As we age, the natural aging process typically causes physical and/or mental deterioration that can make it more difficult to remain independent. At some point, it may become unsafe to remain alone in your home without assistance. The type and level of assistance a senior may need, however, can vary greatly. Some seniors only need help around the house a few times a week while others require around the clock medical care and monitoring. For seniors who need more extensive care, the options are an assisted living facility or skilled nursing home care. Not only is assisted living a more attractive option, it is usually the more economical option as well. Does Medicare or Medi-Cal cover the cost of an assisted living facility or skilled nursing facility? The Medi-Cal attorneys at Dennis M. Sandoval, A Professional Law Corporation in Riverside, California explain when Medi-Cal will pay for assisted living and skilled nursing facilities for those who qualify.
Nursing Home Care vs. Assisted Living
Skilled nursing facilities are hospital like facilities that offer round-the-clock skilled nursing care in addition to other supportive services. They are sometimes referred to as Rehabilitation Hospitals or Convalescent Hospitals. Assisted living is part of a continuum of long term care services that provides a combination of housing, personal care services, and health care. The primary difference between the two is that a nursing home typically offers more extensive medical care but the care is more like that provided in a hospital whereas at an assisted living facility the residents have a considerable amount of personal space and independence in a non-hospital environment. Assisted living facilities are also sometimes referred to as Residential Care for the Elderly. An assisted living facility is often similar to an apartment community with services geared toward seniors and a custodial care component that isn’t found at your basic senior retirement apartment community.
Another noticeable difference between a nursing home and an assisted living facility is the cost. For 2018, the average monthly cost of a private room in a Riverside, California nursing home was $8,669 compared to $3,500 for that same month of care in an assisted living facility. For a senior who needs some assistance, but who doesn’t truly need the level of care offered at a nursing home, an assisted living facility is the obvious choice. The fact that assisted living is almost half the cost of nursing home care would seem to make it a win-win for many seniors.
Will Medicare Pay for Assisted Living or a Skilled Nursing Facility?
No. Medicare only pays for medical care, such as doctors and hospital expenses. So medicare does not cover the cost of assisted living. If you spend at least three days in a hospital and are then transferred to a skilled nursing facility (SNF) or rehabilitation hospital, Medicare will pay for the first 20 days your are in the SNF, and it will pay part of the cost for up to another 80 days. After 100 days in a skilled SNF, Medicare will no longer pick up any of the cost of care.
Will Medi-Cal Pay for Assisted Living or a Skilled Nursing Facility?
The high cost of long-term care caused many seniors to turn to Medi-Cal (California’s Medicaid program) for help paying for care. Medi-Cal will pay for a skilled nursing home only when it is “medically necessary.” California defines medically necessary as “when it is reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain.” For Medi-Cal to pay for a nursing home stay, your treating physician must prescribe a nursing home for you because you either need the continual, round-the-clock availability of skilled nursing care or what’s called “intermediate care.” Skilled nursing care includes things like giving injections, inserting or replacing catheters, changing wound dressings, feeding through a gastric tube, and treating bed sores. Intermediate care means a protective and supportive environment with “observation on an ongoing intermittent basis to abate health deterioration.” Despite the fact that some of the same services are available, at almost half the cost, Medi-Cal does not pay for assisted living expenses as a general rule.
All is not lost, however, if you wish to avoid nursing home care as long as possible. Recognizing the benefit of allowing seniors the option to choose assisted living instead of nursing home care, California has created a Medi-Cal program called the Assisted Living Waiver (ALW). Through the ALW program, seniors who qualify for care in a nursing and who are receiving Long Term Care Medi-Cal benefits can remain in assisted living if they prefer. However, the assisted living facility must participate in the ALW program. There are only a few assisted living facilities in the Riverside and San Bernardino area who participate in the Assisted Living Waiver program. You can find out more about which assisted living facilities participate in the program by the calling the elder law attorneys at Dennis M. Sandoval,a Professional Law Corporation. This program is open to residents statewide. However, there are not providers available in every county. Counties with assisted living facilities enrolled in the program include: Alameda, Contra Costa, Fresno, Kern, Los Angeles, Orange, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, San Joaquin, San Mateo, Santa Clara, and Sonoma. In addition, the Assisted Living Waiver program is only currently funded until 2019. At that time, the state will have to decide whether to extend the program or not. Finally, if you choose to live in an assisted living facility, you may be required to pay a share of cost that is required under the Medi-Cal Assisted Living Waiver program.
Contact Riverside Medi-Cal Attorneys
If you have additional questions or concerns regarding the Medi-Cal Assisted Living Waiver program, contact the experienced Riverside Elder Law lawyers attorneys at Dennis M. Sandoval, A Professional Law Corporation by calling (951) 888-1460 to schedule an appointment. Dennis M. Sandoval is one of very few lawyers certified as an Certified Elder Law Attorney, or CELA, in Riverside and San Bernardino Counties. He has been an elder law attorney for over 20 years and was named a Fellow by the National Academy of Elder Law Attorneys.