MassHealth

What is Massachusetts Medicaid (MassHealth)?

In the state of Massachusetts, the Medicaid Program is called “MassHealth”. MassHealth provides benefits for people who meet specific eligibility criteria. Usually, a person has a disability, and/or falls under a certain income level. MassHealth is an important program for those with catastrophic injury, such as a spinal cord injury, as the Personal Care Attendant (PCA) Program is often needed in order to live in the community.  MassHealth is the only payer of the PCA Program. 
These articles are intended to help you figure out which category you may fall into and help you to understand this program better.  Here is the MassHealth Member Booklet for your reference.
 
UNDER AGE 65 and Disabled
For people under 65, there are 3 programs that you may qualify for. Each program is slightly different and has different types of requirements:
(1)   MassHealth Standard
(2)   MassHealth CommonHealth
(3)   MassHealth Long Term Care
For applying for MassHealth Standard and MassHealth CommonHealth, a person CAN have other insurance. However, MassHealth will be the secondary coverage (meaning, the person’s other insurance gets billed first – and after, MassHealth gets billed). This means, that a person can use both insurance until the primary insurance runs out, and then MassHealth will become the primary coverage.  
 
The first type is MassHealth Standard.
MassHealth Standard gives 100% coverage.  To qualify for this type of MassHealth, there are 2 requirements to be met.
(1)   A person needs to be determined as “disabled” (determined by UMASS Medical, unless the person is already determined as disabled by the Social Security Administration). 
(2)   The individual needs to meet financial criteria (133% of Federal Poverty Level, e.g., less than $1239/month for single person).  Here are the Federal Poverty Level (FPL) guidelines.  Assets are not counted. 
 
The next type is MassHealth CommonHealth.
MassHealth CommonHealth also gives 100% Coverage. The main difference between CommonHealth and Standard is the financial requirement.
(1)   A person needs to be determined as “disabled” (determined by UMASS Medical, unless the person is already determined as disabled by the Social Security Administration). 
(2)   The household can have income above the FPL; in fact, there is no income limit.  Assets not counted.  This means that it may be easier to qualify for this program; however, there is an extra step if your household is over the income limit.
There are 2 ways to qualify for MassHealth CommonHealth if you’re over the income limit – you pay a one-time deductible, or you show that you’re working at least 10 hours per week.
A.    The One-time Deductible Way.  The one-time deductible way requires that a household that is “over income” to pay a deductible before MassHealth CommonHealth will be approved.  The deductible must be met by out-of-pocket expenses paid by the household for medically necessary items (co-pays for premiums, pharmacy supplies, wheelchair costs, ramp or home modifications, and so on.), and paid within a certain time period. This is how they calculate the deductible:
 
 
B.     The Working-10-Hour way.  Regulations for MassHealth state (see page 10 in booklet) that, if a disabled applicant is currently working 10 hours per week, then this will qualify him/her for MassHealth CommonHealth without that person having to pay the one-time deductible.   A “working 10 hour letter” would need to be submitted with the application (or soon thereafter). The letter needs to be written by the disabled person’s employer and must include, at a minimum, these 3 important information pieces:  disabled person’s name and SSN, number of hours per week worked (must be at least 10 hours/week), rate of pay (must be at least $1.00 per hour), and letter must include the type of work performed.  The letter must be signed by the employer and include employer’s phone number.
 
The final type is MassHealth Long Term Care (LTC).
MassHealth LTC also provides 100% coverage, but is intended for people who need long-term care (meaning more than 6 months) in a nursing facility or other institution.   If a person is going to need care, but is expected to be back in the community within 6 months, MassHealth Standard or MassHealth CommonHealth application may be more appropriate.
A big difference between LTC and Standard/CommonHealth – is that assets ARE counted in this program. A person cannot have more than $2,000 in assets (life insurance, savings, 401K, etc.).  Also, the person’s monthly income is used to pay the nursing home (“patient paid amount”, PPA).  A person needs to liquidate assets and spend-down assets on medical care before MassHealth will approve payment for any services. 
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MASSHEALTH FOR PERSONS AGE 65 AND OLDER or PERSONS (of any age) NEEDING LONG TERM CARE
 
