Long-term care like nursing homes, assisted living facilities, and home care are expensive, and private health insurance policies generally do not cover those services. Medicare coverage for long-term care is very limited, and few people have purchased private long-term care insurance policies.
For California residents needing long-term care services, Medi-Cal is the most common source of funding. Medi-Cal pays for the nursing home expenses of approximately 65% of the residents in California nursing homes. Medi-Cal, the name of California's state Medicaid program, is funded by both federal and state funds, and it provides health insurance to one-third of California's population. There are many different ways to become eligible for Medi-Cal, and there are specific eligibility rules 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.
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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 $8,800 per month in California (or $10,600 for a private room). Most people cannot afford to pay their own nursing home expenses.
Medi-Cal, however, 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 bedsores. Intermediate care means a protective and supportive environment with "observation on an ongoing intermittent basis to abate health deterioration." To determine whether you need at least an intermediate "level of care" (LOC), Medi-Cal will do an LOC assessment that looks at your limitations in your activities of daily living (ADLs), cognitive function, and physical function and your need for help with medication and treatments.
If you need a health care aide or nurse only for one or two things a day, then Medi-Cal may find that a nursing home stay is not medically necessary, because you could get these services on an outpatient basis or by a home health provider. In essence, your doctor must find that your health is at risk if you do not have access to skilled nursing or intermediate care.
If you already qualify for Medi-Cal, then your Medicaid 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.
If you are "over-income" for Medi-Cal but have high health care expenses like nursing home fees, then you might 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 all of the expenses incurred afterward. The portion that the Medi-Cal recipient pays is called his or her share of cost.
SOC Medi-Cal is an important resource for individuals who might have higher incomes but who find that they cannot afford the cost of long-term care. However, Medi-Cal only lets long-term care residents keep a very small personal needs allowance ($35-$50/month) when they have nursing home fees paid by SOC Medi-Cal. Any non-exempt income above that personal needs allowance has to be paid to the long-term care facility before Medi-Cal will cover additional costs each month. In essence, Medi-Cal pays the difference between the monthly cost of the nursing home and the monthly income of the Medicaid recipient (minus $35).
In general, Medicaid pays for room and board only when they are offered in an institution that provides skilled care (like a nursing home), and it does not generally pay for room and board expenses in assisted living facilities. However, in California, to assist with the costs of assisted living facilities, the state has created a Medi-Cal program called the Assisted Living Waiver (ALW) that pays for ALFs in some counties.
To be eligible for ALW, you must be eligible for Medi-Cal (without the Share of Cost program) and require an intermediate level of care. You meet that level of care if, without the ALW services, you would need to live in a nursing home. However, because ALW is a Medicaid waiver program, it does not need to be equally available to everyone in the state who is eligible for it. At this time, California has opted to make the services available to some seniors and people with disabilities living in Sacramento, San Joaquin, Los Angeles, Sonoma, Fresno, San Bernardino, Contra Costa, Alameda, San Diego, Riverside, Kern, Orange, Santa Clara, and San Mateo counties.
California covers home health services as part of its state Medicaid plan. Medi-Cal covers home health services that are medically necessary, like skilled nursing care and medical equipment. For individuals who need ongoing, non-skilled care like assistance with bathing, cooking, and chores, California has the In-Home Supportive Services (IHSS) Program.
After a Medi-Cal recipient passes away, California's Medi-Cal program will attempt to recover the costs for nursing home and Home and Community Based Services that were paid for by Medi-Cal. The state, however, can only try to seek repayment from assets that pass through probate, so houses that are put in a living trust, or mobile or manufactured homes, are not subject to liens for recovery.
Medicaid is a health care program for low-income individuals of any age. While there are many different coverage groups, this page is focused on Medicaid long-term care eligibility for California residents aged 65 and over. In addition to nursing home care and assisted living services, California Medicaid, which is also called Medi-Cal, pays for many non-medical support services that help frail seniors remain living in their homes. There are three categories of Medi-Cal long-term care programs for which California seniors may be eligible.
In addition to paying for nursing home care, Medi-Cal offers the following programs / HCBS Waivers relevant to the elderly that helps them to remain living in their homes or in assisted living residences.
For persons with limited financial resources, Medicaid pays for nursing home care. For those who wish to live at home or in assisted living, sometimes Medicaid will pay for care in those locations if it can be obtained at a lower cost than in a nursing home. It does this through Medicaid Waivers, which are also called Home and Community Based Services (HCBS) Waivers or Waiver Funded Services.
The state of California recognizes that individuals qualified for nursing home care can often receive the same level and quality of care in an assisted living residence at a lower cost. The Assisted Living Waiver Program (ALWP) serves seniors who need long term care assistance with personal care and household tasks. Most seniors and their families prefer an assisted living environment rather than a nursing home facility. This creates a win-win scenario for the state and for families.
This page provides basic information about being certified as a Medicare and/or Medicaid nursing home provider and includes links to applicable laws, regulations, and compliance information. In the downloads section, we also provide you related nursing home reports, compendia, and the list of Special Focus Facilities (SFF) (i.e., nursing homes with a record of poor survey (inspection) performance on which CMS focuses extra attention). SFF archives include lists from March 2008.
Many recipients must use income in excess of that amount to pay long-term care costs before Medi-Cal kicks in. Medi-Cal nursing home residents generally may keep only $35-a-month of their income as a personal needs allowance. Someone living at home can keep up to $600. Those rules have not changed since 1990 and are unaffected by the new asset test.
The IHSS Program will help pay for services provided to you so that you can remain safely in your own home. To be eligible, you must be 65 year of age and over, or disabled, or blind. Disabled children are also potentially eligible for IHSS. IHSS is considered an alternative to out-of-home care, such as nursing homes or board and care facilities.
Medicaid coverage of Nursing Facility Services is available only for services provided in a nursing home licensed and certified by the state survey agency as a Medicaid Nursing Facility (NF). See NF survey and certification requirements. Medicaid NF services are available only when other payment options are unavailable and the individual is eligible for the Medicaid program.
In many cases it is not necessary to transfer to another nursing home when payment source changes to Medicaid NF. Many nursing homes are also certified as a Medicare skilled nursing facility (SNF), and most accept long-term care insurance and private payment. For example, commonly an individual will enter a Medicare SNF following a hospitalization that qualifies him or her for a limited period of SNF services. If nursing home services are still required after the period of SNF coverage, the individual may pay privately, and use any long-term care insurance they may have. If the individual exhausts assets and is eligible for Medicaid, and the nursing home is also a Medicaid certified nursing facility, the individual may continue to reside in the nursing home under the Medicaid NF benefit. If the nursing home is not Medicaid certified, he or she would have to transfer to a NF to be covered by the Medicaid NF benefit. 2ff7e9595c
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