Nursing Homes in California
Nursing homes in California are licensed medical facilities regulated by the California Department of Health Care Services. Unlike assisted living or board and care homes, nursing homes are equipped to provide 24-hour skilled nursing care and manage complex, ongoing medical conditions. These facilities are designed for individuals with serious health challenges, such as those recovering from strokes or surgeries, those living with conditions like ALS or multiple sclerosis, and individuals who are bedridden or need advanced care such as wound management, IV therapy, or even coma care.
In addition to long-term custodial care, nursing homes also offer short-term rehabilitative services. Patients recovering from hospitalization due to illness or injury may receive physical therapy, occupational therapy, or speech therapy in a skilled nursing facility. Medicare and Medicare Advantage plans may cover part or all of this care, but only if specific criteria are met—including a minimum three-day hospital stay prior to admission. Even then, coverage is time-limited and subject to ongoing medical necessity. Under the Prospective Payment System, nursing homes are reimbursed based on a fixed rate for care, which has led to more selective admission practices.
Generally, nursing homes are appropriate only for individuals whose care needs exceed what can be safely provided in a home, assisted living, or residential care setting. Unfortunately, financial limitations often play a bigger role in placement decisions than medical need. Families unable to afford the $4,000 to $7,000 monthly cost of 24-hour home care—or $2,500 to $5,000 for residential care—may have no option other than placement in a nursing home, with costs covered by Medi-Cal, California’s Medicaid program for low-income seniors. Eligibility for Medi-Cal long-term care involves strict financial and functional qualifications. For more information, California residents can contact the Senior Advisors Network at (800) 640-5626.
What Medicare Covers—and What It Doesn’t
Many families mistakenly believe that Medicare pays for long-term nursing home care. In reality, Medicare only covers skilled nursing care for a limited time and only under specific conditions. After a qualifying hospital stay, Medicare may cover up to 100 days in a nursing facility. For the first 20 days, Medicare pays in full. From days 21 to 100, patients are responsible for a daily co-pay (historically around $164.50/day, adjusted annually). After day 100, coverage ends entirely unless the patient has supplemental insurance or qualifies for Medi-Cal. Importantly, Medicare only continues to pay as long as the patient shows measurable improvement. If the patient reaches a point where no further progress is expected, Medicare coverage stops—regardless of ongoing need.
Avoiding the High Cost of Nursing Homes
One of the most effective ways to prepare for potential long-term care needs is by purchasing long-term care insurance. However, these policies are only beneficial if purchased before the need arises, and applicants generally must be in good health to qualify. While many companies claim they can “protect your assets” through Medicaid planning strategies, consumers should be cautious. Laws governing Medi-Cal eligibility and asset protection are constantly changing, and strategies that work today may not be viable tomorrow. Some legal services make bold claims about helping families qualify for benefits and keep their savings, but such promises can be misleading or outdated.
When considering Medi-Cal planning, it’s essential to work with an attorney who specializes in elder law or Medi-Cal regulations. General family lawyers may not have the detailed knowledge needed to navigate these complex rules. Legal guidance is highly recommended, as the financial implications of missteps in planning can be significant.
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