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FREQUENTLY ASKED QUESTIONS


DOES MEDI-CAL PAY FOR EVERYTHING?


The “Share of Cost”
is the amount of the nursing home bill which the patient will be responsible to pay and Medi-Cal will pay the rest.  Once you have qualified for Medi-Cal, your Share of Cost will not increase if your “plan of care” changes or if a  nursing homes raises their rates.


I HAVE A HIGH PENSION INCOME, CAN I STILL QUALIFY?


In California, INCOME (no matter how high) will not disqualify you from receiving Medi-Cal benefits for long term care.  Income is categorized differently from Assets and is used to determine the patient’s  Share of Cost for the nursing home. Those with a high monthly income can often qualify for Medi-Cal and benefit by paying the lower “wholesale” room rate.

 

HOW MUCH MONEY (ASSETS) CAN WE HAVE?


Asset Qualifying Levels
:  It is not how much money one has–but how your finances are arranged that determines Medi-Cal eligibility. 
In addition to a primary residence, the Medi-Cal applicant (patient) can retain $2,000 in Countable Assets PLUS more in Exempt or Unavailable Assets.  If Married, the Spouse can retain considerable additional assets .  IRAs, 401Ks and other retirement accounts can also be made Exempt.

 

CAN WE GIVE THE EXTRA MONEY AWAY?


Excess Countable Assets should not be given away
to anyone, without expert advice.   Gifting can cause a penalty waiting period before the patient is eligible for benefits during which they will have to privately pay.  Gifting without proper authority could also cause you to be reported for Elder Financial Abuse. SB 1018 requires bank employees to report “suspected financial abuse” or they face a penalty of up to $5,000.  Medi-Cal eligibility workers must also report suspected financial abuse to Adult Protective Services.  We look over your documents to determine what your gifting rights are and we assist you to perform and document Gifting of Assets correctly to follow the Medi-Cal rules.


WARNING: THE GIFTING RULES ARE IN THE PROCESS OF BEING CHANGED and will be much more RESTRICTIVE IN THE FUTURE
.  Under current regulations, if gifting has occurred within the past  30 months, we will advise you when the “penalty waiting period” is over and when you can apply for Medi-Cal benefits.  Your penalty period may have already expired and if not, gifting can be redone correctly.


WHAT CAN WE LEGALLY DO WITH THE EXCESS ASSETS?


If the patient has Excess Countable Assets (over the qualifying limit), we will create a CUSTOMIZED PLAN
for you, suggesting various ways in which you are allowed to convert Excess Countable Assets  into Exempt or Unavailable Asset categories. 

Your Medi-Cal plan will take the following into consideration:  Income Needs for a Well Spouse, Income tax and Estate Planning Issues (we will consult with your attorney and CPA), Reducing the Share of Cost for the patient and meeting the needs of the heirs.

 

CAUTION: You may hear information that contradicts what we tell you from “Well Meaning” but uninformed individuals who do not process Medi-Cal applications for a living.  Even some Medi-Cal case workers do not know all of the rules and if they do, they are forbidden to advise you on ways to get your Assets under the limits.


If you have ever played the party game “Telephone,” you know how distorted the facts get by the time they are passed around from person to person at the table.  We have processed Medi-Cal applications for over 20-years and we won’t take a case unless we know it can be approved.

 

WE HAVE NO EXCESS ASSETS--IS MEDI-CAL AUTOMATIC LIKE MEDICARE?


Once a patient’s (and spouse’s) assets are down below the qualifying limits, many people mistakenly think that Medi-Cal will automatically begin to pay the nursing home.  This is incorrect!  You are required to provide all of the same documentation no matter how much or how little money the patient has.


CAN I APPLY ON MY OWN--WITHOUT HELP?


Medi-Cal approval can be a lengthy, complicated government “red tape” process and most people prefer to have assistance. Many of our clients are those who have tried on their own and failed to get approval.

If you were to attempt an application on your own, this is the process:

  You start by submitting the short form, then they mail you the long form.

  Later they send you a list of “verifications” that are needed, which is often unclear.  For example, they may ask for a “current bank statement” but not specify exactly which month and bank they need to see.  If you send in the wrong one, they will write to you a few weeks later and tell you to send something else.  If everything is not submitted correctly and in the required time frame, you will be mailed a Denial Notice weeks later.

  They do a social security number search on the patient. They often find bank accounts which have been closed long ago and they may deny your application because they think there is too much money.  You have to prove that their records are incorrect and get the case re-opened.  It is a lengthy process designed for the inexperienced person to give up.

DURING THESE DELAYS, YOU HAVE TO PAY THE NURSING HOME OUT OF YOUR OWN POCKET if the patient has run out of money.  The facility usually requires the family to make the full monthly payment until Medi-Cal is approved.  If you get approval, they will reimburse you for the amount paid over the patient’s Share of Cost, but if you do not get Medi-Cal approval, you won’t be reimbursed.


