Does Medicare Cover Assisted Living in California?

Medicare Benefits Solutions
Apr 8, 2021

At some point in our lives, most of us will need some type of long-term care services. If you are not able to arrange these services at home, there are facilities that accommodate people with long-term care needs. Examples are a skilled nursing facility (SNF), a continuing care retirement community (CCRC) and an assisted living arrangement. 

Varied Levels of Care

Skilled nursing facilities are synonymous with nursing homes. SNFs offer comprehensive health and personal care support. The focus is on medical care. It usually includes nursing services, 24-hour supervision, all meals and helps with daily activities. SNFs are equipped to provide housing on a permanent or temporary basis.

Assisted living offers daily care to a lesser extent than an SNF. Usually, the more care you need, the higher the cost. The facility may board from 25 to over 100 residents. A CCRC will offer you varied service levels based on whether you can live independently, need close supervision, or require something in between. One campus may encompass houses, apartments, SNFs and assisted living facilities. As your needs change, you can move from one type of living arrangement to another within the same community, pending availability.

Medicare Benefits for Long-term Care

Medicare does not cover long-term services. Also known as custodial care, long-term care includes non-medical services and non-skilled assistance, such as help with dressing, bathing and meals. However, under Part A, Medicare benefits include short-term care in an SNF under certain conditions. If you have been an inpatient in a hospital for at least three days, you may qualify for medically necessary SNF coverage for a related illness or injury. Benefits are covered for up to 100 days. 

Some Medicare recipients are covered by Medicaid as well. If you are covered by Medicaid, you may be eligible for long-term services in an SNF if you are at least 21 years old and have a qualified mental or physical condition. Medicaid benefits vary by state. However, states must adhere to core federal requirements, such as coverage for nursing, rehabilitative, pharmaceutical, dietary and emergency dental services.

Medi-Cal – California Medicaid

If you are a California resident covered by Medicaid, your benefits would fall under Medi-Cal. Medi-Cal covers long-term nursing home care. Additionally, the California Department of Health Care Services (DHCS) introduced an Assisted Living Waiver (ALW) Program. The program is designed to enable Medi-Cal recipients to stay in their communities as an alternative to long-term placement in a nursing home. Benefits are geared toward eligible seniors and people with disabilities.

ALW began as a pilot program in 2009 and was renewed in 2014. In September 2020, the Centers for Medicare & Medicaid Services (CMS) authorized COVID-19 hotspot enrollment. This is a temporary measure to expedite your ALW application if you reside in an SNF situated in an area with one of the highest COVID-19 infection rates.