Monday, June 24, 2013

Am I eligible for Medi-Cal? I need to go into a nursing home.

First, let me explain what Medi-Cal is:  Medi-Cal, California’s version of Medicaid, is a state and federal program that covers most nursing home costs for those who have low incomes or whose resources have been depleted by health care costs. For the majority of California nursing home residents — about 65% of them — care is paid for by Medi-Cal.

Medi-Cal does not cover the costs of care in a Congregate Living Health Facility, except for hospice care at the end of life.

Who Is Eligible

In general, an individual who is over age 65 can qualify for Medi-Cal coverage if he or she has either:

A low income and little savings or other assets, as described below under “Income and Asset Levels,”


Personal resources that are reduced because of paying for health care expenses, as described below under “Higher Limits for High Medical Expenses.”

Also, individuals enrolled in these programs can automatically qualify for Medi-Cal:

  • Supplemental Security Income (SSI) or State Supplementary Payment (SSP): These federal and state programs provide income to those who are 65 and over, blind, or disabled who meet income and resource limits. For a quick analysis of whether you qualify, use the SSI Benefit Eligibility Screening Tool.
  • In-Home Supportive Services (IHSS): This program provides services to those over 65, disabled or blind who want to remain living at home, administered through county offices. Learn more.
  • California Work Opportunity and Responsibility to Kids (CalWORKs): This program provides income and services to some families with special needs. It is administered through the county social services department. Learn more.
  • Refugee Programs: This program is run by California's Refugee Program's Bureau. Learn more.
  • Foster Care or Adoption Assistance Program: This program is run by California's Children and Family Services Division. Learn more.

Income and Asset Levels

Not all income and assets are counted when determining eligibility (income limits change frequently; for current information contact the local Medi-Cal office). Assets that are not counted include:
  • A home, if the nursing facility patient intends to return to it as a primary residence, or his or her spouse lives there;
  • A cash reserve of $2,000 for single people, more for married couples;
  • One car and household and personal belongings including clothing, heirlooms and wedding and engagement rings;
  • Burial plots and any money in a designated burial plan fund; and
  • Life insurance policies and the balance of pension funds, IRAs, and certain annuities.

Individuals with income and assets above Medi-Cal limits who are not in immediate need of long term care may be able to become eligible by getting rid of some of their assets. For example, Medi-Cal rules allow reducing assets by paying off medical bills or a mortgage or other debts, paying for home care, replacing an old vehicle, updating home furnishings, or prepaying funeral expenses. Some people may also qualify for Medi-Cal by transferring their property to others, with the important limitation that anything transferred during the 60 months before applying for coverage will be taken into account in determining eligibility.

Higher limits for high medical expenses. Some people with relatively high incomes may qualify for Medi-Cal if a designated amount goes exclusively to paying medical costs. This is called paying a “share of cost.” The amount may change with an individual’s monthly income.

When one spouse remains at home. A couple does not need to sell their home to qualify for Medi-Cal when one spouse enters a nursing facility. Also, the spouse who remains at home is allowed to receive a certain amount of income each month, and to retain some of the couple's combined assets.

What Is Covered

Once a person meets the strict requirements for qualifying for coverage, Medi-Cal will pay all costs of skilled nursing services in facilities it certifies and all medical equipment a doctor deems is necessary. However, certain care that was formerly covered — including dental, acupuncture, audiology, speech therapy, chiropractic, optometric and optician, podiatric, and psychology services — is now specifically excluded.

How to Apply

Individuals may apply for coverage at the local Medi-Cal office. If a person is homebound or already in a nursing facility, the individual or family can request that a Medi-Cal representative assist in completing the application during a visit to the home or facility.

Within 45 days after the paperwork is completed, the Medi-Cal office will send a written notice about eligibility. Individuals have 90 days to appeal a denial of coverage and request an informal hearing for reconsideration.

Dual Coverage with Medicare

People who qualify for both Medi-Cal and Medicare benefits are known as “dual eligibles” or “Medi-Medis.” For them, Medicare will be the primary payer, with Medi-Cal providing secondary coverage to take up some of the slack. Medi-Cal may also cover deductibles and copayments. It will also pay for Medicare Part A and Part B deductibles and copayments and for Part B premiums as well as some types of drugs, vitamins, and minerals that Medicare does not cover.


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