OWL Presentation: Saturday, Sep’t. 23, 2023 11a
Navigating the Medicare/Medi-cal Maze
by Chris Dillon
My professional credentials:
*Licensed Nursing Home Administrator; State and Federal Licensures
*Licensed Residential Care Facility Administrator/State of Ca.
*Certified Eden Alternative Associate: Culture Change facilitator
*Certified Social Services Designee/SNF Level
*Member of the employee/ownership team of Foresight Management Services.
* I ended my career in LTC as a consultant to the Foresight Management
Services buildings statewide.
*Current: District 11 appointee to Disability and Aging Services Advisory Board
My theme: Keep It Simple, Stupid!
Not as easy as it should be in the convoluted world of long term care!
I. Understanding your care options
II. Understanding the payor source
Acronyms commonly encountered:
SNF: skilled nursing facility. (medical model of care)
● Licensed through Ca. Dep’t of Public Health (CDPH) &/or Center for
Medicare and Medicaid Services (CMS)
● Includes: Rehab. Facilities, Sub-acute Facilities, Distinct Part Facilities
(these are special units within SNFs and Acute hospitals which receive higher Medi-cal reimbursment due to severity of diagnosis and clinical care requirements)
You can learn more about this designation here:
This level of care receives strictly limited/tightly controlled Medicare A Reimbursement.
RCFE: Residential Care Facility for the Elderly
A.L.: Assisted Living Facility
CMS: Center for Medicare and Medicaid Services
CDPH: Ca. Dep’t of Health Services
D.S.S.: Ca. Dep’t of Social Services
I. RCFE & Assisted Living
Options are rooted in your specific needs
1). This is Custodial Care – not clinical
a). Residential Care for the Elderly
This licensure is not clinical.
It is licensed through the state Dep’t. of Social Services & is a social model.
RCFE inspection/surveys are mandated to be unannounced
and performed annually by Department of Social Services.
b). Assisted Living (AL): these facilities offer assistance with some activities of daily living (ADLs).
This is custodial care.
The staff member providing the service is not required to be
licensed or certified.
IMPORTANT: these facilities may not administer or assist a resident with actually taking their medications. They may not change dressings or provide wound care, etc.
*They may remind and encourage, but cannot put the med into a residents mouth, administer injections, etc.
*They may contract with a Medicare licensed Home Health Agency to provide preparation and/or administration of meds, wound care, etc.
*Services provided by a licensed home health agency must be ordered by the attending physician and are billed under Medicare Part B.
This link will provide an explanation of assisted living facilities:
The above types of care are not covered by Medicare or Medi-cal. Some ‘Board and Care’ coverage may be provided by SSI assignment.
A board and care is a small home like facility, usually consisting of 6 to 8 beds, many in 2 bed shared rooms. It is licensed as an RCFE.
2). This link will take you to the overview of custodial levels of care.
3). This link will take you the search engine which you can use to research the licensing record for facilities which you may be interested in learning more about:
II. Continuing Care Retirement Community (CCRC)
This designation refers to a spectrum of services including both custodial
and skilled nursing.
1). You can learn about this type of care here:
a). a caveat: be very careful of this designation at present. Read and understand the contract well, before signing. You may want to consult an elder care attorney. The skilled nursing facility component is changing rapidly at this level of care (LOC)
III. Skilled Nursing Facility (SNF)
A). The majority are licensed through Ca. Dep’t of Public Health (CDPH) &/or Center for Medicare and Medicaid Services (CMS) California licensing and certification is rooted in Ca. Title 22 Federal licensing and certification is rooted in OBRA ‘87
(the nursing home reform act)
1). Includes: Rehab. Facilities, Sub-acute Facilities, Distinct Part Facilities (these are special units within SNFs and Acute hospitals which receive higher Medi-cal reimbursment due to severity of diagnosis and clinical care requirements).
You can learn more about this designation here:
This level of care receives strictly limited/tightly controlled Medicare A Reimbursement. The majority of payment for this LOC is private or Medi-cal.
