Medicare, Medi-Cal, CalAIM and PACE: How the Pieces Differ

Medicare usually pays for medical care, not ongoing custodial living

Medicare covers hospital care, physician services, prescriptions and certain short-term skilled services when its rules are met. It generally does not pay for long-term custodial care—the ongoing help with bathing, dressing, supervision and daily living that many residents need in assisted living.

A short Medicare-covered skilled nursing stay should not be confused with permanent payment for an RCFE. Ask the current medical team what Medicare-covered services may continue after a move, such as home health or hospice, and what conditions apply.

Medi-Cal can cover services Medicare does not

Medi-Cal helps eligible Californians pay for health care and some long-term services. Eligibility, managed-care enrollment, Share of Cost and service rules are individual. A person who has both Medicare and full Medi-Cal is often called dually eligible; Medicare generally pays first for Medicare-covered care and Medi-Cal pays after other coverage when applicable.

Medi-Cal status alone does not mean every assisted living cost is paid. Families still need to identify the specific benefit or Community Support, the approving organization and any resident responsibility.

CalAIM Community Supports are defined services

CalAIM includes Enhanced Care Management and Community Supports. Assisted Living Facility Transitions is one Community Support that a Medi-Cal managed care plan may authorize for an eligible member who needs nursing-facility level of care and can live safely in an assisted living setting.

The Community Support includes defined transition and ongoing assisted living services; DHCS excludes room and board. Availability, network and authorization depend on the managed care plan and current policy.

PACE integrates a broad package under one team

PACE coordinates Medicare- and Medicaid-covered care and other services the interdisciplinary team determines are needed. Eligible participants must be at least 55, live in the service area, meet nursing-home level-of-care criteria and be able to live safely in the community with support.

PACE can be powerful because it coordinates the whole plan, but joining changes how the participant receives care and prescriptions. Families should compare the network, team model, transportation, residence relationship and cost before enrollment.

Create a responsibility map

For each need—housing, meals, personal care, medication assistance, physician care, pharmacy, transportation, therapy, equipment and emergency care—write down who pays, who delivers, who authorizes and when the decision should be reviewed. If an answer comes only by phone, request written confirmation.

Independent counseling can help. California HICAP provides free Medicare counseling, while the county and health plan address Medi-Cal questions. The residence should explain its own admission agreement and services without presenting itself as the final authority on government benefits.

A Poway perspective from Huntington Manor

Huntington Manor works with Community Health Group and San Diego PACE when the resident, program and authorization are an appropriate match. Our team can explain the residential-care side of the process, but the health plan or PACE organization makes eligibility and coverage decisions. Families should confirm every approval and cost in writing.