What followed was a nine-month struggle that exposed a stark gap in how the state’s Medi-Cal program treats older adults depending on where they live — a gap that ultimately led to a new pilot program aimed at giving rural Californians more say in how and where they age.

John had moved back to the ranch to help his sister with daily tasks like bathing and dressing, but caring for her while also managing the property and his own work as a writer became unsustainable. The siblings agreed that Roselie, who qualifies for Medicaid, should transition into assisted living.

That’s when John discovered a frustrating reality: Medi-Cal does not fund assisted living care in Siskiyou County — or in 42 other counties across California. Only 15, mostly in urban areas, offer that option through what’s known as an assisted living waiver.

The disparity leaves many rural seniors with only one real alternative: a nursing home, even when their needs don’t require that level of institutional care, simply because they cannot afford to pay for assisted living privately.

“You’re wasting money by dumping somebody like my sister in a skilled nursing facility and lessening her quality of life and her chance at doing better,” John said. “By doing this, it makes no fundamental sense.”

**A statewide problem coming into focus**

California is bracing for a dramatic shift in its population — within a decade, one in four residents will be over 60. State officials have said they want to help older adults age in their own communities rather than in institutions. But whether that promise is fulfilled often depends on which managed care organization administers Medi-Cal benefits in a given county, and what services that plan chooses to offer.

Roselie is covered by Partnership HealthPlan, the dominant Medi-Cal managed care provider across a swath of Northern California, serving nearly a million residents. In 15 counties, it’s the only option available to Medi-Cal enrollees.

According to the California Department of Health Care Services, managed care organizations are “encouraged” — but not obligated — to offer optional benefits known as community supports, which can include help with the cost of assisted living, temporary rental assistance, respite care and in-home personal care. These fall under CalAIM, the state’s sweeping effort to modernize Medi-Cal. Even after related waivers expire at year’s end, these community support benefits are expected to continue.

Dustin Lyda, a spokesperson for Partnership, said the plan opted not to include an assisted living benefit due to cost concerns and a shortage of qualified facilities in the rural communities it serves. Any change, he said, would require evidence that assisted living leads to better outcomes than nursing homes. Still, he acknowledged the shortcomings.

“There’s definitely a lot more work that we need to do on our end to navigate the more rural areas,” Lyda said.

Maura Gibney, executive director of California Advocates for Nursing Home Reform, said the lack of options compounds an existing shortage in rural regions.

“There’s not a lot of options to begin with in rural counties,” Gibney said. “You take (the assisted living waiver) off a table, which already has a history of a long waiting list, and the options are pretty bleak.”

**Fighting for a place close to home**

John initially assumed his sister would have to leave Siskiyou County altogether, since it offers just one Medi-Cal-approved facility — a nursing home. Roselie had previously stayed at an assisted living facility in neighboring Shasta County and felt at home there, but Partnership doesn’t cover assisted living costs in that county either.

The plan instead offered to place Roselie in Sonoma County — roughly five hours from the family ranch. The Aiellos refused, worried the distance would cut Roselie off from the relatives she relied on for emotional support.

“If you remove her totally from a family contact, she would not be thriving right now. She needs to see family,” John said. “When there were resources available that fit her needs in Redding — that’s the closest point to her home county — why do I need to move her to Oakland, to Los Angeles, to San Diego?”

For nine months, John pushed back — sending emails, making calls, and enlisting Roselie’s doctor to advocate on her behalf, all while trying to secure her a spot at the Shasta County facility. The process took a toll on both of them.

“He was doing all of this to help me,” Roselie said. “Where was it going to end?”

**A system with built-in gaps**

Advocates say most people would rather remain in community settings than move into nursing homes, which tend to be significantly more expensive to operate. But nursing home capacity is limited and should be preserved for people who genuinely need round-the-clock medical supervision, Gibney said.

“We really try to help people look at the other options that exist for remaining in the community,” she said. “You’re going to have better health outcomes, better quality of care, if you can stay in the community and out of an institutional setting.”

Still, the picture isn’t entirely one-sided. Dr. Kenneth Lam, a geriatrician and assistant professor at the University of Colorado Anschutz Medical Campus, noted that people in assisted living are sometimes hospitalized more often than nursing home residents, which can offset some of the anticipated savings.

“The evidence suggests that it’s a trade-off,” he said.

State officials confirmed that managed care contracts aren’t competitively bid, and plans aren’t required to offer specific community supports like assisted living assistance as a condition of their contracts.

“Whether a plan chooses to provide specific community supports is not a factor in contract renewal, which focuses instead on overall compliance with state and federal performance standards,” said Tessa Outhyse, a spokesperson for the Department of Health Care Services.

Partnership’s state contract, originally set to expire in December, has been extended to 2029 after California delayed its broader process for awarding managed care contracts. Lyda said demand for community supports, including requests for assisted living help, has been rising steadily. But even in counties where such benefits exist, waitlists can stretch on for months.

Statewide, the number of new enrollees approved for an assisted living waiver actually declined at the start of 2025, even as the waitlist kept growing. By September, more people were waiting for a waiver than were actually receiving one.

