SERVICES

We provide Medi-Cal Planning services to those individuals or families facing the daunting task of paying for skilled nursing care in California. To understand Medi-Cal Planning, is it necessary to know the difference between Medi-Cal vs. Medicare.

Medicare is a federal insurance program paid out of Social Security deductions. All persons over 65 who have made Social Security contributions are entitled to the benefits, as well as disabled workers who have been eligible for Social Security disability benefits for at least two years. Medicare is not based on financial need. Anyone who meets the age, disability and/or coverage requirements is eligible.

Medicare does not pay for all medical expenses, and usually must be supplemented with private insurance (“medigap”) or consumers can enroll in an HMO plan that contracts with Medicare. After 3 days of prior hospitalization, Medicare will pay up to 100% for the first 20 days of skilled nursing care. For the 21 to 100 days, the patient will pay a co-payment. The premiums and copayments are increased every year. There will be no Medicare coverage for nursing home care beyond 100 days in any single benefit period. It should be noted that Medicare only pays for “skilled nursing care,” does not pay for “custodial care” and the average stay under Medicare is usually less than 24 days. Thus, few can look to Medicare to pay for any substantial nursing home costs.

Medi-Cal is a combined federal and California program designed to help pay for medical care for low-income persons. Although Medi-Cal recipients may receive Medicare, the Medi-Cal program is not related to the Medicare program. Medi-Cal is a need-based program and is funded jointly with state and federal Medicaid funds.

SSI and other categorically-related recipients are automatically eligible. Others, whose income would make them ineligible for public benefits, may also qualify as “medically needy” if their income and resources are within the Medi-Cal limits.

California sets a “maintenance need standard”. Since January 1, 1990 the maintenance need standard for a single elderly/disabled person in the community has been $600 monthly; the Long Term Care maintenance need level (i.e., personal needs allowance when someone is in a nursing home) remains at $35 monthly for each person. Individuals whose net monthly income is higher than the state payment rate may qualify for the program if they pay or agree to pay a portion of their income on monthly medical costs. This is called the “share of cost.” Individuals eligible with a share of cost must pay or take responsibility for a portion of their medical bills each month before they receive coverage. Medi-Cal then pays the remainder, provided the services are covered by the program. This works much like an insurance deductible. The amount of the share of cost is equal to the difference between the “maintenance need standard” and the individual’s net non-exempt monthly income.

Medi-Cal pays for health care services which meet the definition of “medically necessary.” Services include: some prescriptions (although the Medicare Part D program now covers most prescriptions), physician visits, adult day health service, some dental care, ambulance services, some home health, X-ray and laboratory costs, orthopedic devices, eyeglasses, hearing aids, some medical equipment, etc. All covered services, or the remaining costs over the share of cost of nursing home care, will be covered if the individual meets income/resource requirements. Some services such as home health care, durable medical equipment, and some drugs require prior authorization.

Nursing home care is covered if there is prior authorization from the physician/health care provider. Residents are admitted on a doctor’s order and their stay must be “medically necessary”. Residents are allowed to keep $35 of their income as a personal needs allowance. Residents with no income may apply for the Supplemental Security Income/State Supplemental Program (SSI/ SSP), and, if eligible, they will receive a payment of $50 as a personal needs allowance.

To qualify for Medi-Cal the recipient must demonstrate that they have limited resources available. Medi-Cal classifies property as “exempt” and “non-exempt.” Exempt property is not counted in determining eligibility; non-exempt property is counted. One’s home is considered exempt; this presents unique and profound planning opportunities.

A “Community” (at home) spouse may retain up to $109,560 in liquid assets, not including the home and other exempt assets, such as IRAs and retirement funds. Any assets above the property reserve limit of $2,000 or $109,560, in the case of a community spouse, or any asset that is not exempt will be counted by Medi-Cal in determining eligibility. These numbers adjust on a yearly basis.

Medi-Cal applicants, beneficiaries and their spouses should always be aware of the Medi-Cal Recovery rules and plan ahead by consulting a qualified professional if they want to avoid recovery on their home or other assets. Our services include both assisting individuals in qualifying for Medi-Cal as well as protecting their estates from state recovery efforts.

What Should You Expect?
The first step in the planning process is to Request a Consultation with one of the attorneys in our office. If, after your initial consultation, it is determined that Medi-Cal is a viable planning option for you, then we will gather information about your personal care needs, monthly expenses, your goals regarding long term care, and your financial resources. We will discuss the benefits that might be available to you if you qualify, the application process, and what role we would play in that process.

We will discuss fees with you in advance. Once the assessment is completed, we will make a recommendation to you about whether you might qualify for Medi-Cal benefits, and you will have the information you need to decide whether you would like to file an application for benefits.