Massachusetts Medicaid Long Term Care Eligibility
Massachusetts Long Term Care
Once recipients of MassHealth benefits are approved, their eligibility needs to be reevaluated annually. This means that documentation must be sent in once a year, with a re-approval process taking between one and three months.
Massachusetts has multiple long term care programs for disabled or elderly adults seeking long-term care:
Adult Day Care: This type of programs provides care for adults during daytime hours in a group setting. Adult day care is intended for frail seniors, adults with mental or physical disabilities, and others who need supervision. These programs include adult day health, social day care, supportive day care, and dementia day programs.
Home and Community-Based Waivers (HCBS): HCBS are programs for low-income Massachusetts residents who qualify for nursing home or other institutional level care, but prefer to remain at home. HCBS allow people to receive the care they need in their homes rather than in an institution. This is intended for people with disabilities, traumatic brain injuries, and eligible frail elders.
Home Care Program: This program exists to help seniors live in their own homes, independently. Seniors must meet income limits and show a medical need, but it is intended for those who do not need daily nursing care. Frail seniors who are medically eligible for nursing facility care should get a higher level of service from the Enhances Community Options Program (ECOP).
Adult Foster Care: Also called Adult Family Care or AFC, this is for elderly or disabled people who cannot live alone safely. AFC recipients live with trained caregivers who are able to provide the amount of daily care needed. Caregivers can be family members (except legally responsible guardians), non-family members, or paid caregivers.
Group Adult Foster Care (GAFC): GAFC pays for personal care services for eligible seniors or disabled adults who live in GAFC-approved housing. Residents must be eligible for MassHealth and need help with at least one activity of daily living such as bathing, dressing, or going to the bathroom.
Nursing Homes: Nursing homes provide long-term care to people who cannot live on their own. This is for people who are medically eligible because of physical, emotional, or mental disabilities. Nursing homes offer housing, meals, social activities, assistance with activities of daily living, and around the clock nursing services.
Home Care Assistance Program (HCAP): HCAP provides help with homemaking for adults with disabilities who are under the age of 60. Services generally include meal preparation, laundry, grocery shopping, and housekeeping. This program helps people with disabilities live on their own rather than going to a nursing home or other institution.
MassHealth Home Health: MassHealth will pay home health agencies to provide nursing; aides; and occupational, physical, and speech therapy to MassHealth members who need it. Home health level of care must be medically necessary and ordered by a doctor.
1. Residency and Citizenship – the applicant must be a Massachusetts resident and be a U.S. citizen or have proper immigration status.
2. Age/Disability – the applicant must be age 65 or older, or blind, or disabled. The applicant must meet certain medical requirements consistent with the level of care requested.
3. Income Limitations – if single, the applicant’s income (wages, Social Security benefits, pensions, veteran’s benefits, annuities, SSI payments, IRAs, etc.) must be less than $1,025 per month. If married, the income limitation increases to $1,374. If your income is too high for MassHealth limits you will have a deductible. The deductible is the amount of monthly income greater than the income limit over a six month period. It is your responsibility to pay the deductible as MassHealth will not pay for these medical bills. To meet the deductible you must have medical bills that are equal or greater than the amount of the deductible. Medical bills may be counted for both spouses if they are not covered by insurance. MassHealth has specific rules about meeting a deductible and for more information call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648).
- There is an income disregard for $73 of earned income (money made through working, either at a job or in your own business) with a further disregard of one half of all other earned income.
4. Asset Limitations (Exempt vs. Available) – Medicaid divides assets into two categories: Exempt and Available. Exempt assets are specifically designated under the rules, and ownership of an exempt asset by the applicant will not result in a denial of benefits. If an asset is not listed as exempt then it needs to be liquidated and applied toward the costs of nursing home care before the applicant can receive Medicaid benefits. Massachusetts has a look back period of 5 years with a penalty for people who sell assets below fair market price, transfer assets to others, or give money and property away.
Exempt Assets for an applicant in Massachusetts include:
i. $2,000 or less in cash/non-exempt assets if single; $3,000 if married. For home and community based waivers the asset limit is $2,000. MassHealth allows applicants to spend down their assets in accordance with their rules. See page 19 for spend down rules: Senior Guide to Health Care Coverage.
ii. Personal effects and household goods
iii. One home (equity value limited to $858,000) is exempt if you are receiving long term care at home, or a spouse, a child under 21, or a disabled person resides in it. The house can be transferred with no penalty to the spouse; a natural, adopted, or step child who is under 21, blind or disabled; a sibling who has equity interest in the home and lived with the institutionalized individual one year prior to institutionalization; another adult, who lived with the resident and provided care for at least two years thereby delaying institutionalization.
iv. One motor vehicle if the vehicle is used for the long term care recipient’s medical treatment, employment, modified to accommodate a disability, or the primary vehicle of the community spouse—no matter the value.
v. Burial spaces and funeral expense funds up to $1,500 in separate, identifiable accounts. An irrevocable burial trust or prepaid irrevocable burial contract set up for future payment funeral or burial expenses is also exempt.
vi. Life insurance policies for both spouses if the total face value for each is $1,500 or less.
Amount of assets community spouse may retain: The community spouse can keep non-exempt resources owned by one or both spouses with a maximum of $128,640. Also, actuarially sound annuities are permitted for community spouses.
Community spouse impoverishment protection: The community spouse can keep part of the institutionalized spouse’s income if the community spouse has an income of less than $2,113.75 per month. If the spouse can document high shelter expenses (rent, utilities, phone, etc.) then the income limit may be raised to a maximum of $3,216.00.
- There is a personal needs allowance of $73.00/month for the spouse receiving institutional care which is not figured into the total countable income.
Massachusetts long term care insurance partnership:
This is a program between the state and private insurance companies. Partnership policies protect assets by matching dollar for dollar what policy holders pay into their policies. For example, if you bought a Partnership Policy with a maximum benefit payout of $155,000 then you are able to protect $155,000 of your assets. For married couples each spouse needs to purchase their own policy. Once the $155,000 worth of long term care coverage is used, you may apply for Medicaid with $155,000 worth of assets exempted.