Gibney said the sequence itself can be part of the problem — many Medi-Cal recipients are advised to join the waitlist before they’ve even applied for the funding, adding to the delays. Some spend months waiting only to learn they don’t qualify.

“It’s a lot of shifting sand, that’s what people are finding themselves in the middle of,” Lam said. “They’re being told that they get to choose, but it’s a complex choice.”

**A new chapter for Roselie**

In March, Roselie finally moved into Sundial Assisted Living in Shasta County — the very facility she and John had hoped for from the start. Two months earlier, Partnership had agreed to cover her care, offering her a spot in a new pilot program launched July 1 that expands assisted living access to select members of its network. There’s no formal application process; eligible members are referred through healthcare providers or can request consideration directly.

The pilot is designed to test whether expanding assisted living coverage leads to better health outcomes and lower costs overall.

“Success would also be having these individuals being able to continue to receive care within their community setting, being in their home,” Lyda said. “We know that that is more impactful to health than being completely taken out of a familiar area.”

The transition hasn’t been simple for Roselie, who has been hospitalized twice since moving to Sundial and spent a brief stint back in a nursing home. But socially, she has flourished — making new friends, teaching card games to fellow residents, and receiving visits from caretakers and neighbors during her hospital stays.

“I’m looking at it like this: It’s a new adventure,” she said.

John remains uneasy about his sister’s health and whether Sundial will be a lasting solution. He’s relieved the fight paid off, but still troubled that it took so much effort to get there.

“I don’t understand why I was the guy fighting for everybody,” he said. “I’m just one person trying to support myself, trying to take care of a family member.”

Original source: CalMatters

The post Medi-Cal Rarely Covers Assisted Living in California — This Brother Refused to Accept That appeared first on The Hemet & San Jacinto Chronicle.

By Emily DeRuy

There is no elder care system in California. Instead, there is a patchwork of options. And because, with limited exceptions, we don’t dedicate public funds to long-term daily care, many options are wildly out of reach to families without significant resources.  

The COVID-19 pandemic made all of this abundantly clear, and showed just how fragile the existing options are, from assisted living homes overrun by infectious disease to at-home care delivered by underpaid workers who were not prioritized for protective gear when the pandemic hit.

While we may not have another pandemic like the one that has gripped the world for the last two years in our lifetime, we felt it was important to explore the problems it exposed in our elder care system — problems that, in many cases, were decades old and will not be solved anytime soon. 

We focused on elder care in part because seniors make up a growing proportion of California’s overall population. About 16% of our state is over 65, up from just 9% in 1970. Many of our Bay Area News Group — particularly our print subscribers — also fall into this category. 

Ultimately, we tried to unpack a piece of the elder care story through the eyes of four families. These families each grappled with the need to find care for elders and made vastly different choices in the process. One family moved into an assisted living facility during the winter 2020 surge in COVID cases. One woman moved her frail mother out of a memory care facility and into her dining room as the pandemic first hit. Another woman relied on professional caregivers, while another — who had worked as a paid caregiver for other families — provided the care herself. 

Our goal was to weave in the broader policy discussion — touching on a series of bills in Sacramento aimed at reforming the nursing home industry and a federal push to boost funding for caregivers — into the piece without getting bogged down. We also put together a companion piece on care options, costs and important forms families should know about. Finally, we held a webinar attended by hundreds of people, which featured some of the families in the story, as well as a geriatrician and a social worker. It was one of our most-attended live events ever, which I think speaks to the need for stories focused on seniors, a demographic that is too often overlooked or excluded. 

The reporting process was not without its challenges. What we thought would be a process of finding families to write about through visits to senior centers, assisted living facilities and other organizations instead initially played out online. Senior centers were still closed and facilities generally weren’t open to visitors because of COVID-19. Instead, we spoke first with advocacy organizations, nonprofits and geriatricians, who connected us with families. Getting families to go on the record was also difficult. We spoke with a number of people who do not appear anywhere in the story about their (sometimes traumatic) experiences with elder care, but many were reluctant to speak openly because they feared reprisal from facilities still caring for their loved ones or other blowback. And families were sometimes reluctant to discuss finances. 

As with most long-term reporting, it was important to build relationships and trust with the families we wrote about, and to internalize that what for us might be one project was for them potentially a once-in-a-lifetime experience that involved sharing deeply personal stories. 

In the end, we were able to touch upon just a fraction of the elder care landscape. The good news is that there are plenty of other stories to tell. And while there are gaps in accessible information and data, the state does make available nursing home inspection reports, and COVID cases and deaths for various facilities. There are a number of studies from researchers like Charlene Harrington at UC San Francisco that delve into the links between COVID-19 infections and deaths and factors like staffing levels, ownership status and size. Reporters could compare facilities that weathered the pandemic well and those that did not. What went right, what went wrong and why? What needs to change? 

Lawmakers passed some legislation but other bills — including one that would limit nursing home squatting, where people or companies run nursing homes without state approval — have stalled amid intense opposition. They deserve continued attention, as does the implementation of those passed. 

There is much more to be written about the workers who put their lives on the line, often with very little protection, to care for seniors. And then of course there is the broader thorny question of whether the state or country will move to include elder care as a public benefit. 

Find your latest news here at the Hemet & San Jacinto Chronicle

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