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.
Participants in the Medicare
are liable for co-payments and deductibles as well as for monthly
payments for Part B coverage. Medicare is not based on financial
need. Anyone who meets the age, disability and/or coverage
requirements is eligible.
is a combined federal and California State program designed to help
pay for medical care for public assistance recipients and other
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.
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, (current
resource limit is $2,000 for a single individual).
State 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.
Deductions from the Share of Cost:
addition to the income deductions and the monthly maintenance needs
allowance, any monthly medical premiums can also be deducted before
the share of cost is determined. Other deductions can also be made,
depending on the circumstances.
Does Medi-Cal Cover?
pays for health
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.
qualify for Medi-Cal the recipient must demonstrate that s/he has
limited resources available. Since January 1, 1989, the property
limit for one person has been set at $2,000.
property as exempt and non-exempt. Exempt property is not counted in
determining eligibility; non-exempt property is counted. If the
applicant has more than $2,000 in non-exempt property, he/she will
not be eligible, unless the property is spent down for adequate
consideration before the end of the application month.
home of a Medi-Cal beneficiary continues to be exempt from
consideration as a resource under a wide variety of circumstances.
Under these provisions, a home will continue to be considered an
exempt principal residence
principal residence is exempt based upon a person's subjective intent
to return, even though he/she may never have the ability to return to
that residence. If the applicant is unable to complete the
application, his/her representative may indicate that intent. The
eligibility worker may not restrict, in any way, the individual or
his/her 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, the house will be treated as a
principal residence exempt from being counted as a resource by
Real Property/Business Property
property other than the principal residence can be exempt if the net
market value of the property (minus encumbrances) is $6,000 or less
and if the beneficiary is utilizing the property, i.e., receiving
yearly income of at least 6% of the net market value.
amount allowed for upkeep of the home depends on the living
circumstances of the LTC resident.
individual whose personal property is above the Medi-Cal
limit may spend down to $2,000. Resources must be reduced to the
property limit for at least one day during the month in which a
person is establishing eligibility. Giving away resources may render
a person ineligible for a period of time running from the date of the
law allows the community spouse to retain a certain amount of
otherwise countable resources available to the couple at the time of
application. This is called Community Spouse Resource Allowance
(CSRA) and it increases every year according to the Consumer Price
Index. The 2008 CSRA is $104,400.
reduction requirements can usually be easily handled and documented,
and it can be tempting for many attorneys to advise clients to reduce
excess property on the purchase of exempt assets prior to a nursing
home entry. It may be difficult however, to find a nursing home
placement for a person who has spent all of his/her resources or who
has few resources. In addition, a private pay patient may receive a
higher level of service.