Paying for an RCFE in California: private pay, insurance, and benefits

Private pay: know what the price includes

When you pay privately, the admission agreement is your most useful tool. State rules require it to spell out the basic services and their rate, any extra services and their fees, billing and payment procedures, and refund conditions. Read it before you sign, and ask about anything that is unclear.

• The home must give you a blank copy of its current admission agreement on request. It may charge only the cost of copying or mailing.
• A separate charge is allowed only if the admission agreement authorizes it.
• Residents must receive an itemized monthly statement of the separate charges the home collects.
• The home must give at least 60 days' written notice before raising rates.
• If a rate goes up because a resident needs a higher level of care, the home must give written notice within two business days after starting that care, with an explanation and itemized charges.
• A home may charge only one preadmission fee per admission, and must explain in writing what it covers and when it is refunded.
• A home may not ask for or accept a deposit against possible damages.

Long-term care insurance

Whether a long-term care insurance policy pays for an RCFE depends on the policy. Read the policy, then call the insurer. Ask what it covers in a licensed RCFE, what it needs from you and the home before it pays, and how claims are filed.

For free, confidential help, contact HICAP, the Health Insurance Counseling and Advocacy Program, at 1-800-434-0222. HICAP counsels people who have Medicare or will soon be eligible, and its help covers long-term care insurance and planning for long-term care needs.

VA Aid and Attendance

Aid and Attendance is a monthly payment added to a VA pension for qualified veterans and survivors. You may be eligible if you get a VA pension and at least one of these is true:

The payment goes to the veteran or survivor, not to the home. You can apply online, by mail, or at a VA regional office. Confirm current eligibility rules and amounts directly with VA.

• You need another person to help with daily activities such as bathing, feeding, and dressing.
• Illness requires you to stay in bed, or spend much of the day in bed.
• You are a patient in a nursing home because of a loss of mental or physical abilities related to a disability.
• Your eyesight is severely limited, as VA defines it.

Medi-Cal Assisted Living Waiver

The Assisted Living Waiver helps eligible Medi-Cal members who need a high level of daily support receive care in licensed assisted living settings, such as RCFEs, instead of nursing facilities. It is run by the California Department of Health Care Services (DHCS). There are important limits:

• It is offered only in certain counties. Check the current county list on the DHCS website.
• It works only at homes that take part in the waiver. DHCS publishes a list of participating facilities.
• Participants need full-scope Medi-Cal with no share of cost, and care needs like those of Medi-Cal residents of nursing facilities.
• Slots are limited, and there is a waitlist. Contact a Care Coordination Agency to ask about openings.
• The waiver does not cover room and board. Participants pay the home directly for room and board.

SSI/SSP in licensed board and care homes

SSI is a federal benefit, and SSP is California's state supplement to it. California pays a special supplement rate, called nonmedical out-of-home care, to an aged, blind, or disabled person who needs nonmedical care or supervision and lives in a state-licensed residential care facility. Social Security checks the license on the state's website and pays this rate only for homes shown as licensed.

If a resident receives SSI/SSP, the home must provide its basic services at the SSI/SSP basic rate, with no extra charge for those basic services. A home may not require an SSP recipient to pay a preadmission fee or deposit. Family members may still make voluntary contributions.

A home does not have to accept a particular resident, so ask each home whether it accepts residents on SSI/SSP. Ask Social Security about eligibility and current payment amounts.

Questions to ask before you sign

Ask every home the same questions. Then you can compare their answers side by side.

• What is the monthly rate, and exactly what does it include?
• What costs extra, and how much?
• How do you set fees for higher levels of care?
• Is there a preadmission fee, and when is it refunded?
• Do you accept long-term care insurance, the Assisted Living Waiver, or SSI/SSP?
• What happens if my parent's savings run out?

Get help with the details

This guide is general information, not legal or financial advice. Benefit rules and amounts change over time. Before you decide, confirm details with each program: VA for Aid and Attendance, DHCS or a Care Coordination Agency for the Assisted Living Waiver, Social Security for SSI/SSP, and your insurer for long-term care insurance. An elder law attorney or a financial professional can help you plan.