Long-Term Care Medi-Cal
Qualifying for Medi-Cal for nursing home care can help preserve needed assets and income. Medi-Cal is California's version of the Medicaid Program and is funded jointly by the state and federal governments.
Although Medi-Cal recipients often receive Medicare, the Medi-Cal program is not the same as Medicare insurance benefits.
Medi-Cal provides financial assistance in meeting the expenses related to:
Skilled nursing facilities
Aged and Disabled Medi-Cal
Medi-Cal is California’s health insurance program for low-income or low-resource individuals, funded jointly through state and federal dollars. There are many different Medi-Cal programs, and each program has different eligibility criteria. The programs described below are designed for elderly or disabled individuals living at home or in community-based settings, like assisted living facilities. This information is not applicable to individuals in Skilled Nursing Facilities (SNFs) seeking Medi-Cal for long term care.
Aged and Disabled Federal Poverty Level Program (A&D FPL)
The Aged and Disabled Federal Poverty Level Program (A&D FPL) serves individuals aged 65 and older and persons with disabilities. The program makes full-scope Medi-Cal (i.e., health coverage for medically necessary services such as physician visits, hospital care, ambulances, prescription drugs, and in-home care) available with no Share of Cost (SOC). To qualify for this program, individuals must meet all of the following three criteria:
- To qualify as disabled, you must demonstrate that you receive Social Security Disability Income (SSDI) OR would be eligible because of your disability to qualify for Supplemental Security Income (SSI) but have been determined ineligible due to your income being too high. In other words, you must show that you cannot work due to a physical or mental impairment (expected to last at least 12 months).
- This limit does not include exempt assets, e.g., your home.
- $20 from unearned income
- Health insurance premiums
- Earned income deductions:
Why Seek Advice for Medi-Cal?
As life expectancies and long-term care costs continue to rise, the challenge quickly becomes how to pay for these services. Many people cannot afford to pay $10,298.00 per month or more for the cost of a nursing home, and those who can pay for a while may find their life savings wiped out in a matter of months, rather than years.
Fortunately, the Medi-Cal Program is there to help.
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Who Pays for Long-Term Care?
One of the things that concerns people most about nursing home care is how to pay for that care. There are basically four ways that you can pay the cost of a nursing home:
#1: Long-Term Care Insurance
If you are fortunate enough to have this type of coverage, it may go a long way toward paying the cost of the nursing home. Unfortunately, long-term care insurance has only started to become popular in the last few years and most people facing a nursing home stay do not have this coverage.
#2: Pay with Your Own Funds
This is the method many people are required to use at first. Quite simply, it means paying for the cost of a nursing home out of your own pocket. Unfortunately, with nursing home bills averaging between $7,500 to $9,000 per month in our area (Los Angeles county), few people can afford a long-term stay in a nursing home.
This is the national health insurance program primarily for people 65 years of age and older, certain younger disabled people, and people with kidney failure. Medicare provides only short-term assistance with nursing home costs, but only if you meet the strict qualification rules.
This is a federal and state funded and state administered medical benefit program which can pay for the cost of the nursing home if certain asset and income tests are met. Since the first two methods of private pay (i.e. using your own funds) and long-term care insurance are self-explanatory, our discussion will concentrate on Medicare and Medi-Cal.
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What is Medicare?
There is a great deal of confusion about Medicare and Medicaid or Medi-Cal.
Medicare is the federally funded and state administered health insurance program primarily designed for older individuals (i.e. those over age 65). There are some limited long-term care benefits that can be available under Medicare.
In general, if you are enrolled in the traditional Medicare plan, and you've had a hospital stay of at least three days, and then you are admitted into a skilled nursing facility (often for rehabilitation or skilled nursing care), Medicare may pay for a while. (If you are a Medicare Managed Care Plan beneficiary, a three-day hospital stay may not be required to qualify.)
If you qualify, traditional Medicare may pay the full cost of the nursing home stay for the first 20 days and can continue to pay the cost of the nursing home stay for the next 80 days, but with a deductible that's nearly $150 per day. Some Medicare supplement insurance policies will pay the cost of that deductible.
For Medicare Managed Care Plan enrollees, there is no deductible for days 21 through 100, as long as the strict qualifying rules continue to be met; $0, in the best case scenario. The traditional Medicare or the Medicare Managed Care Plan may pay up to 100 days for each "spell of illness."
In order to qualify for these 100 days of coverage, however, the nursing home resident must be receiving daily "skilled care" and generally must continue to "improve".
