MassHealth / Medicaid Eligibility
When Will Medicaid (MassHealth) and Medicare Pay for Nursing Home Costs?
To be eligible for Medicare coverage, the benefit recipient must have had an inpatient hospital stay of three (3) consecutive days or more (including the day of in-patient admission, but excluding the day of discharge) and must enter a Skilled Nursing Facility (“SNF”) within thirty (30) days of leaving the hospital. The benefit recipient must need SNF care, which requires skills of professional personnel, such as occupational therapists, physical therapists, speech-language pathologists, registered nurses, and licensed nurse practitioners. The benefit recipient must receive the required skilled care daily. Medicare will provide coverage for up to 100 days, but coverage can and often does end before the 100 day period in situations such as, but not limited to: when the benefit recipient hasn’t been in a SNF or a hospital for at least sixty (60) consecutive days, the skilled care or therapy is rejected by the benefit recipient, or there is a lack of improvement as a result of the skilled care or therapy.
To be eligible for Medicaid in Massachusetts, known as “MassHealth,” applicants must live in Massachusetts and be both clinically and financially eligible. In general, those persons in a household with low to medium income and assets are financially eligible. Other factors that are considered for MassHealth financial eligibility include family size, living situation, and the type of coverage to be attained. In addition, the individual must fall into an eligible category, determined by age (some programs are only for persons aged 65 and older), family situation, work history, immigration status, and health care needs.
Clinical Eligibility Needs to be Met for Long-term Care in a Nursing Home or for MassHealth Home and Community Waiver Services and PACE
Having certain health care needs may establish medical eligibility for nursing-facility care, as well as Frail Elder Waiver under Home and Community Based Waiver Services, and Program of All-inclusive Care for the Elderly (PACE) . To qualify, the applicant must require one skilled service daily, or have a medical or mental condition that requires a combination of at least three services, including assistance with activities of daily living or nursing services. At least one of the three required services must be a nursing service.
Skilled services are health care services performed by or under the supervision of a registered nurse or therapist. This may include the administration or application of an IV, feeding tube, oxygen, sterile dressings, catheters, or physical, speech, or occupational therapy. Skilled services also cover any professional evaluations or observations that may be necessary under the patient’s care or treatment plan or in an institutional setting. Nursing services are performed at least three times per week and can incorporate any of the above-mentioned skilled services, as well as any assistance associated with positioning while in bed or a chair as part of a treatment plan, measurement of intake or output based on medical necessity, administration of medications, and intervention for certain types of behavior that are considered medically to be disruptive, abusive, or hazardous to one’s one health or to the safety of others. Assistance with activities of daily living encompasses all services that are required for the patient to live his or her daily life. These activities range from bathing, toileting, and eating to dressing, transferring from different locations or positions, and general mobility; assistance with activities of daily living are not covered by Medicare, but can be covered by Medicaid / MassHealth.
Eligibility for Medicaid (“MassHealth”) is based largely on income. To be eligible, an individual cannot have countable assets that are worth more than $2,000 and cannot have a home with equity of more than $858,000 in 2018 (adjusted annually). For married couples, the family cannot collectively have assets worth more than $123,600 and a home. With proper planning, however, some of these assets can be protected in order to make an individual eligible.
Don’t Wait Until You Run Out of Money — Experience the Value of Planning with an Experienced Attorney who Prepares MassHealth Applications for Long-term Care and Nursing Home Care
Planning on how to pay for a nursing home stay should happen as soon as possible. Planning should happen as soon as someone is admitted to a skilled rehabilitation facility or SNF, sometimes even when it is likely he or she will return home. It is important not to wait until Medicare coverage ends or when the applicant becomes MassHealth eligible after spending all of his or her money on nursing home care. To learn more about Medicaid / MassHealth benefits and planning in Massachusetts, call us at 1-800-701-0352 or contact us online to find out more about the personalized assistance with MassHealth applications for nursing homes, Medicare, and eligibility for other long term care planning services like Frail Elder Waiver and Program for All-inclusive Care for the Elderly (PACE) .
