Medicare and Medi-Cal eligibility

An annoyance of mine is when I see a non-attorney make a legal determination involving an ostensibly simple matter that is wrong and consequential. While reading through appellate opinions, I stumbled upon a case involving such a a scenario.

Wong v. Tam, Los Angeles County Superior Court, Case # BC541794.   

In this case, the plaintiff and defendant agreed to purchase a property for their elderly parents (presumably they were brother and sister). According to a declaration by the defendant:

"At a wedding reception in December 1999, plaintiff told the parties' parents and siblings that their parents would need to divest their assets in order to qualify for Medicare and Medicaid and suggested they and defendant buy a home in a new senior living community in Walnut, California. Defendant expressed interest in purchasing a home in that community because it would allow him and his wife to use the home when he retired or earlier in order to live closer to their children. He and his father also said they were open to purchasing the home provided it was not sold for the lifetimes of the parents' children and "hopefully" their grandchildren, which stemmed from the Chinese cultural tradition of passing family homes through generations. With that understanding, defendant, plaintiff, and their parents orally agreed that defendant and their parents would pursue buying a home."

This declaration is wildly inaccurate in terms of qualifying for benefits, i.e. the parts in bold

Medicare, the medical insurance program for the elderly, is an entitlement. If you earn enough credits, you are eligible to receive it. It makes no difference whether you are a billionaire or living a meager existence. If you pay for it, you get it. It is as simple as that.

Conversely, "Medi-Cal," the name California uses for the federal program known as "Medicaid," is a medical insurance program for the poor and disabled. Medi-Cal is not an entitlement. Essentially you have to be poor and/or disabled to qualify for it. Therefore, Medi-Cal is described as a needs-based public benefit.   

While the case did not turn on benefits eligibility, it does demonstrate the defendant's ignorance of the law on this topic. This can be particularly damaging because of the legal adage "ignorance of the law is no excuse." A person is stuck with their mistake, whether they knew the law or not. This can be a sobering reality for the legally uninformed.  

Medi-Cal

One of the largest federal programs is Medicaid, which is known as Medi-Cal in California. The following are some frequently asked questions associated with Medi-Cal.

1. What is Medi-Cal?

Medi-Cal is a needs-based public benefit program that provides payment for various medical services to qualified individuals here in California.

2. What is Medicare?

Medicare is the federally subsidized health care system for individuals over the age of 65.

Yes, the fact that there is Medicaid, Medi-Cal and Medicare can be quite confusing.

3. What is a needs-based public benefit?

A needs-based public benefit is a benefit that is granted to individuals who demonstrate need. For example, those with low-incomes or are disabled are eligible for Medi-Cal because they have a need for medical services but are unable to afford it. Conversely, an entitlement public benefit is where the recipient qualifies just for the sheer fact that they are a member of a certain class of individuals, regardless of their background. For instance, Medicare is an example of an entitlement benefit because anybody 65 or older will qualify.

4. What does Medi-Cal provide?

Medi-Cal provides eligible recipients with payment for hospitalization, doctors' services, prescription drugs, lab tests, home health care, nursing home care and other related medical services. Welf & I C §14132.

5. What makes Medi-Cal unique?

Medi-Cal is the only government program that pays for long-term nursing home care.   

6. Who is eligible?

There are two main types of Medi-Cal beneficiaries: (1) the "categorically needy" and (2)beneficiaries whose incomes are above the supplemental security income (SSI) limit but whose medical costs would leave them impoverished.

Examples from category (1) would be persons age 65 or older and blind or disabled persons of any age who receive SSI payments. Examples from category (2) would be individuals enrolled in the following programs: Aged and Disabled Federal Poverty Level program; Aged, Blind, and Disabled Medically Needy program; 250 Percent California Working Disabled program; Institutional Deeming Waiver program; Nursing Facility/Acute Hospital Waiver program; and Transition programs.

7. Does the beneficiary of the Medi-Cal have to repay the benefits?

The precise answer is that no, the recipient of Medi-Cal benefits does not have to re-pay the benefits received. However, the beneficiary’s estate is, generally speaking, liable for the reimbursing the State of California for the amount of Medi-Cal benefits received. 42 USC §1396p(b)(1); Welf & I C §14009.5.

For example, Donna Decedent was of modest means and disabled. She received Medi-Cal during her lifetime. When Donna passed away, her estate was worth $50,000. The State of California, via Medi-Cal, paid $100,000 for Donna’s medical care during her lifetime. Donna’a estate, namely $50,000, would be subject to recovery by the California Department of Health Care Services (DHCS) for the benefits paid.  

8. Are there instances when recovery is delayed or barred?

Yes, DHCS may not make a claim when there is a surviving spouse during his or her lifetime. Welf & I C §14009.5(b)(2)(A); 22 Cal Code Regs §50961(d)(2). Furthermore, DHCS may not make a claim if there is a surviving child of the deceased beneficiary who is under 21 or who is blind or permanently and totally disabled. Welf & I C §14009.5(b)(2)(B)-(C); 22 Cal Code Regs §50961(d)(3)-(4).

9. Is there a citizenship requirement for Medi-Cal?

No, there is no citizenship requirement for receiving Medi-Cal. Medi-Cal beneficiaries may be aliens lawfully admitted for permanent residence, as well as to persons Permanently Residing in the United States Under Color of Law. Welf & I C §14007.5.