Medi-Cal Benefits

Medi-Cal benefits are the  most often utilized to help pay the cost of long-term care for an elder in California.

Medi-Cal Benefits are available under three major  programs for adults, generally known as the “Categorically Eligible Medi-Cal” programs, the “Needs-based (Community) Medi-Cal” programs, and the “Medically Needy (Long-term Care) Medi-Cal” program. There are also other types of programs for certain children and for persons who suffer from specific illnesses, including End-stage Renal Failure (needing dialysis), Tuberculosis, and Breast or Cervical Cancer.

To qualify for any of the three main types of Medi-Cal programs, the individual must be either blind, aged 65 or over, or permanently and totally disabled. In addition, the individual must be “financially needy” for any of the three main types of programs. The Categorically Eligible Medi-Cal program only covers persons who are eligible for Supplemental Security Income (SSI) or who would be eligible for SSI but for the annual cost of living income increases by Social Security (this is called the Pickle Program). For the Medically Needy (Long-term Care) Medi-Cal program, the individual must also need medical care provided by a skilled nursing facility. Generally, this last requirement means that the person must be residing in a skilled nursing facility. However, there is a Medi-Cal “waiver” program that provides for some in-home or assisted living facility care for persons who would otherwise have to be in a skilled nursing facility. Unfortunately, there are relatively few slots available under the waiver program and it is only available in a few counties in California at this time.

The most common Medi-Cal program used by elders has historically been the Medically Needy (Long-term Care) Medi-Cal program as generally elders have been most concerned about the cost of skilled nursing facilities in case they need “long term care”. However, there appears to be a shift happening such that elders and their families increasingly are determined to keep the elder at home (or in the home of one of his/her children) rather than send him or her to a skilled nursing facility, unless that is simply not an option. If the elder does not have the resources to pay for skilled nursing facility care or desires to protect his/her resources for his/her spouse and family, the knowledgeable Elder Law lawyer will explain the options to the elder and his/her family to protect assets and qualify for Medi-Cal benefits.

The rules for the Medically Needy Long-term Care Medi-Cal program and the Needs-based (Community) Medi-Cal program differ with regard to the treatment of assets and income and are quite complicated. It is recommended that you make an appointment with an Elder Law lawyer, like those at Sugai & Sudweeks, to discuss your planning for Medi-Cal benefits. For a simplified explanation of some of the Medically Needy Long-term Care Medi-Cal rules, we recommend that you review the information on the Medi-Cal pages of the Santa Clara County Superior Court Probate Department’s self-help website.