Most everyone agrees it can be very difficult — next to impossible, really — for Medi-Cal enrollees to snag a spot in a nursing home, especially if they’re transferring from their homes or assisted living facilities rather than going straight from the hospital.
Not everyone agrees on the reasons, however.
“There’s massive, systemic Medi-Cal discrimination,” says Pat McGinnis, executive director of California Advocates for Nursing Home Reform. She believes some nursing homes illegally turn away enrollees because they don’t want to accept Medi-Cal’s lower reimbursement rates.
“If they can get more money with private pay or Medicare, they would rather accept one of them,” she says.
Deborah Pacyna, director of public affairs for the California Association of Health Facilities, which represents most of the state’s standalone nursing homes, says it’s illegal for nursing homes to discriminate based on payment type. She blames access problems on the state’s rapidly aging population.
“Projections are that we will run out of nursing home beds by 2020,” Pacyna says. “That is putting even more pressure on the Medi-Cal population.”
No matter what you believe, the situation amounts to a crisis for Californians who desperately need a nursing home and are covered by Medi-Cal, the state’s version of the federal Medicaid program for low-income residents, says Susan Geffen of Hermosa Beach, an elder law attorney, gerontologist and author of the book “Take That Nursing Home and Shove It!”
If you think low-income doesn’t mean you, think again. Many middle-class Californians need Medi-Cal to help pay for their long-term care because they run out of money paying the bills on their own, she says.
Despite the access challenges many Medi-Cal enrollees face, about two-thirds of California’s nursing home residents rely on the program to cover all or part of their costs.
The state Department of Health Care Services (DHCS), which oversees Medi-Cal, says that nearly 90 percent of California’s 1,400 nursing homes accept its enrollees. The department is the only entity I interviewed that “is not aware of Medi-Cal members who are having difficulty finding a nursing home that will accept them.”
Today, I’m offering some advice if you or a loved one needs a nursing home for a long-term stay. It will be easier if you’re already in the hospital, which I realize is cold comfort.
Finding a bed if you’re not in the hospital — especially a bed in your community — might mean you’ll have to pay out of your own pocket initially. Or it might require some creative maneuvering, like working with your doctor to get you admitted to a hospital. Even then, “a hope and a prayer” might be necessary, says Derrell Kelch, executive director of the California Association of Area Agencies on Aging.
If You’re Coming From the Hospital
More than 90 percent of nursing home admissions last year came directly from hospitals, according to data from the Office of Statewide Health Planning and Development.
If you or a loved one is in the hospital and may not be able to return home afterward, “start working with the hospital discharge planner immediately” and ask for a list of nearby nursing homes, Kelch advises.
If you have fee-for-service Medi-Cal, you will require prior authorization, and the request must be made by the hospital or the nursing home, says DHCS spokeswoman Carol Sloan. If you’re in a Medi-Cal managed care plan, it will help determine where you go, she says.
You may want to visit the facility first before committing your loved one to it, Pacyna suggests. Also check out Nursing Home Compare on the Medicare website for quality ratings.
Medicare, the publicly funded health insurance program for older Americans, is often the first payer when you move into a nursing home. Under certain conditions, it will cover you for a limited time — up to 100 days.
The traditional form of Medicare will pay 100 percent for the first 20 days, after which you will owe $164.50 a day for up to 80 additional days. But you can qualify for this coverage only if you enter a Medicare-approved nursing facility within 30 days of an inpatient hospital stay that lasted at least three days. Beware: “Observation” care in the hospital won’t count as an inpatient stay.
Medicare does not cover long-term nursing home stays.
So, once you are in the nursing home, don’t wait to apply for Medi-Cal if you’re not already enrolled in it, Geffen says. Medi-Cal can help cover your Medicare copays, if you’re eligible, and then take over when your Medicare coverage ends, she says.
“They can’t just discharge somebody [from a nursing home] because they’re going on Medi-Cal,” McGinnis says.
If the nursing home balks and says it can’t keep you after you’ve switched to Medi-Cal, you can seek help from McGinnis’ organization (www.canhr.org or 800-474-1116) or another advocacy group, including legal services organizations or your local Long-Term Care Ombudsman, she says.
Be sure to let the facility know that you know it can’t discriminate against Medi-Cal enrollees, McGinnis adds.
If You’re Coming From the Community
Just because a small percentage of patients admitted to nursing homes last year came from their homes or assisted living facilities doesn’t mean people aren’t trying, says Mike Connors, an advocate for McGinnis’ group.
“It’s just extraordinarily difficult,” he says. “People end up waiting for months. … They get sick and get hospitalized.”
To find a facility that is certified for Medi-Cal, go to the state Department of Public Health’s database at hfcis.cdph.ca.gov. You might need to target larger nursing homes that have higher turnover, McGinnis says.
If it’s financially possible, consider starting out as a private-pay client.
Instead of getting rid of all of your money ahead of time to become eligible for Medi-Cal long-term care coverage, Geffen suggests keeping some in reserve so you can gain entry as a cash customer.
Then, once you’re a resident and run out of money, “they’re not allowed to kick you out,” Kelch says.
Geffen also knows of people who have gone to the hospital in the hope of getting admitted, so they can be discharged directly into a nursing home. “Some people have had to go to extraordinary feats in order to get into a nursing home on Medi-Cal,” she says.
You can also consult with your doctor to devise a plan. If she agrees that you need to be in a facility, request documentation that you can take to the nursing home as proof, Pacyna says. Or, “if you’re ill, it may be appropriate to be admitted to the hospital,” Connors says.
I wish there were more support for individuals and families struggling through this.
Placement services, such as A Place for Mom, can help you find a nursing home with openings. You can also talk to an elder law attorney.
You can even ask your county social services department for help, says Benson Nadell, director of the San Francisco Long-Term Care Ombudsman program. “People cannot navigate this complex system on their own,” he says.