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Medicaid at Risk – Should I Care?

When Margaret fell for the second time in two years breaking her other hip, she was unable at 86 to remain at home any longer. Her ability to walk, get up or down and take care of her every day needs was so diminished that once she completed the rehabilitation in the skilled nursing facility, it was obvious she couldn’t return home. After anguished discussions with her family and her doctor, a decision was made for Margaret to remain in the nursing home. There was an initial assumption that Medicare would continue to pay for Margaret’s care. This however, was not the case.

While Margaret receives regular physical therapy and/or occupational therapy, Medicare is billed & pays. Once the patient reaches a “plateau” (their progress has been maximized) the patient is then considered custodial care. Custodial care is not covered by Medicare or a Medicare supplemental insurance. Patients are then responsible for the $7,000-$10,000/month privately. Costing from $84,000-$120,000 a year, it isn’t long before a nursing home resident goes through any retirement savings they may have accrued and saved throughout the years. If there is an at home spouse, division of assets for Medi-Cal also guarantees the at-home spouse a portion of the couples income & savings.

What happens when the money runs out? At the present time Medicaid, a federal health insurance program, supplements the patient’s portion in paying the monthly nursing home costs. In California the Medicaid program is called Medi-Cal. For long-term care residents living in a nursing home, Medi-Cal is the lifeline that allows them to have the care they need in a 24-hour care setting.

Currently all states in the United States have Medicaid in one form or another. Although it is commonly associated with younger adults and children unable to afford private pay health insurance, it is and has been the safety net for older adults who are unable to live independently at home anymore or don’t have the income to purchase Medicare Supplemental insurance. Eligible older adults on low incomes have Medi-Cal as their supplemental coverage. For individuals on Medicare who are over 65 and on SSI (Supplemental Security Income), Medi-Cal is their Medicare supplement. Without it, they would be responsible for all co-pays on all health care charges including prescription medications. Many of these older adults, a great many 80+ continue to live independently at home relying on their combined health insurance to provide coverage when they need it.

States have chosen to provide Medicaid benefits in a variety of ways with the baseline funded by the federal government. Some states expanded Medicaid (Medi-Cal) benefits once the Affordable Care Act was passed giving the states additional funds to help uninsured residents gain access to healthcare.

More than 7 years ago California recognizing the costs associated with nursing home care applied for a Medi-Cal waiver. Recognized as the Medi-Cal Assisted Living Waiver Project (ALWP), it ran as a pilot project for several years before state and federal officials established it as a permanent Medi-Cal program in California. The program has been an unqualified success throughout numerous counties in the state. The purpose is to have individuals in a nursing home who require a lesser level of care move into an Assisted Living facility with Medi-Cal supplementing the resident’s Social Security/pension to allow for the move. Individuals at risk living in the community who are on Medi-Cal with no share of cost can also apply for the program and thus, live a more independent lifestyle while receiving the supervision and care they need. One of the key tenets of ALWP is that the resident be appropriate for assisted living and the cost of their care be “cost neutral” for Medi-Cal.

Finally for Tom Medicare came early to him. Only 58 when he had his stroke, he was disabled and had to retire early. He was entitled to Medicare after two years of his disability with Medi-Cal as his supplemental insurance. He continues to live at home with help from his wife and family. He relies on his health insurance (Medicare/Medi-Cal) to take care of his medical needs at home. Should his condition deteriorate and his family be unable to provide his care, his combined “Medi-Medi” will be there to help with a type of placement – assisted living facility or a nursing home.

As we listen carefully to the legislators in Washington, D.C. debate the pros and cons of new healthcare legislation, don’t think it won’t affect you or the people close to you. Limiting nursing home coverage or defunding a vital Medi-Cal waiver program will eventually affect us all. It doesn’t matter how old you are.

—Carol S. Heape, MSW, CMC


Carol S. Heape, MSW, CMC is Founder/CEO of Elder Options. Ms. Heape helped to found the Older Adults Task Force (OATF) in El Dorado County, began the first Alzheimer’s Support Group in the country, served on the El Dorado Community Foundation Board for a number of years, Community Thanksgiving dinner, 4-H/FFA Junior Livestock Auction committee and helped establish the Sierra Renaissance Society, a life-long learning collaboration.
Serving the Sacramento Region with care managed home care since 1988. www.elderoptionsca.com

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