Because current costs for nursing-home care are incredibly high, more and more Californians are seeking financial support through Medi-Cal. Those who are eligible can receive the equivalent of a no-interest loan.  With it, Medi-Cal pays a portion of the patient’s monthly nursing home fees, while the patient’s continued income defines his or her monthly deductible or share of cost.

When the patient passes away, Medi-Cal seeks reimbursement from the remaining estate. If the patient is married, it will not seek reimbursement until both spouses have died.

So many nursing home residents need Medi-Cal because Medicare’s nursing home coverage is quite limited. An insured patient must first be hospitalized for at least three consecutive days and then transferred to a skilled nursing facility (SNF) for rehabilitation services. After 100 consecutive days, Medicare’s SNF coverage stops, and the patient must find a way to finance continuing care.

Unlike Medicare, Medi-Cal neither requires prior hospitalization nor the need for skilled nursing assistance.  Instead, it only requires that nursing home care is medically necessary. This occurs when a treating doctor confirms the patient’s needs for assistance with at least two activities of daily living, i.e., eating, bathing, dressing, toileting or just getting around.

Medi-Cal also has financial eligibility requirements. The value of a single person’s countable assets cannot exceed $2,000. Common examples of countable assets include cash, bank accounts, stocks, bonds and certain business and real properties. In determining eligibility Medi-Cal does not consider a patient’s home, one car, prepaid burial plot, certain IRAs and work-related pensions and term life insurance. It defines these as exempt assets.

If the patient is married, the countable asset limit rises to $128,640 (effective 4/1/2020)– with the spouse who stays at home retaining all but the $2,000. Without this unequal division, Medi-Cal’s eligibility requirements might cause a couple to divorce for no other reason than financial support.

In determining a patient’s eligibility, Medi-Cal will review financial records covering the previous 2-1/2 years. If Medi-Cal concludes that, during that time, the patient made gifts with the goal of reducing assets to meet eligibility guidelines, it might find him or her ineligible for a calculated period of time.

California law requires all nursing homes to provide high quality care. Although Medi-Cal may offer many people financial support, not all nursing home facilities accept it and, unfortunately, those that do often have long waiting lists.

For more specific information on Medi-Cal’s eligibility requirements, and anticipated legislative changes, be sure to attend one of H.E.L.P.’s upcoming “Medi-Cal Coverage for Nursing Home Care” classes. To view H.E.L.P.’s upcoming class schedules click here.