Q.  I was obliged to move my wife into an Assisted Living Facility, where she now resides in the memory care unit. It costs almost $6,000 a month and I see our savings dwindling.  If we qualify financially, will Medi-Cal help with the cost of her care?

A. Maybe.  Here’s is how it all works:  The general rule is that Medi-Cal will help pay the cost of care for those who financially qualify, only if received in a nursing home and then only if the nursing home participates in the Medi-Cal program. Essentially, generally — but subject to the exceptions discussed below — care received in any other kind of care setting must be paid for with one’s own savings or– if one is lucky enough to have it – Long-Term Care Insurance or, perhaps, a Veterans Aid and Attendance Pension.  Unfortunately, as a general rule neither Medicare nor Medi-Cal will subsidize the cost of care received in a facility which is not a nursing home. This limitation generally leaves out Assisted Living Facilities (“ALF’s”).

Many clients are surprised by this limitation, and often only make this discovery only after their loved one has lived for a time in an ALF, often at great personal sacrifice to family resources.  Sometimes this belated discovery requires that a loved one be relocated to a nursing facility in order to receive a Medi-Cal subsidy and avoid the further depletion of financial resources.

There are, however, a few exceptions to this general rule:

1) Assisted Living Waiver: Medi-Cal is experimenting with offering a Medi-Cal subsidy to some individuals residing in assisted living facilities (“ALF’s”) who would otherwise be required to reside in a nursing facility.  In order to participate, applicants must be eligible for no share of cost Medi-Cal benefits and require a nursing facility level of care. Only selected counties participate in this program, and fortunately Alameda and Contra Costa Counties are two of them.  Unfortunately, the available beds are very limited, and at my last check most of them were already taken.  The following facilities in Alameda County participate in this program:  Bellaken Garden and House of Palms, both in Oakland; Elm Assisted Living II in Castro Valley; and Lotus Residential Care in Hayward. Some good news:  as of March 1, 2019, the CA Assisted Living Waiver Program (“ALW”) has been renewed for another five (5) years and 2,000 more slots have been added for qualified candidates, for a current total of 5,744 in the combined CA counties participating in the program.  More good news:  On 07/09/2019,  California legislation was signed into law by the Governor which is  expected to increase the qualifying income threshold for low income persons, but this increase (a) will not take effect until January 1, 2020, and (b) must be approved by the Federal Agency in charge of Medi-Cal/Medicaid (i.e., the Center for Medicare and Medicaid Services, aka. “CMS”).  As of 12/1/2020, that increased qualifying income threshold is now  $1,468/month for unmarried persons and $1,983/month for married persons.

By the way, the “waiver” in the name of the program refers to the fact that, for this experimental program, Medi-Cal waives the requirement that the individual receive care in a nursing facility. For more information contact the facilities or the Department Health Care Services at 916-552-9105.

2) SSI Beneficiaries:  SSI beneficiaries are eligible for special rates in ALF’s. It may be difficult, however, to find a slot if one searches for an ALF as an SSI beneficiary. However, if one converts to SSI after entry, the ALF’s must honor the SSI rate, which is $1,058.37 for a single individual or $2,116.74 for a couple where both live in the same facility (in 2019). In this situation, the bulk of the beneficiary’s SSI benefit goes to pay the ALF, but at dramatically reduced rates. After payments to the facility, the SSI beneficiary may keep a modest amount of their SSI benefit as a Personal & Incidental Needs Allowance (“PNA”) as follows:  $136 for a single individual and $272 for a married couple living in the same facility.

3) In-Home Care (“IHO”): the Medi-Cal program, at least officially, does help with the cost of care for a very few individuals receiving care in their home.  Unfortunately, the available openings are extremely limited, and the program typically has a very long waiting list, sometimes several years in duration.  Thus, as a practical matter the program is not a real option for most Californians.  A little-known secret:  reportedly, individuals moving from an extended hospital stay directly back to their own home receive priority on the waiting list, but – in my experience – the In-Home Unit is reluctant to publicly acknowledge this priority for those in the planning stage. For more information, contact the Department of Healthcare Services, In-Home Operations (“IHO”) Unit, at 916.552.9105.

References: Assisted Living Waiver;  In Home Operations Unit; SSI Recipients; RCFE Board & Care Deduction.  Good news. On February 28, 2019, the federal CMS approved the renewal of the CA Assisted Living Waiver for another 5 years from March 1, 2019, and added 2,000 more slots for persons who wish to apply for the ALF Waiver. CA Budget Bill increased the threshold income level for low income persons to qualify for the ALW Program and the Aged and Disabled program. It was included in one of the state budget trailer bills, SB 104.  The trailer bill amends Welfare and Institutions Code § 14005.40.

More reading.  The newly released Assisted Living Waiver Report entitled “Evaluating California’s Assisted Living Waiver Program”. May, 2019.

The ‘No Share of Cost’ requirement for a married Beneficiary who would otherwise need a Nursing Home, but who prefers to be cared for at home or in an Assisted Living Facility, is contained in the most recent Assisted Living Waiver Document, submitted by California as the “Application for a 1915(c) HCBS Wavier”, and approved by CMS: https://www.dhcs.ca.gov/services/ltc/Documents/ALW-Renewal-2019-2024-Approved.pdf under Appendix I (found at page 130 in PDF format): Financial Accountability: “All ALW participants have full-scope Medi-Cal eligibility with no share of cost.”

Aged & Disabled Federal Poverty Level Program income increases, as of 12/1/2020, can be found at ACWDL 20-24 and 20-18.