Medi-Cal Eligibility & Nursing Home Care

You might want to think again if you believed Medi-Cal planning meant only meeting strict income and asset limits to qualify for long-term care. Medi-Cal eligibility can be challenging because the criteria are not always clear. You will also need to demonstrate you need the level of care typically provided in a nursing home setting. Health eligibility rules are valid if you apply for nursing home coverage or a Medi-Cal waiver program for coverage in your home or assisted living facility. California has a level of care requirement and criteria to determine if you meet the mandated level of care.

How To Determine One’s Level Of Necessity

  • Needing assistance with two or more activities of daily living, such as bathing, toileting, dressing, eating, and mobility.
  • Requiring frequent medical care, like IVs or other injections, medications, or other medical treatment.
  • Exhibits behavioral problems such as aggressiveness or wandering away from home.
  • Alzheimer’s disease or another form of dementia that impairs one cognitive ability; making decisions on your own is problematic, or you cannot correctly process information.

California evaluates the assessment of a Medi-Cal applicant and, in many cases, will require a doctor’s diagnosis. The evaluation generally requires the applicant to answer questions about their abilities to perform daily living activities and any behavioral issues or cognitive problems. There are further questions regarding the applicant’s family and their ability to provide support.

Understanding Medical Services Covered by Medicare

Medicare covers medical services you may need beyond nursing care and institutional Medi-Cal. Suppose you need to see a specialist or go to a doctor’s office. In that case, Medicare pays first, and Medi-Cal will cover your remaining costs like copayments, coinsurances, and deductibles. 

When applying for institutional Medi-Cal, consider the following:

  • Typically, you can set aside a certain amount of assets and income to protect your spouse’s standard of living. This spousal amount does not count towards Medi-Cal eligibility. The program considers you and your spouse together when calculating assets and income.
  • You will still be able to keep a small amount of income for your allowance even though you qualify. The remainder of your income will pay for the nursing home. Your local Medi-Cal office can provide more information.
  • There is a look-back period of up to thirty months for long-term care Medi-Cal. When determining your eligibility, California will count any assets you have transferred in the past thirty months. You may be penalized if Medi-Cal determines any transfers violate the Medi-Cal eligibility rules. Medi-Cal may opt to pay only a portion of your nursing home stay or none at all.
  • Owning your own home can affect Medi-Cal eligibility and coverage. An elder law attorney can characterize your specific circumstances and how your home may count as an asset.

Nursing Home Level of Care, What Is It?

Also referred to as Nursing Facility Level of Care (NFLOC), it is not an easily definable term as there is no formal federal definition. Each state has the task of defining the term, and rules are not always consistent from one state to the other. Generally, there are four areas of concern; physical functional ability, medical needs/health issues, cognitive impairment, and behavioral problems. Keep in mind not every state considers all four.

For families with a loved one who requires more care than they can provide at home but do not require a high enough level of care to qualify for nursing home admittance, there is an in-between care type typically offered in assisted living. However, Medi-Cal coverage of this type of assisted living is very limited in numbers.

Medi-Cal Is Changing

Medi-Cal is adapting to provide this coverage type in-home to those who may meet NFLOC Medi-Cal eligibility requirements. In addition, they do not pose a danger to themselves or others in a home environment. Perhaps using this as a springboard as a potential nursing home residence is waitlisted for full-time care.

Before applying to qualify for Medi-Cal nursing home coverage, there is much to consider. Applications that are insufficient or incorrectly filed can create delays.

The need is more significant than ever before for long-term nursing home care. Meeting California’s eligibility requirements can be a long and complex series of providing documents, answering questionnaires, having assessments and reviews, and filling out and filing forms. The scope of the project can be overwhelming. 

I hope you found this article helpful. To get to your best outcome, don’t wait. Proactive planning with an elder law attorney will help you understand and address all criteria you need to act and succeed. Please contact us today at 877-585-1885to schedule a free consultation to discuss your legal matters.

Thanks for reading.

Christopher E. Botti, Esq., Certified Specialist in Estate Planning, Trust and Probate Law