Skilled nursing care includes things like giving injections, inserting or replacing catheters, changing wound dressings, feeding through a gastric tube, and treating bed sores. Intermediate care means a protective and supportive environment with “observation on an ongoing intermittent basis to abate health deterioration.” Even though many of the same services are available, at almost half the cost, at an assisted living facility, Medi-Cal typically does not pay for assisted living expenses as a rule.
The good news is that recognizing the benefit of allowing seniors the option to choose assisted living instead of nursing home care, California has created a Medi-Cal program called the Assisted Living Waiver (ALW). Through the ALW program, seniors who qualify for Medi-Cal can remain in assisted living if they prefer. This program is open to residents statewide; however, there are not providers available in every county. Participants must be willing to live in an assisted living residence located in one of the following counties though: Alameda, Contra Costa, Fresno, Kern, Los Angeles, Orange, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, San Joaquin, San Mateo, Santa Clara, and Sonoma.
Please download our FREE estate planning checklist. If you have additional questions or concerns about Medi-Cal planning, contact us at theNorthern California Center for Estate Planning & Elder Law by calling (916)-437-3500 or by filling out our online contact form.