California’s Medi-Cal program requires beneficiaries to pay a monthly Share of Cost towards meeting their healthcare expenses. Share of Cost is computed based on the beneficiary’s monthly income less deductions, such as for the personal allowance and for any monthly maintenance needs allowance (to keep the beneficiary’s well spouse from impoverishment). Share of Cost, however, may be used to pay for necessary medical or remedial drugs or services that Medi-Cal otherwise does not pay-for itself. The foregoing applies both in the skilled nursing home and at home settings.
In a skilled nursing home, the Share of Cost can be used to pay for “necessary medical or remedial care, supplies and/or equipment” provided these items are “included as part of the physician’s plan of care, and have the physician’s prescription or order in his or her medical records at the facility” (All County Wide Director’s Letter (“ACWD”) No. 89-54 (July 24, 1989)).
Federal law requires skilled nursing facilities to have a written “Plan of Care” for each resident (42 USC 1396r(b)(2)). The plan discusses the kind of services the patient needs; what type of health care professional should provide the services; how often the patient needs the services; what kind of equipment or supplies the patient needs; if the patient needs a special diet; the patient’s goals; and how the care plan will help the patient to reach such goal. The resident’s family and advocates can give their input as to treatment.
Input into the written care plan is an opportunity for families to use the Medi-Cal beneficiary’s Share of Cost that would otherwise go to the skilled nursing facility to pay for necessary medical or remedial care, supplies and/or equipment. Medi-Cal makes up the difference to the nursing home.
If a resident at a nursing home has unpaid prior medical bills, including any unpaid nursing home bills incurred prior to beginning Medi-Cal, the resident may seek to use his or her monthly Share of Cost to gradually pay off these unpaid medical bills (Department of Health Care’s “Medi-Cal Procedures Manual”, Article 10, Subsection 10R).
Next, a Medi-Cal beneficiary who receives In-Home Health Care Services (“IHSS”) may also use their Medi-Cal Share of Cost to pay out of pocket expenses paid for personal care. “Out-of-pocket personal care services must, however, be prescribed by a physician, nurse case manager, assessed as part of the IHSS Assessment of Need (but not provided under the IHSS program), or included in the beneficiary’s plan of care as necessary to prevent him/her from being moved to a long term care facility for essential treatment”. “Personal care services are services which are required to accomplish the activities of daily living and are defined in Title 22, CCR, Section 51183(a).” (ACWDL No. 15-02, page 2 (January 12, 2015).
There are specific rules detailing how to use share of cost to pay for expenses. Documentation of all expenses are required to be provided. The rules as to what is allowed to be claimed and what documentation is needed is provided for beneficiaries in a long term skilled nursing home is in ACWDL 89-54, and for beneficiaries receiving IHSS in ACWDL 15-02.
Families wishing to amend a beneficiary’s care plan to include additional medicine or services may consider hiring a “geriatric care manager” or “ageing life care specialist” as an advocate to discuss the patient’s medical and remedial care needs with the physician. Anyone wishing to read ACWDL 89-54 or ACWDL 15-02 can read them online at www.dhcs.ca.gov/services/medi-cal/eligibility/Pages/ACWDLbyyear.aspx.