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Reimbursement of Private Pay funds paid while Medi–Cal is pending


Many nursing homes ask for payment of the private pay rate while the Medi-Cal application is pending. However, if the resident is determined to be eligible for Medi–Cal for any month in which you paid privately, the facility must bill Medi–Cal and return any funds paid above the share of cost. Usually, the resident has already spent his or her funds, so the bill is often paid by a spouse or a family member.

You should present a written request for a refund with the Medi–Cal card or proof of eligibility to the appropriate facility staff person. The facility must bill Medi–Cal and return any funds over and above the share of cost. Failure to comply with the law constitutes Medi–Cal fraud and penalties can include suspension or termination of the Medi–Cal provider agreement (see Welfare & Institutions Code ยง 14019.3). If you are refused a refund, contact your county legal services office or CANHR.

Residents cannot be transferred within the facility (except from a private room to a semi–private room) or be evicted as a result of changing from private pay or Medicare to Medi–Cal.

This also applies to residents who have made a timely and good faith application for Medi–Cal benefits and for whom a final determination has not yet been made (Welfare & Institutions Code § 14124.7).