Note: Once the Medicare and Managed Care beneficiary has not received a Medicare covered level of care for 60 consecutive days, the beneficiary may again be eligible for the 100 days of skilled nursing coverage for the next spell of illness.
While it is never possible to predict at the outset how long Medicare will cover the rehabilitation, from our experience it usually falls far short of the 100 day maximum. Even if Medicare does cover the 100 day period, what then? What happens after the 100 days of coverage have been used? At that point, in either case, you're back to one of the other alternatives: Long-term care insurance, paying the bills with your own assets, or qualifying for Medi-Cal (Medicaid in states other than California).
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What is Medi-Cal?
Medicaid (Medi-Cal in California) is a benefits program primarily funded by the federal government and state administered. The rules do vary from state to state. One primary benefit of Medicaid is that, unlike Medicare (which only pays for skilled nursing), it will pay for long-term care in a nursing home once you've qualified.
Medicare does not pay for treatment for all diseases or conditions. For example, a long-term stay in a nursing home may be caused by Alzheimer's or Parkinson's disease, and even though the patient receives medical care, the treatment will not be paid for by Medicare. These stays are called custodial nursing stays for which Medicare does not pay, thus you'll either have to pay privately (your own funds or long-term care insurance, or you'll have to qualify for Medi-Cal).
Medi-Cal has a special benefit to cover the cost of Skilled Nursing Home Care. These are special programs for home care and for care in a few select assisted living facilities. There is optimism that these programs will keep people in the community and out of the nursing home, but for most people, Medi-Cal is used to pay for the very expensive stay in skilled nursing care.
New Rules As Of July 1, 2022
Assets that Won't Disqualify You from Medi-Cal
The following property is generally exempt and therefore not counted in determining Long-Term Care Medi-Cal eligibility:
All other assets are generally non-exempt and are countable. All money and property, and any item that can be valued and turned into cash, is a countable asset unless it is one of those assets listed above as exempt. If you don't do proper planning, you will spend down assets unnecessarily. Countable assets include:
Please remember the Medi-Cal rules themselves are complicated and tricky. With proper planning, assets can be preserved and protected by the use of Medi-Cal Asset Protection Trusts or other techniques depending on the circumstances.
Protecting Your Home
The home of a Medi-Cal beneficiary continues to be exempt from consideration as a resource under a wide variety of circumstances. These are spelled out in detail in W&I Code §14006(b). Under these provisions, a home will continue to be considered an exempt principal residence if:
Note: Because the home is exempt for eligibility purposes does not mean that the home is immune from an estate claim after the beneficiary dies. If the home is still in the name of the beneficiary when they die, Medi-Cal can recover from the estate.
In Order To Protect Your Home, You Must Avoid Probate!!!!
Intent to Return Required
The principal residence is exempt based upon a person's subjective intent to return, even though they may never have the ability to return to that residence. If the applicant is unable to complete the application, their representative may indicate that intent. The eligibility worker may not restrict, in any way, the individual or their representative in the process of indicating that intent. As long as the applicant or beneficiary declares an intention to return home on the Medi-Cal application (i.e., checks the "yes" box), the house will be treated as a principal residence exempt from being counted as a resource by Medi-Cal.
Unless the applicant is requesting an income deduction to maintain the home for the return within six months pursuant to Title 22, Section 50605, the county may not require any verification of the individual's ability to actually return home. If the applicant or their representative incorrectly states that there is no intent to return and later makes a correction, the county must accept that correction (See ACWDL Nos. 95-48 and 00-11).
"Intending to return home" will also keep the home safe if the community spouse dies first, but only for the life of the institutionalized spouse.
Applicants/beneficiaries may want to transfer the home entirely to the community spouse in order to avoid an estate claim after the surviving spouse dies. In addition, if the community spouse dies first, the home will likely end up in the probate estate of the institutionalized spouse and be swallowed up in estate recovery claims.
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Some Common Questions and Difficult Answers
California's Medi-Cal applicants and beneficiaries are often confused about their rights regarding Medi-Cal and are particularly concerned that the state will "take" their homes after they die if they received Medi-Cal benefits.
The following "Frequently Asked Questions" attempts to answer some of these concerns and to provide consumers with the information necessary to make informed choices about their estates when they are applying for Medi-Cal.
