Nursing Homes and MassHealth – What You Should Know About Functional Eligibility Criteria

Nursing Homes and MassHealth – What You Should Know About Functional Eligibility Criteria

If you’re 65 or over and female, you have a 52% chance of needing a nursing home stay in your future, whether briefly or perhaps for the rest of your life. Men have a 33% chance.

Depending on your physical condition and financial situation, you may be able to qualify for MassHealth and Medicaid. Massachusetts uses federal Medicaid requirements as a guide to determine whether they will cover a nursing home stay.

Nursing homes are quite expensive, which is why it’s crucial to make an estate plan that maximizes your MassHealth eligibility—especially on the financial side because there’s a five-year prohibition on asset gifts or transfers before you can apply.

Functional Criteria for a Nursing Home Stay

In the Commonwealth of Massachusetts, a nursing home is defined as “A facility licensed by the Department of Public Health that is primarily engaged in providing nursing care and related services on an inpatient basis for short and long-term care stays at skilled, intermediate or custodial levels of care.”

Functional criteria for nursing home eligibility looks at how well an individual can or can not care for themself.

The federal government simply requires that your physician certifies your need for care in a skilled or intermediate nursing facility. Periodic recertifications are required depending on the length of your stay.

For the Commonwealth of Massachusetts to determine you need nursing home care, they look at whether you can adequately take care of yourself. This is referred to as “activities of daily living,” or ADLs. The patient must need help in at least two ADL areas as well as have either a medical need or a mental dysfunction.

According to the Massachusetts Long-Term Care Project guidelines, the care:

  1. must be needed “in accord with accepted standards of medical practice for the diagnosis and treatment for the insured’s condition”;
  2. are “delivered in the least intensive health care setting required by the insured’s condition when possible” and
  3. are “not solely for the convenience of the insured or the insured’s family or health care provider, except for respite care…”.

ADLs include bathing or showering, personal hygiene or grooming, dressing, using the toilet, functional mobility and feeding oneself.

“Medical dysfunction” for the purposes of MassHealth can include abusiveness, wandering, inability or unwillingness to perform hygienic tasks, or a diagnosed mental disorder.

Ultimately, your physician(s) will be able to advise you as to whether you meet the functional criteria to qualify for MassHealth long-term care.

MassHealth Eligibility Financial Caveats

Although you may qualify for MassHealth coverage medically or clinically, you may not qualify financially. Nursing home care is expensive, and MassHealth is designed for indigent citizens. You may not qualify for full coverage, however, in some circumstances you may simply be required to pay whatever MassHealth does not cover. It’s important to consult with an estate elder planning attorney to maximize your eligibility while preserving your assets and those of your spouse.

Contact Us

When you’re ready to plan for your long-term health needs, contact Baker Law Group, P.C. for assistance. We can help you strategize so that your assets are protected, and your health care needs will be provided for. View our Attorney Profiles. Also read about our services for Elder Law and Estate Planning.

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