MassHealth / Medicaid and
To be eligible for Medicare coverage of nursing home costs, there are many requirements that must be satisfied.
- 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 have entered 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 certain 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 / 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.
Medicaid Financial Eligibility
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 $893,000 in 2020 (adjusted annually). For married couples, the family cannot collectively have assets worth more than $128,640 (2020) and a home. With proper planning, however, some of these assets can be protected in order to make an individual eligible.
Medicaid Clinical Eligibility
Qualify for Medicaid Nursing Home Care, MassHealth Home, Community Waiver Services and PACE
Having certain health care needs may establish medical eligibility for nursing-facility care, as well as other programs including the 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.
Daily Living Services
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.
Plan Ahead for Medicaid Spend Down
Planning on how to pay for a nursing home stay should happen as soon as possible.
If not in advance, contact us as soon as someone is admitted to a skilled nursing or rehabilitation facility, 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 (Medicaid spend down).