Yes. The entire amount is counted unless you can prove some or all of the money was contributed by the other person who is on the account. This rule applies to cash assets such as:
Savings and checking accounts
Credit union share and draft accounts
Certificates of deposit
U.S. Savings Bonds
Many people wonder, can't I give my assets away? NO! The reason you don’t want to give your assets away is that once you give them away, they don’t belong to you (even if your children can be as honest and trustworthy as possible).
The State of California does not take away anyone's home, per se. Your home can, however, be subject to an estate claim after your death. For example, your home may be an exempt asset while you are alive and is not counted for Medi-Cal eligibility purposes. However, if the home is still in your name when you die, the State can make a claim against your estate for the amount of the Medi-Cal benefits paid or the value of the estate, whichever is less. Thus, if your home or any part of it is still in your name when you die, it is part of your "estate" and can be subject to an estate claim. The State may go after all assets that go through probate.
Consumers often confuse liens and estate claims. Both have been used by the State in attempts to reimburse the Medi-Cal program for payments made to beneficiaries. Liens are placed on living Medi-Cal beneficiaries' estates to "hold" the property until the person dies. Estate claims are claims made against the estate of the Medi-Cal beneficiary after he or she dies. As of January 1, 1996, California is not permitted to impose liens against the homes of nursing home residents or their surviving spouses, except in cases where the home is not exempt (i.e., the nursing home Medi-Cal applicant did not indicate an intention to return home) and the home is being sold. Under current law, these are the only liens that can be placed on the homes of living beneficiaries.
Most Medi-Cal applicants' homes are exempt because a spouse, child or sibling lives there or they do indicate an intention to return home on the Medi-Cal application, so even these liens are rare. After the beneficiary has died, the heirs or survivors may sign a "voluntary" lien for Medi-Cal recovery purposes, if they cannot otherwise avoid an estate claim against the property.
After the Medi-Cal beneficiary's death, the State can make a claim against the estate of an individual who was 55 years of age or older at the time he or she received Medi-Cal benefits or who (at any age) received benefits in a nursing home, unless there is a surviving spouse or a minor, blind or disabled child. Thus, if there are any assets left in the estate of the deceased beneficiary, Medi-Cal will seek to be reimbursed for benefits paid. It is important to note that, even if you received Medi-Cal at home, any benefits paid while you were 55 years of age or older will be subject to Medi-Cal recovery.
California's definition of "estate" includes such assets subject to probate. Small estates are excluded as are some other assets. If the State is making a claim, you should contact an attorney familiar with the exceptions to make sure they have the right to recover.
The amount of recovery is limited to the amount of benefits paid or the value of the beneficiary's estate, whichever is less. For example, if the appraised value of your home is $200,000 and you left it in a Will to your three children, the State can only collect the amount they paid.
When the State files an estate claim, they are also required to send an itemized billing of benefits paid over the deceased's lifetime. It is important to review the billing to see if there are any errors. Payments made for personal care services under the In Home Supportive Services (IHSS) program, the cost of premiums, co-payments and deductibles paid on behalf of either Qualified Medicare Beneficiaries or Specified Low-Income Medicare Beneficiaries (QMB/SLMB) are exempt from recovery. Thus, if payments for these services are included in the itemized billing, the collection representative should delete this from the billing.
Surviving Spouse: The state is prohibited from recovery while a surviving spouse of a deceased Medi-Cal beneficiary is alive. However, after the surviving spouse dies, recovery may be made against any property received by the spouse through distribution or survival, e.g., property left under a will or community property. However, if the home is transferred out of the nursing home resident's name while he or she is alive, no claim can be placed on the home. Spouses should be careful to "transmute" the property, i.e., through a court order or by having the nursing home spouse sign a declaration relinquishing his/her interest in the property.
Minor, Blind or Disabled Child: If a minor child under the age of 21 or a blind or disabled child of any age survives the beneficiary, a claim is prohibited by federal and state laws. The surviving minor child or his/her representative only needs to send proof, such as a birth certificate or adoption papers, that they are the child of the decedent or, in the case of disabled child, documentation of disability or blindness, such as a Social Security or SSI award letter and a birth certificate showing they are the child of the deceased. If the surviving child does not have documentation of disability from the Social Security Administration, he/she can still file for a disability determination with the Department of Health Services. It is important to note that the surviving child does not have to live in the home (or even in the State, for that matter) in order for recovery to be barred.
