Paying for Long-Term Care
In most cases, assisted living facilities in California are a private pay service. This means that health insurance plans, Medi-Cal, and Medicare will not cover the costs of an assisted living home. With typical costs ranging from $2,500 to $7,000 a month in San Diego County for a bed, it is important to plan ahead.
Getting Long-Term Care Insurance
Long-term care insurance is designed to cover the costs of assisted living. Policyholders purchase a policy and pay into it before they require long-term care services. A policy will cover expenses for a specified duration of time with a limit to the total covered costs. It is important to plan ahead for this insurance, as those who are already in poor health may not qualify, or the policy may be prohibitively expensive. Many policies have a requirement that before a claim is paid, the policyholder must get a doctor to determine they need help with at least two or more activities of daily living. In addition, it is common to have an “elimination period” where the policyholder must pay out of pocket for the first several months of care. 30, 60, and 90 day elimination periods are common. For more information on long-term care insurance, click here: https://acl.gov/ltc/costs-and-who-pays/what-is-long-term-care-insurance
Medi-Cal and Medicare Only Cover Skilled Nursing Facilities
For those who require medical care in a skilled nursing facility, Medi-Cal and Medicare will cover some or all of the costs. However, both programs only cover up to a maximum of 100 days in a facility. Therefore, Medi-Cal or Medicare-funded skilled nursing care should not be considered a permanent solution. There are also many exclusions that can shorten the duration, as well as the amount of coverage a patient receives.
Less Common Options
Veterans Administration (VA) Aid and Attendance
Those who are eligible for a VA pension and who need assistance with activities of daily living, such as bathing, feeding, and dressing, may qualify for Aid and Attendance. Aid and Attendance is additional money provided to recipients in addition to their pension that can be used to help pay for an assisted living facility. The program has an income and asset limit. For more information and ways to apply, click here: https://www.va.gov/pension/aid-attendance-housebound/
Assisted Living Waiver
The Assisted Living Waiver, or ALW, program allows patients staying at a skilled nursing facility to live in an assisted living home. The resident is responsible for the room and board fee, which is capped at $1,089.37. If SSI is the source of payment, room and board is capped at $1069.37 as of 2020.1 (Rates are slightly increased for 2021. Please refer to link a the bottom of this article for 2021 rates.) The resident’s Medi-Cal benefit will cover the cost of care. Because the total reimbursement to the facility is often lower than private pay fees, there are few facilities that participate in the ALW program. To be eligible, an individual must qualify for Medi-Cal with zero share of cost and have needs equivalent to those living in a skilled nursing facility. The goal of the ALW program is to safely transition individuals in a skilled nursing facility into a more home-like setting of an assisted living home. Assisted living homes also cost less than skilled nursing facilities, resulting in a mutually beneficial arrangement for the Medi-Cal program and ALW residents. For more information on the ALW program and detailed eligibility requirements, click here: https://www.dhcs.ca.gov/services/ltc/Pages/AssistedLivingWaiver.aspx
A list of facilities in California accepting ALW is available here: https://www.dhcs.ca.gov/services/ltc/Documents/List-of-RCFE-facilities.pdf
The list is sorted by county, and the facilities in San Diego County can be found by scrolling down the PDF. There is usually a waiting list, as the number of beds available are limited.
Supplemental Security Income
SSI, or Supplemental Security Income, can also be used to pay for long-term care. If a facility agrees to admit a resident paying with their SSI, it must accept the SSI payment as full compensation for board and care. As of 2020, this payment is $1,206.37. The facility receives $1,069.37, and the resident keeps $137 for personal needs. Because this rate is significantly less than what the facility would receive from a private pay resident, there are few facilities that admit residents who pay with SSI. SSI also provides a safety net if a resident runs out of money to pay the facility, but later qualifies for SSI. If a resident becomes eligible for SSI, that facility must lower its rate for board and care to the SSI rate. For additional information on paying for board and care with SSI, please click here: http://canhr.org/factsheets/rcfe_fs/html/rcfe_fs.RCFEs_and_SSI.htm
San Diego County residents have various options to pay for long-term care. The course taken depends on age, income, and assets. Planning early will help to manage the costs later on should long term-care be needed.