When Can A Nursing Home Apply For Medi-Cal For Their Resident?


Many individuals in skilled nursing facilities cannot afford to pay $6,000 to $8,000 per month but require care around the clock. In such situations, they may want to apply for Medi-Cal benefits to pay for their skilled nursing monthly bills. But what happens when such individual lacks capacity and does not have a spouse, guardian or conservator to apply for Medi-Cal benefits for them? The skilled nursing facility can actually apply for Medi-Cal benefits for their incapacitated patient.

22 CCR § 50163(a) states that if the individual has no spouse, conservator, guardian, or executor and such individual is incompetent, then a person who has knowledge of the applicant’s circumstances may apply for Medi-Cal benefits for the individual. The term “person who has knowledge of the applicant’s circumstances” can be interpreted broadly to include the office manager, administrator or social worker of a nursing facility, so long as they have sufficient information and knowledge of the incompetent individual’s circumstances.

If a skilled nursing facility applies for Medi-Cal for their incompetent patient, many times assets in excess of the eligibility limit for Medi-Cal will be considered exempt, resulting in approval of Medi-Cal benefits. This is the case only if the nursing home does not have access to the patient’s assets, which is generally the case. If the incompetent patient is the only person who has access to the account, such account will be regarded as unavailable since the patient lacks capacity to withdraw from such account. These funds will remain unavailable until a conservator is appointed to manage the patient’s assets.

In other words, a nursing home which is not getting paid because the patient lacks capacity to pay, can apply for Medi-Cal for the patient and get paid so long as the patient does not have a spouse, guardian, conservator, or executor and the nursing home does not have access to the patient’s finances.

The Medi-Cal regulations governing this area are complex. We do not recommend that a nursing home attempt to apply for benefits without the assistance of an attorney when dealing with an incapacitated patient who has no spouse or other agent to assist them.

#MediCal

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