When a person is age 65 or older (or if a person of any age needs Long Term Care in an institution such as a nursing home for a time period greater than 6 months), then the rules of eligibility change in order to receive MassHealth.
The biggest differences (as compared to the under age 65 category) are the fact that income rules are stricter (based upon 100% of the Federal Poverty Level (FPL), instead of 133% of FPL) AND assets are now counted:  an applicant must have less than $2000 in assets such as life insurance, 401K, savings, checking, bonds, annuities, etc.)
There are two programs that apply for persons with disabilities who are 65 years or older and who are going to live ‘in the community’ (e.g., at home):
(1)   MassHealth Standard / Home and Community Based Waiver
(2)   MassHealth Long Term Care (LTC)
Here is the application form for those who are 65 or older.
 
The first type is MassHealth Standard.
For MassHealth Standard, the guidelines are stricter (than if you’re under 65). You must meet the following requirements:
(1)   Must have income that is less than 100% of FPL (Link to Chart) 
(2)   Have assets no more than $2,000. 
For example, a single person would need to have less than $931 per month. If income is more than $931 per month, then the person will not qualify unless that person does a spend-down every six months.  The spend-down is calculated as the income difference from $532. 
In other words, if the single person receives $1000 in income, then the spend-down would be $1000 – $532 = $468 x 6 (months) = $2808.  This means that, in any one six-month period, the individual has to spend $2808 on medical expenses out-of-pocket, and then MassHealth will be approved for the rest of that six-month period.
Income and assets are based on household income and household assets.  Therefore, if the disabled person is married and there are shared assets and income, then the MassHealth, as described above, would only be approved when the household has little to no financial resources remaining.  What would often happen in the past is that the disabled person would need to go into a nursing home because he/she was unable to obtain MassHealth and he/she required the services of MassHealth in order to stay at home.  The costs of maintaining that person at home, without the MassHealth coverage, were prohibitive.
Approximately ten years ago, a program called the Home and Community Based Waiver was developed.  This program is for persons who are disabled, 65 years of age or older, who need MassHealth services in the community and who would otherwise be at risk for a nursing home without such services.  This program allows for:
(1)   The disabled person to have monthly income up to $2094 (instead of $931).  It also allows for the legitimate transfer of assets of the disabled person to a family member so that assets for the disabled person are less than $2000.
(2)   If a disabled person is married, the Waiver allows for the non-disabled spouse’s income to be ignored, and allows for transfer of assets to the non-disabled spouse without hesitation.  These two important facets of the Waiver create an opportunity for the disabled member to receive MassHealth Standard, thereby enabling the disabled person to receive necessary MassHealth services (such as a Personal Care Attendant) which enable that member to remain in their home as opposed to going to a nursing home.
In order to qualify for the Home and Community Based Services Waiver the disabled person must be deemed “at risk” for nursing home care.  Therefore, a nurse from Elder Services must perform an evaluation of the disabled member, attesting to the severity of the disability.   Here is a link to the Aging Service Access Points through Massachusetts. It is highly recommended that a disabled person seek the counsel of an Elder Law Attorney when there are assets, income and disability.
From the moment that the person is approved for the Waiver, a 5-year “look-back period” begins.  That is to say, if at any time along the next 5-year period, the disabled person needs to go into a nursing home for Long Term Care, then any assets that were previously transferred are now mandated to be used for LTC.  Then, in this case, the MassHealth approval is retracted until the person’s assets are spent down to below $2,000.
 
The second type is MassHealth LTC
MassHealth LTC is the type of MassHealth that a person may need who will be living in a nursing home (for a period greater than 6 months) and who is age 65 or older.  To be eligible for this coverage, a person must have less than $2,000 in assets.  A person’s income will be paid to the nursing home as the Patient Paid Amount to offset costs of care.  If the person has a spouse, then the spouse living at home may keep $109,000 of the jointly owned assets.
To learn about LTC, you will need to read the booklet:  MassHealth and You, A Guide for Seniors and for Persons of Any Age Needing Long-Term-Care Services