How to qualify for assisted living in CA? Your guide to requirements and funding

With more than 6 million adults aged 60 or older, California has a large senior population. For many, a key question is how to qualify for assisted living in CA, which requires understanding the specific health, financial, and state-specific criteria to find the right care solution.

Quick Summary

Qualifying for assisted living in California depends on meeting specific age, health, and financial criteria, which vary based on whether you are self-paying or using a program like the Medi-Cal Assisted Living Waiver. The process involves a needs assessment and navigating specific state regulations for care facilities.

Key Points

• Health and Safety First: All applicants must pass a health assessment demonstrating they can live safely in a non-medical RCFE setting, with limitations on bedridden status and certain conditions.

• Two Primary Funding Paths: You can either pay for care and room and board privately or, if eligible, use the Medi-Cal Assisted Living Waiver (ALW) program to cover care services.

• Medi-Cal's Expanding Accessibility: As of January 2024, California removed asset limits for Medi-Cal, potentially opening the ALW program to more low-income seniors who previously wouldn't qualify.

• Location Matters for ALW: The Medi-Cal Assisted Living Waiver is only available in a limited number of California counties, and waitlists are possible due to limited enrollment slots.

• Consider All Costs: Even with the ALW program, residents are responsible for paying their room and board, which can sometimes be covered by Supplemental Security Income (SSI).

• Specialized Care has Extra Rules: Facilities offering specific dementia care must meet additional staff training and safety requirements, and admissions are subject to assessment of behavioral stability.

Understanding Assisted Living in California

Assisted living facilities in California are known as Residential Care Facilities for the Elderly (RCFEs). These are non-medical facilities licensed by the Department of Social Services (DSS). The primary role of an RCFE is to provide care and supervision to adults over the age of 60 who need assistance with daily activities but do not require 24/7 skilled nursing care. The process to qualify can vary significantly depending on your financial situation and care needs, with options ranging from private pay to state-funded programs like the Assisted Living Waiver (ALW).

General and Health-Based Eligibility

Before financial considerations, all prospective residents must meet a baseline of health and safety requirements for admission. These are governed by Title 22 of the California Code of Regulations and are focused on ensuring the safety of the individual and the community. Generally, to be admitted to an RCFE, a person must be able to reside safely in that setting.

• Age: The standard age requirement is 60 or older. However, individuals as young as 21 with a disability may qualify for the Medi-Cal Assisted Living Waiver (ALW) program, provided they meet all other criteria.
• Needs Assessment: A comprehensive assessment by the facility is required to evaluate the applicant's care needs. This determines the level of assistance required for Activities of Daily Living (ADLs), such as bathing, dressing, grooming, eating, and mobility. A resident's needs must fall within the scope of services the RCFE can provide.
• Mobility: While assisted living is suitable for those needing some mobility assistance, there are limitations. Residents must be able to walk, stand, or get in and out of a bed or chair with minimal assistance. Generally, an individual who is bedridden for more than 14 days is not eligible for retention unless the condition is temporary and specific fire safety standards are met.
• Medical Conditions: RCFEs cannot admit or retain individuals with certain health conditions that require a higher level of medical care than the facility is licensed to provide. For example, individuals with active, communicable diseases or those requiring 24-hour skilled nursing are typically excluded. Facilities can, however, provide incidental medical services like oxygen administration or certain types of injections if a licensed professional or the resident provides the care.
• Behavioral Concerns: For individuals with dementia or mental health issues, the facility must assess if their behaviors would pose a risk or disrupt other residents. Specialized dementia care is available in some RCFEs, but they must meet strict requirements for staff training and safety protocols.

Funding and Financial Requirements

Funding assisted living is one of the most critical aspects of qualifying. California offers a few pathways, including private pay and the Medi-Cal Assisted Living Waiver program.

Private Pay This is the most straightforward method, where the individual or their family pays for all costs out-of-pocket using private funds, long-term care insurance, or other personal assets. Qualification is not based on income or assets, but rather the ability to cover the facility's monthly costs, which vary significantly by location and services provided.

