California’s Medi-Cal program, the state’s version of Medicaid, offers comprehensive health coverage to low-income residents, but its coverage for assisted living is often misunderstood. Assisted Living Facilities (ALFs) are residential settings that provide personal care and supportive services, which differs from institutional medical care. Medi-Cal does not typically pay the full, all-inclusive cost of residing in an ALF. Instead, the program covers the services a resident receives, rather than the costs associated with housing itself. This means a resident will always have some financial responsibility, even if they qualify for Medi-Cal support.
Defining Assisted Living Costs Versus Skilled Nursing
The way Medi-Cal covers long-term care depends heavily on the type of facility a person resides in. Assisted Living Facilities (ALFs), formally known as Residential Care Facilities for the Elderly (RCFEs) in California, focus on non-medical, custodial care. These facilities help residents with Activities of Daily Living (ADLs) such as bathing, dressing, and medication management.
Skilled Nursing Facilities (SNFs), by contrast, are licensed medical institutions that provide 24-hour skilled nursing care and medical treatment. Medi-Cal fully covers the cost of care, including room and board, for eligible individuals in a SNF because this is considered medically necessary institutional care. Assisted living costs are divided into Room and Board (housing, meals, utilities) and Services (personal care assistance and care coordination). Medi-Cal coverage targets only the Services component.
The Assisted Living Waiver Program
The specific mechanism Medi-Cal uses to help pay for assisted living services is the Assisted Living Waiver (ALW) program. This Home and Community-Based Services (HCBS) waiver allows eligible individuals to receive nursing facility-level care in a community setting instead of an institutional one. The ALW pays the residential care facility for the supportive services provided, covering the care portion of the monthly bill.
Covered services under the ALW include personal care, intermittent skilled nursing, medication oversight, care coordination, housekeeping, laundry services, and assistance with activities like eating and mobility. The waiver coordinates a safe transition for those who are in a nursing facility or are at risk of being placed in one.
The ALW is not an entitlement program and is currently available only in a limited number of California counties. As of early 2024, the program operates in 15 counties, including Los Angeles, San Diego, Orange, and Sacramento. Due to limited enrollment slots, there can be a waitlist, and applicants must be willing to move to a facility located within one of the ALW counties.
Qualification Requirements for Coverage
To access the benefits of the Assisted Living Waiver, a person must meet both financial and functional eligibility requirements. Financial eligibility requires the applicant to be eligible for full-scope Medi-Cal benefits with a zero Share of Cost (SOC). This means income must be below the set limit, which is approximately 138% of the Federal Poverty Level for an individual.
The most significant functional requirement is the need for a Nursing Facility Level of Care (NFLOC). This means a person must have care needs that would qualify them for admission to a Skilled Nursing Facility, but they choose to receive those services in an assisted living setting. Applicants must be age 21 or older, and a registered nurse from a contracted Care Coordination Agency (CCA) completes an assessment to determine this level of need.
The application process begins with ensuring the individual is enrolled in full-scope Medi-Cal. The next step is to contact a local CCA operating within an ALW county to request an assessment. The CCA uses a standardized tool to determine the individual’s level of care and confirm whether their needs can be safely met in a residential care facility.
Costs Not Covered by Medi-Cal
Even for those successfully enrolled in the Assisted Living Waiver, Medi-Cal does not cover the Room and Board portion of the assisted living costs. This expense includes the rent, utilities, and the cost of meals. The resident is solely responsible for paying this portion of the bill from personal income sources, such as Social Security or retirement funds.
The monthly amount a resident must pay for Room and Board is standardized and based on their income, with a small personal needs allowance kept by the resident. For an individual receiving Supplemental Security Income (SSI), most of that income is directed toward the Room and Board payment. Individuals with income slightly above the limit for zero Share of Cost Medi-Cal cannot participate in the ALW.