Question: If a Partnership policy covers a patient’s stay in a private room in the nursing home until policy benefits are exhausted, and the patient transitions into Medi-Cal, with a SOC, and the nursing facility intends to transfer them out of their private room and into a semi-private room, can the patient use their SOC to guarantee their continued stay in a private room?
Reply: Yes, as long as the patient’s SOC, or some combination of their SOC, their assets and/or any remaining insurance, is high enough to cover the rate for the private room. If the nursing facility charges Medi-Cal for any portion of the facility cost, the patient cannot pay the difference between the Medi-Cal covered accommodation and a private roam. The patient may be able to afford to pay the entire cost of the nursing facility charge as their SOC, because they will no longer need to use any of their income to pay for drugs, Medi-Gap (part B) policy co-pays or deductibles, etc.
This is because once the patient is on Medi-Cal; the Medi-Cal benefits will cover all these medically necessary services. The patient’s income therefore, depending on each individual’s circumstances, may be sufficient to pay the facility costs (while meeting their SOC) so they can be sure to remain in a private. If not, the patient may have to move into Medi-Cal covered accommodations. For example, if the private room cost is $3,500 and the policyholder has $3,500 in income, they can use that amount to pay for the private room. Medi-Cal would then be available to cover any other medically necessary item.