By JUDD MATSUNAGA, Esq.
For several years, finding out a way to pay the high cost of long-term care was the biggest problem that faced most families. The average cost for a California nursing home is $10,000-$12,000 per month. And that’s just for the bed!!! If you require additional apparatus such as a feeding tube, ventilator, or trach, costs could easily exceed $30,000-$40,000 per month.
People were told that they didn’t qualify for Medi-Cal benefits because they had savings, too much income, or they had a house. Not true. Especially since a new law in California (AB 133) makes it much easier to qualify for Medi-Cal by increasing the “Asset Test” to $130,000 per individual and $65,000 for each additional household member. Starting Jan. 1, 2024, Phase II eliminates the “Asset Test” entirely.
But why? The official explanation for the change is that the income from these newly allowed assets goes to share-of-cost, reducing the amount paid by the state. My non-official explanation is that the state wants to shift the cost of long-term care to the private sector. In other words, the government is going to make long-term care insurance mandatory. If you don’t purchase it voluntarily, they’ll deduct it from your paycheck, just like Social Security.
But that’s a topic for a future Rafu Shimpoarticle. This article is to discuss how to get your parent into a Medi-Cal nursing home (Medicaid in non-California states). According to the California Advocates of Nursing Home Reform (CANHR) website, “Over the past five years, one of the most disturbing violations of state and federal laws has been the increase in discrimination against Medi-Cal beneficiaries who need nursing home care.”
This is why the sale of Keiro Nursing Home was so tragic. Keiro was “nonprofit.” Keiro provided quality long-term care for its residents regardless of the form of payment. Not anymore. Call a nursing home and tell them that your mother, a Medi-Cal beneficiary, has dementia along with other medical issues and that her doctor has recommended a nursing home — good luck in finding a placement within 200 miles — or at all!
However, if you tell them that your mother is in the hospital on Medicare, your chance of finding a nursing home placement increases 100%. That’s because Medicare reimbursements are higher than the Medi-Cal daily rates; discrimination against accepting Medi-Cal-eligible residents has become the preferred way for nursing homes to increase their profits.
But why? Almost all nursing homes are “for-profit” business entities. There are three major sources of payment: (1) Private pay; (2) Medicare; and (3) Medi-Cal. Medicare beds pay up to 10 times more per day than Medi-Cal beds. Therefore, the facility makes more money if they fill the nursing home with short-term Medicare beds. Medicare will pay up to 100 days if they are discharged from a hospital stay of three nights or more.
You may ask, “Isn’t that illegal?” You bet! Such discrimination is illegal under both state and federal laws. In fact, certification for Medi-Cal is totally voluntary and nursing homes who wish to participate in the Medi-Cal program must sign a provider agreement certifying under penalty of perjury that they will adhere to all state and federal laws, which include a prohibition against Medi-Cal (Medicaid) discrimination.
If a resident does happen to find placement as a Medicare patient, when Medicare days are terminated, the facility will often tell the resident or the resident’s family that the resident must leave; that they only retain “short-term” residents; that they don’t have any Medi-Cal beds; or that the resident — despite all evidence to the contrary — no longer needs the nursing home level of care.
These are falsehoods (aka, lies), of course, aimed at scaring residents out of the facility. The truth is that in California, if a nursing home is certified for Medi-Cal — ALL the beds are Medi-Cal-certified. There is no such animal as a “short-term” nursing home. If they have a bed at all, it’s a Medi-Cal bed. Despite these laws, nursing homes have found numerous ways of discriminating to reduce their Medi-Cal population and free beds up for private pay or Medicare residents.
So how do you get Mom and/or Dad into a nursing home and get Medi-Cal to pay for it? If the nursing home is saying that there is a 6-to-9-month waiting list to get a Medi-Cal bed, and you don’t want to wait that long, you have a couple of options. The first is to have the doctor admit Mom or Dad into the hospital for a three-night stay. Then give the discharge planner at the hospital the business card of the admissions director of the nursing home.
Somehow, they almost always find a bed. That’s because the nursing home is going to get paid from Medicare for the first 100 days at reimbursement rates higher than private pay or Medi-Cal rates. Of course, you’ll need the doctor’s cooperation. And actually, that’s a misnomer. Medicare will pay 100% for the first 20 days, and pay partial payment days 21-100. You may have a “co-pay” even before the 100 days.
