California’s Medi-Cal Program and In-Home Care: An Arcane Process for a Bygone Era

Healthcare is one of the most important, complicated, and difficult issues in modern American life.  In working with families to help the mentally disabled and elderly qualify for health insurance, maximize the benefits of that insurance, and defend their rights to full coverage and against discrimination in the provision of insurance in court if necessary, I often come across suffering and hardship.  

Even with the passage of the Patient Protection and Affordable Care Act of 2010 (ACA), too few individuals are able to access quality health insurance and far more are barely able to afford the insurance they have, much less receive in-home care when necessary which can cost thousands of dollars a month.  These individuals are relegated to the margins of economic life, painfully avoiding the doctor for fear of the cost and living one medical emergency away from total financial collapse.  The impact of this broken system is even clearer when one considers the financial and economic situations of families trying to support elderly and disabled individuals in their later years, often being sued by medical debt collectors and declaring bankruptcy as a result.  But I am still consistently surprised by one particular aspect of health insurance in America: The plight of disabled and elderly individuals seeking concurrent health and in-home care.  

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A recent case my office took provides a useful example of the strain. 

An elderly woman, one of many of my clients and their families in similar situations, suffers from severe Alzheimers disease.  She is over the age of 65 and is receiving Social Security retirement benefits.  She is therefore concurrently eligible for and is receiving Medicare Part A for hospital insurance and Part B for outpatient care.  She lives with her adult children, and they help take care of her when they can.  As her Alzheimers progresses, her family finds her physically injured even after brief moments alone.  They know they need full-time home health care, but after checking with local private care providers, realize that the cost is too much to bear on meager incomes.  Costs for home health care can range from 1200-2000 dollars a week, depending on location, severity of illness, and care and supervision needs.  A family of two earning income of even $10,000 a month is scarcely able to afford this cost.  The family understands that they need to access home health care through public funding, if feasible.  

At first glance, an advocate for this family may believe that they need to exercise more fully their right to Medicare.  After all, Medicare does provide some home health care.  But on closer investigation, the federally funded home health care that Medicare provides is intermittent and part time (approximating close to 20 hours a week), and may not cover even a fraction of the needs of a family in this situation.  Although Medicare home health care would cover some of the need, the family must access other public resources to make a dent.  The family’s only recourse to affordable in-home health care in this situation will be Medi-Cal.  

Medi-Cal is the partially federally funded Medicaid health insurance program administered by the California Department of Health Care Services.  Medi-Cal is divided into dozens of programs and subprograms and individuals are determined eligible on a step-basis based on the first and most favorable program that they are eligible for.  

The Medi-Cal program is divided into MAGI Medi-Cal and non-MAGI Medi-Cal.  MAGI Medi-Cal programs include the Federal Poverty Level Program, Children’s Health Insurance programs, and Working Disabled programs.  MAGI programs have income requirements based on percentages of the federal poverty level up to and including 133% of the poverty level.  MAGI programs cover primarily the poorest of the poor in need of medical treatment in our society, including infants and children in impoverished families and welfare recipients.  
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Non-MAGI Medi-Cal programs are different in the sense that they require a small premium or share of cost, which in the case of a family or individual earning a reasonable income, can be substantial and almost unaffordable.  
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Take again the family mentioned above.  Assuming they or their advocate is able to navigate the complex, contradictory, and at times non-existent Medi-Cal regulations regarding family units and income and resources, they will be tasked with navigating the application and determination process to qualify for Medi-Cal and thereby In-Home Supportive Services.  If the elderly woman suffering from Alzheimers disease has over $2000 in life savings or other property currently available to her, she will need to spend down or transfer her life savings to another person to qualify for Medi-Cal.  Furthermore, if this transfer is not done properly, it can cause significant consequences to the family in the form of a transfer penalty making the family ineligible for Medi-Cal for a significant period of time (the time during which the resources would have covered basic living expenses) and may disqualify them from certain forms of Medi-Cal in the future. 

Finally, the applicant may not expect the share of cost that they are assessed.  All Medi-Cal non-MAGI programs have a share of cost or other premium that the recipient must pay before receiving payment of health services or home health care from Medi-Cal.  Faced with this immediate requirement, and having a total income of $2400 a month in pensions and Social Security retirement benefits (barely twice the annual poverty level), the elderly woman will need to pay a nearly 1400 dollars a month in out-of-pocket costs before Medi-Cal will provide home health care or other health care services.
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The share of cost calculation in this situation will go as follows: Medi-Cal will determine the family’s (in this case the elderly woman is treated as existing her in own family unit, despite what some of Medi-Cal’s confusing regulations have to say on the subject) net non-exempt income.  The net non-exempt income of the elderly woman in this case will total about $2400 a month.  

Then Medi-Cal will subtract any income deductions or exclusions from this amount.  In this case, the only applicable deductions or exclusions are deductions from unearned income in the amount of $20 for the standard unearned income deduction and $380 for health insurance premiums paid by the elderly woman for Part A and B Medicare health insurance.  Finally, the net non-exempt income minus deductions totaling $2000 is further subtracted by the family maintenance need of $600 for one person, resulting in a $1400 share-of-cost.  Since her monthly income totals no more than $2400, she will be left with $1000 a month for basic living expenses such as food, clothing, bills, and rent.  

The effect of Medi-Cal qualification for her middle income group, too high to qualify for free Medi-Cal based on federal poverty levels, and too low to completely pay for private home health care, is to further impoverish her and her family.  Where a family is unable to provide the money necessary to front costs for the share-of-cost or other basic necessities for the elderly woman, she may be left without recourse but to live alone for a significant amount of the day.  Families may not be able to save enough to pay the elderly woman’s share of rent or food or other expenses, whether it be 500 or 1500 dollars extra, and the entire family will suffer for it.  This is unfortunately just another example of the manner in which our public and private system of health care fails to provide adequate care for those who have it and limits the quality of life of our most vulnerable seniors and persons with disabilities.

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Please contact my office today for a consult on Medi-Cal planning for middle income families and elderly or disabled individuals.  The rules are complex and my firm provides planning and counsel for families to navigate the complicated and sometimes contradictory process of applying for and retaining adequate health insurance coverage and home health care.  We are passionate about defending the fundamental human right to health care.