2). This is a clinical/medical model of care.
a). You must have a physician order to be admitted
*a facility may not admit anyone for whom it cannot provide the mandated quality of life and quality of care. Involuntary discharge from the level of care is almost impossible.
b). Care is rooted in your diagnosis & related physician orders. Care is provided by licensed and certified staff.
c). Assessment of the quality of care is rooted in your resident care plan (RCP) and your progress in attaining the interdisciplinary care plan goals
d). Data is gathered in strictly defined protocols and reviewed a minimum of quarterly or at change of condition.
*the resident &/or the resident’s agent must be included in this review and must approve of their care plan.
2). Medicare will cover a maximum of 100 Part A days in a SNF. To qualify, you must be admitted to an acute facility and remained there for ‘3 midnights’. Be careful: many acutes now hold elders on ‘observation’ for the regulatory capped 2 midnights…if this happens to you, you do not qualify for Medicare Part A coverage in the SNF.
a). Day 1-20 is covered at 100% of the cost, as determined by an assessment system known as the Minimum Data Set (MDS). On day 21 a co-payment of $200 per diem is required.
b). The MDS covers all aspects of the clinical care required. A resident must show measurable progress toward their Resident Care Plan goals in order to be medicare covered. With the exception of some types of G-tube feedings, ostomy care, wound care, etc which require clinical assessment, very few residents qualify for 100 days of coverage.
c). When a resident no longer qualifies, the resident &/or their agent will receive a m-care cut letter 72 hours prior to end of coverage. They have the right to appeal the finding. During the interim of the appeal, they cannot be billed privately. If they lose the appeal, they must then
pay the retroactive amount due.
d). Discharge planning is mandated to begin at the date of admission and be included in the Resident Care Plan.
3). Medi-cal is the major source of funding for most SNFs. At present, it’s re-imbursement rate is beginning to fall below the per diem cost of care.
4). Surveys for this LOC are in the purview of Ca. DPH/Licensing and Certification. They are mandated to be within a 15 month window and unannounced, inc. a certain percentage of which must be launched on the PM or midnight shift.
● CMS may also perform surveys for OBRA ‘87 compliance separately.
so as to confirm the accuracy and objectivity of the state survey process.
Further background information:
LTC cost fact sheet: (this is from CAHF, the for profit nursing home advocacy org.)
Medi-cal overview of costs and eligibility:
Medi-cal well spouse impoverishment program: (there will be significant changes in the program in Jan. 2024. I’ll update the link/info as it evolves).
Resources to assist in making care choices:
You can access the quality of life/quality of care survey outcomes & complaint files for SNFs at this site:
This site is difficult to navigate but contains important information. It is worth visiting and working with to the best of your ability.
You can access the survey outcomes and complaint files for RCFEs at this site:
My preferred resources:
CANHR (California Advocates for Nursing Home Reform): this is an advocacy program which has often taken an adversarial stance toward SNFs. That being said: I’ve collaborated intermittently with the founder, Pat McGuiness, for 30 years. Most recently, I worked on a team led by CANHR, seeking mental health funding for SNFs. We were not successful, sadly. Pat and I respect each other and seek to collaborate, even when we disagree. This organization fills an important role in our complex long term care terrain! This organization can link you to elder care attorneys, as well.
The Long Term Care Ombudsman Program:
This is a federally mandated program which is administered differently in each county in the nation. The ombudsman is essentially a problem solving resource for residents, and their families/friends, in long term care facilities. I found their services indispensable. When tours of our facility occurred, if I was present, I always encouraged the visitors to check in with the ombudsman before making a final choice. They have a different perspective and experience of the nursing homes to which they are assigned and can be an excellent resource.
Legal Services for the elderly:
HICAP: Understanding your health insurance, includingMedicare, Medi-cal, Medicare Advantage Plans, et al. This is an important, invaluable resource:
Information and Referral
Area Agencies on Aging:
For San Francisco residents:
The HUB: this one site will assist you in navigating all aspects of the aging services sector in our city. All I&R personnel and case managers have a minimum of a masters degree in social work or its equivalent. It is easy to access via Muni &/or BART. You can make an appointment or drop in. There is a small parking area.
ADRCs (aging and disability resource centers)
These are ‘mini-HUBs’ scattered throughout the city:
Community Living Campaign (CLC) – Aging in Place programs