Medi-Cal Assisted Living Waiver (ALW) For low-income individuals, the ALW program is an option that can help cover the cost of care services in a participating RCFE. To qualify for the ALW, applicants must meet several strict requirements:

• Be a resident of one of the participating counties, which currently includes Los Angeles, Orange, San Diego, and several others.
• Be 21 years of age or older.
• Have full-scope Medi-Cal eligibility with a zero share of cost.
• Require a nursing facility level of care, meaning they would otherwise need to be in a nursing home.
• Be willing and able to live safely in an assisted living setting as an alternative to a nursing facility.
• Have enough funds to cover room and board costs, as the waiver only pays for care services.

A note on Medi-Cal asset limits

As of January 2024, California eliminated asset limits for Medi-Cal eligibility, making it easier for many seniors to qualify for programs like the ALW.

Comparing Private Pay and Medi-Cal ALW

To help you decide the best route, here is a comparison of the two primary funding options for assisted living in California.

Feature	Private Pay	Medi-Cal ALW
Cost Coverage	Resident or family pays for all costs, including care and room & board.	Medi-Cal covers care services. Resident pays for room and board.
Eligibility	Based on the resident's ability to pay and health assessment.	Based on strict health and financial criteria, including Medi-Cal eligibility and a demonstrated need for nursing facility level of care.
Asset Limits	None, but costs can be high.	No asset limits as of January 2024.
Program Availability	Wide availability across most RCFEs in California.	Limited to participating RCFEs and only available in certain counties.
Waitlists	Less common.	Waitlists can be long due to limited enrollment slots.
Speed of Admission	Generally much faster, dependent on facility availability.	Can be a lengthy process (3-6 months) involving multiple steps.

The Application Process: Step-by-Step

The process for entering assisted living in California typically follows these general steps, regardless of the funding source:

1. Initial Assessment: Contact assisted living facilities to schedule an initial health assessment. For Medi-Cal ALW, a state-approved Care Coordination Agency (CCA) will perform the assessment.
2. Gather Financial Documentation: For private pay, prepare statements showing your ability to cover costs. For Medi-Cal ALW, apply for Medi-Cal if you don't already have it and gather proof of income and medical expenses.
3. Facility Tour and Selection: Visit facilities to find the best fit for your needs and preferences. Confirm if the facility accepts your intended funding method (private pay, ALW, or SSI).
4. Submit Application: Complete the RCFE's application, which includes personal and health information. For ALW, you will be enrolled through the CCA.
5. Develop Care Plan: Once admitted, a personalized care plan will be created based on your needs assessment.

Conclusion

Qualifying for assisted living in California is a multi-faceted process that depends on a combination of health, safety, and financial factors. By understanding the distinct pathways for private pay versus the Medi-Cal Assisted Living Waiver, families can make informed decisions. Proactive planning, thorough research, and working with care coordinators can help streamline the process and ensure a smooth transition to a safe and supportive assisted living community. For more details on California's residential care regulations, please refer to the official resources.

For additional information on the state's Community Care Licensing Division, visit the California Department of Social Services website.

Frequently Asked Questions

What is the age requirement to qualify for assisted living in CA?

Generally, RCFEs in California are for individuals aged 60 and older. However, the Medi-Cal Assisted Living Waiver program is available to eligible individuals who are 21 or older with a disability.

Does Medi-Cal cover assisted living in California?

Medi-Cal can cover care services in participating facilities through the Assisted Living Waiver (ALW) program. It does not cover the cost of room and board, which the resident is responsible for.

Are there financial limits to qualify for assisted living in CA?

For private pay, there are no financial limits, but you must demonstrate the ability to cover costs. For the Medi-Cal ALW, income limits apply, but asset limits were eliminated as of January 2024.

What kind of health conditions might prevent someone from qualifying for assisted living?

Assisted living facilities (RCFEs) cannot admit residents who require a level of care beyond their license. This includes those who need 24-hour skilled nursing care, have active communicable diseases, or are bedridden for extended periods.

Is the Medi-Cal Assisted Living Waiver available statewide?

No, the ALW program is only available in a limited number of California counties. Applicants must reside in one of the participating counties to be eligible.

What is the first step to starting the qualification process?

The first step is to undergo a health and needs assessment. For private pay, this is done by the facility; for the ALW program, it is handled by a state-approved Care Coordination Agency (CCA).

How long does the application process for the Assisted Living Waiver take?

The full application and enrollment process for the ALW program can take several months, ranging from 3 to 6 months, due to various assessment and approval stages.