When there is Nothing Left in the Estate: Since most deceased Medi-Cal Beneficiaries leave nothing but their homes, it is most important to look at the deed to the property: Whose name was on the property at the date of death? If the beneficiary transferred the property outright prior to death, then send a copy of the deed, along with a letter explaining that the beneficiary left nothing in his/her estate and ask that the case be closed. If the beneficiary transferred the home outright while he or she was alive and reserved a life estate or an occupancy agreement, send a copy of the deed showing the property was transferred before the beneficiary died.
Under current law, "estate" is defined as any real or personal property and other assets in which the individual had any legal title or interest at the time of death (to the extent of such interest), including assets conveyed through joint tenancy, tenancy in common, survivorship, life estate, living trust or other arrangement. Anything left in the decedent's bank accounts, for example, can be subject to recovery, after estate and burial expenses or other documented expenses are paid. The State can also recovery from annuities purchased by a beneficiary on or after September 1, 2004, regardless of whether the remainder interest in the annuity is a lump sum or a stream of income. Call Martha Jo Patterson if you have specific questions regarding what assets are subject to recovery.
Life Estates: Under the new recovery rules, claims on irrevocable life estates are waived, but the state is placing claims on "revocable" life estates. For example, if you retain a life estate and, "upon death the remainder to the children", this would not be considered a transfer and your home could be subject to recovery. If the gift deed transfers the home outright to the individual(s) and you retain a life estate, this would be considered irrevocable and would be immune from recovery.
The State cannot recover from IRAs, work-related pension funds or term life insurance policies, unless they name the state as the beneficiary or they revert to the estate. This is rare, as most people name a beneficiary for pension funds and insurance policies.
Notice of Death: When a Medi-Cal beneficiary dies, the County Medi-Cal office notifies the Department of Health Services in Sacramento and benefits are terminated. However, for recovery purposes, the burden of notifying the State of the death is still on the beneficiary's estate. California law, under Probate Code §215, requires that, when a deceased person has received or may have received health care benefits or was the surviving spouse of a person who received such benefits, the estate attorney, the beneficiary of the estate, the personal representative or the person in possession of the property is required to notify the Director of the Department (at the Sacramento office of DHS) no later than 90 days after the person's death. A copy of the death certificate is required to be sent.
Beware of Forms: The Recovery Unit has sent out a number of questionnaires to consumers implying that they are under a legal obligation to complete and return them. The only legal obligation under law is to send a notice of death and a copy of the death certificate when a deceased Medi-Cal beneficiary or the spouse of a deceased beneficiary dies.
If the State has sent an estate claim, then the questionnaire is a way for them to find out what property, if any, is left in the deceased beneficiary's estate. If there was no property left in the deceased's name, then completion of the form (or an attached letter) should be an easy matter. Enclose a copy of the deed to show the property was transferred during the life of the beneficiary. If the estate is more complicated, then consumers should seek advice from their attorney, before completing and returning any questionnaires or forms.
But I Heard ... There is NO Way To Qualify for Help!
Myths About Medi-Cal
1. There is a 5-year look back (or penalty) on any gift or transfer
California has not implemented the 5-year look back which is part of the Deficit Reduction Act of 2005 (DRA 05), and can only look back for 3 months. The rules in California allow for transfers and gifts if done correctly to be ignored for the purposes of qualifying for benefits.
2. You must be poor to qualify for Medi-Cal
Poverty is required for many programs; however, the Long-Term Care Program was designed specifically to provide care for middle class families. The program is designed to prevent the impoverishment of spouses. Spouses now include all married couples including same gender couples.
3. I must "spend down" to qualify.
"Spending down" your assets is not required. There are many options available to preserve assets and qualify a person for Medi-Cal. For Elder Law Attorneys like Certified Elder Law Attorney Martha Patterson, the reward for preserving assets for clients especially when the at home spouse is able to thrive due to the planning done is priceless.
4. I have too much income to qualify.
Income determines the Share of Cost, but will not disqualify someone in California from qualifying for Long-Term Care Medi-Cal and in many circumstances an Elder Law Attorney like Martha Patterson can obtain a Court Order which will allow the income of the Spouse in a Facility to be transferred to the at home spouse.
5. There is no way we can qualify; we have way too many assets.
It is rare that someone has so many assets that they cannot qualify. There are many strategies that can be used to preserve assets while qualifying a person for Medi-Cal. Don't Assume You Won't Qualify. If you call Martha Patterson, you may be (like most people who call) surprised to hear that Martha Patterson can help you qualify for Medi-Cal to pay for your stay in a Skilled Nursing Facility.