WHY IS IT BEST TO HAVE EXPERT HELP?

We submit your application in a ready-to-be-approved manner. We include all of the required documentation at the beginning to make it easy for the case worker to see why the application should be approved.  We calculate the “Share of Cost” at the beginning and inform the nursing home that this will be the entire amount that you will owe both during and after the application process.

We are able to get Medi-Cal approval retroactive to the date on which the patient’s assets are correctly arranged and also to have prior medical expenses paid.  The nursing home is happy when you have Medi-Cal ready to start paying on the day after Medi-Care stops because they don’t like to wait for payment.

We  advise you every step of the way during your Medi-Cal application process and we handle all of the complicated paperwork for you.  You will not need to have any contact with the Medi-Cal office.  We assist you in compiling the necessary “verifications” and work with you until the case is approved.

You will work closely with one of our  Medi-Cal application experts.  We have over 20 years experience processing Medi-Cal applications full time.  Our experts have worked for County Medi-Cal offices in the past and now work in the private sector, helping families to avoid spending down their life savings and family inheritance.  This “inside” experience gives us an edge because we “speak their language” and get cases approved more quickly.

 We are constantly updated on changes in the Medi-Cal laws so you can rest assured that all information you receive from us is current and accurate. Most people believe that it is better to spend some of the patient’s  money on assistance at the beginning, to make sure that you get Medi-Cal approval, rather than risk spending your own money trying to do it yourself and possibly having to hire help if you get it wrong.  We have a 100% approval success rate!

IS EVERYTHING LEGAL AND MORAL?

Absolutely!  It is your Legal Right to preserve assets to be passed on as they were intended instead of being spent down on a nursing home. Medi-Cal planning is every bit as Legal and Moral as Estate Planning and Tax Planning which are mainstream practices.  The rules are there for your protection but because they are very complicated, expert help from someone who knows how to interpret and utilize them is extremely valuable.  

 

                                                MYTHS vs. FACTS:

 

QUALITY OF CARE:

A nursing home is often necessary near the end of life.  The quality of care is determined by choosing the best facility available and frequent visits to your loved one.  Quality of Care is NOT BASED ON WHO PAYS THE BILL!  The average cost of a skilled nursing facility is currently between $6,000 and $7,000 per month.  A family estate can be depleted quickly at that rate.  Medi-Cal will pay for skilled nursing for many families.  It is in your best interest to find out if you can qualify.

 WHAT ABOUT MEDICARE AND OTHER HEALTH INSURANCE?

MediCare  (if over age 65 or disabled) will pay up to 100 days of skilled care if the patient has been in the hospital for at least three days prior.  If the patient does not improve and needs “custodial care,” there is NO health insurance plan, including MediCare that will continue to pay the bill.  The patient must go on private payment or leave the facility.

 

"I HAVE BEEN TOLD THAT I WILL LOSE MY HOME "

If the Medi-Cal application is prepared correctly, the home will be an Exempt Asset and with correct advice, it can also be kept safe from Medi-Cal Recovery (a claim to pay back the state for benefits provided).

 

"I UNDERSTAND THAT AS A COUPLE WE CAN ONLY HAVE $3,000 AND SINGLES CAN HAVE ONLY $2,000. "

If one spouse is in long term care, the at-home spouse follows different asset rules called “Community Spouse Resource Allowance, or CSRA rules.”  In addition, both single people and married couples can keep a considerable amount of additional assets depending on the categories in which the assets fall. 

 Medi-Cal eligibility workers are NOT ALLOWED to teach you which assets fall into what category or how to reposition assets to follow the Medi-Cal rules.   The worker’s job is to request asset information and then make a determination as to whether or not you are over or under the “allowances.”  However, they often deny claims that should have been approved and mistakenly count assets that are supposed to be categorized as “exempt” or “unavailable.”

 

"THE LEVEL OF CARE WILL BE INFERIOR IF I GO ON MEDI-CAL." 

Discrimination is against the law and the person in charge of your care does not have access to the billing records.  The person in the next bed could be paying with long term care insurance, private payment, or be on Medi-Cal and they all receive care prescribed by their own doctor’s plan of care.

 

MEDI-CAL BEDS ARE DIFFICULT TO FIND. 

Most skilled nursing homes (not Board and Care or Assisted Living facilities) have chosen to be on the Medi-Cal program and if so, all semi-private rooms must be made available for Medi-Cal patients. We provide you with a list of nursing homes in your area that accept Medi-Cal.

 

I HEARD THIS TYPE OF PLANNING IS AGAINST THE LAW!

A few years ago, the long term care insurance industry tried to penalize advisors for instructing patients on their rights in an effort to sell more insurance.  However, that attempt was defeated.  As long as you have a comprehensive knowledge of the Medi-Cal rules and follow those rules, the Medi-Cal application will be approved.  If you are unaware of the rules, your application may be unjustly denied.  

 

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