Seniors – or people of any age – may find that their financial resources aren’t sufficient when they need an extended hospital stay or long-term care, and other avenues may need to be pursued. If income, assets, and long-term care insurance have been depleted, Medicaid/MassHealth can help those with limited resources in Massachusetts if an individual meets financial and other qualifying criteria.
Who does Medicaid/MassHealth help?
- Adults with a low income
- Children
- People who are pregnant
- People age 65 or over
- People with disabilities
What does Medicaid/MassHealth cover?
MassHealth pays for routine and acute health care services and for long-term care. Once an individual meets qualification requirements, the following levels of care may be covered, for varying lengths of preauthorized stays, as long as the facility is a state-contracted Medicaid provider.
- Inpatient and outpatient hospital services
- Acute health care
- Long-term care (skilled nursing facility, home health services)
- Physical, respiratory, and occupational therapy
See a complete list of covered care services here.
Qualifying for Medicaid/MassHealth – an overview
Medicaid is a joint federal and state medical assistance program based on financial need administered in Massachusetts by the Division of Medical Assistance. To qualify, an individual may have no more than $2,000 in assets. The individual must be assessed and determined to need extended hospital care or long-term care services provided in a nursing home setting. The individual must have at least one nursing need and two additional nursing or Activity-of-Daily Living (ADL) needs.
For an individual applicant, a house and/or a vehicle are countable assets. MassHealth will give them up to 9 months to sell these assets if no one lives in the house. ON OCCASION, MassHealth will also allow them to keep the car. Still, they need to provide a letter of reasoning why the vehicle is necessary, i.e.: they take mom/dad out of the nursing home for family events, day trips, or to outside doctor appointments.
In the case of a married couple in Massachusetts – with a spouse still living in the community— the spouse may keep ALL assets up to the limit of $154,100 for 2024. (This is expected to increase in 2025 as it does annually.). If the spouse has OVER the $154,100 asset limit, there are options for spending this down and protecting the assets as income for the spouse through an SPIA annuity.
Applying for MassHealth
Mass.gov has an easy-to-use website with information to guide you through the application process. The application can be completed and submitted online, by mail, fax, or in person. To apply, you may need to provide the following information and documents:
- Your name and date of birth
- Social Security numbers, if you have them, for every household member who is applying
- Your monthly payment amounts for rent, mortgage, or utilities
- Proof of citizenship or immigration status
- Proof of income, like paystubs or W-2s
- Proof of assets
- A verification of what other government benefits you receive
- Information about an insurance plan your employer has offered you or an insurance plan you are currently enrolled in or have access to
The American Council on Aging also has an excellent page with more detailed information on the steps to take when applying for Medicaid long-term care.
Four tips for the application process
At Whittier, our case managers, administrators, and consultants have helped guide many patients through the Medicaid application process for long-term care placement. Here they offer some tips and advice:
- Apply for Medicaid AFTER assets have been reduced below the limit
Because an individual may have no more than $2,000 in countable assets, money must be ‘spent down’ within 90 days before applying for MassHealth. The application should not be submitted until assets are below the limit. Be sure to include the completed Authorized Representative Designation and Permission to Share Information forms with the application so that MassHealth will continue communicating with you throughout the application process.
Maria Tilton, regional bookkeeper for Whittier Health Network, says: “One thing to keep in mind is that there can be no gifting or transferring of assets within the last five years. I have helped with MassHealth applications for years and always sit with families to explain and provide a list of all documents needed. There are many different case scenarios, so I always refer for any application that requires legal assistance.”
- Expect to submit additional information within 3-4 weeks after the application is submitted
You may be asked for more detailed information about your finances, including financial statements, real estate deeds, etc., going back five years.
“Before the Medicaid application is even close to submission, gather all financial documentation possible. There is much more involved with your or your loved one’s assets, spending, accounts, etc., than you may realize. The more you have prepared, the quicker you can submit any requested information. This includes details (such as receipts) for larger purchases.” says Brook Griffin, administrator at Masconomet Healthcare Center.
- Be patient and expect that the entire process may take time
Medicaid applications can take time, sometimes up to six months, and may involve hearings and further requests for information if deemed necessary by Medicaid.
Darcia Tremblay, owner of Silver Linings Solutions, says, “It is not uncommon to be denied with the first application if you are submitting it on your own. Remember to always file a fair hearing request appeal on any denial notice to keep the current application active, protect the Medicaid start date, and resolve the outstanding issue with the MassHealth case worker.”
- Pay the estimated monthly Patient Paid Amount (PPA) to the skilled nursing facility while the application is pending
Even while the application is pending, the Medicaid applicant must pay an estimated monthly co-pay. This PPA is calculated by taking the individual’s monthly GROSS income (not the net amount), deducting any health insurance premiums, and deducting a $72.80 personal needs allowance. If there are any federal or state taxes deducted from a pension, MassHealth does not recognize those. Only health insurance and Medicare premiums are allowable income deductions in calculating the PPA, along with the $72.80 personal needs allowance.
Brook Griffin advises: “Be mindful of any spending during the Medicaid application process. The estimated PPA is usually very close to what Medicaid will determine as the amount owed to the facility. The funds must be available to the facility at the time of Medicaid approval, even retroactively, to when the application was filed.” For more advice on PPA, click here.
At Whittier, we are here to help!
If you are at a hospital or facility in Massachusetts and need help with extended care placement, contact one of our Whittier Health Network hospitals individually and ask for admissions. We’ll connect you with someone who can help guide you through the process.
- Whittier Rehabilitation Hospital-Bradford – Bradford, MA – (978) 372-8000
- Whittier Rehabilitation Hospital-Westborough – Westborough, MA – (508) 870-2222
- Whittier Bradford Transitional Care Unit – (978) 478-3888
- Whittier Westborough Transitional Care Unit – (508) 870-2222
Other helpful resources:
- Massachusetts Senior Care Association – Payment eligibility for Medicaid coverage
- Mass.gov – Long-term care application checklist (downloadable pdf)
- Medicaid Planning Assistance – Answers to all your questions about Medicaid long-term care
- Whittier Health Network – How to pick the best nursing home in Massachusetts
- Whittier Health Network – The difference between LTACHs, IRFs, and SNFs