The supplemental health insurance, e.g., Anthem Blue Cross, United HealthCare, etc., is supposed to cover what Medicare doesn’t cover days 21-100. However, if your parent is elderly, they may deem Mom and Dad “custodial,” i.e., not getting better, which allows them to cut benefits even before the 100th day. In other words, it’s not about getting Mom or Dad the best of care — it’s about money.
Quite often, a nursing home will inform a family that Mom or Dad is out of Medicare’s 20 days, and that they will be discharging them back home. This is not legal but they do it anyway. If they say this to 10 residents who are running out of the 20 Medicare days, and nine families take them home so they can fill the bed with a fresh Medicare bed, they make out. However, for the one family that says, “No. We’re applying for Medi-Cal,” they’ll leave that resident alone.
If this option is not available (perhaps because the doctor won’t help admit Mom or Dad to the hospital), there is another option. Admit Mom or Dad as private pay just to get his or her “foot in the door.” Then after 30 days, convert to Medi-Cal. The nursing home can’t kick Mom or Dad out. If they have a pillow, they have a bed, regarding of the form of reimbursement. This will, however, cost you one month of private pay.
There may be a social worker, perhaps with the best of intentions, who will offer to help you fill out the Medi-Cal application. But be careful. The Medi-Cal application is not a “user-friendly” application. Many families relying on the nursing home staff to get the parent qualified for Medi-Cal don’t know they’ve been denied until 60 days later. They’re then handed a bill for
$20,000-$30,000 and they’re shocked, i.e., SHOCKED!!!
I strongly recommend that families use an attorney versed in the Medi-Cal rules and regulations to file the application and act as the “authorized representative” to answer and respond to any questions or problems that the caseworker might have during the application process. Even for people who believe they are eligible, Medi-Cal denial is common, costing families thousands of dollars of nursing home expenses.
If it looks like Mom and/or Dad may need long-term care in the not-so-distant future and you have some time, start looking for nursing homes sooner than later. If you want Medi-Cal to pay for the nursing home, i.e., $12,000 per month, you have to place Mom or Dad in a licensed Medi-Cal facility. Medi-Cal will not pay for home care. Medi-Cal will also not pay for retirement homes or board and care.
In order for Medi-Cal to pay, they have to be in a Medi-Cal-licensed facility, i.e., skilled nursing facility or “SNF.” There are, however, some assisted living facilities that will take a Medi-Cal waiver. To be at an assisted living facility, Mom or Dad has to be able to walk. To qualify for the Medi-Cal waiver, there are income requirements, e.g., combined income cannot exceed $2,250 per month.
As you shop around for nursing homes to place Mom or Dad in, you don’t want the best-rated nursing home located across town. You want the best available conveniently located for family to visit and check in on Mom or Dad. California nursing homes are notorious for illegally drugging residents.
“Say what?” These nursing homes are “for profit.” How do make more money? By cutting expenses. Quite often, this is done by cutting staff. So how does one caregiver take care of a floor that used to take two caregivers? They put them to sleep — without consent!!! That’s why families say, “Whenever we visit Mom or Dad, they’re always groggy or asleep.”
If the nursing home is caught, they get a slap on the wrist and pay a fine. That’s all. But, they won’t drug residents that get visited regularly. Make sure when you visit, you don’t sneak in and out the back. No, make sure you stop by the nurses’ station and let them know you’re checking in on Mom or Dad. It’s the “squeaky wheel that gets the grease.” You, the family member, are Mom or Dad’s biggest advocate for their care.
“What about home care?” Medi-Cal, even if you qualify, will not pay for home care. If Mom or Dad is not quite ready for a nursing home, there is only one public program that will help pay for some part-time home care. It’s a county program called In-Home-Supportive-Services, or IHSS. IHSS will pay for some part-time home care if: (1) you first qualify for Medi-Cal; and (2) your income is low enough.
In conclusion, nursing home discrimination against Medi-Cal beneficiaries and residents has become epidemic in California, and the state regulatory agencies do nothing to contain it. For more information about discrimination and resident discharges, you may want to contact your helpful, friendly Medi-Cal planning attorney for help and guidance.
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Judd Matsunaga, Esq., is the founding partner of the Law Offices of Matsunaga & Associates, specializing in estate/Medi-Cal planning, probate, personal injury and real estate law. With offices in Torrance, Hollywood, Sherman Oaks, Pasadena and Fountain Valley, he can be reached at (800) 411-0546. Opinions expressed in this column are not necessarily those ofThe Rafu Shimpo.