Massachusetts Medicaid / MassHealth Long Term Care Programs, Benefits & Eligibility Requirements

Summary
Medicaid is a joint federal and state program, so its rules, coverage plans and even its name all vary by state. This article focuses on Massachusetts Medicaid Long Term Care for seniors. This is different from regular Medicaid, which is for low-income people of all ages. In Massachusetts, Medicaid is called MassHealth and it is administered by the Executive Office of Health and Human Services. Massachusetts residents can receive long term care benefits through Medicaid in a nursing home, their own home, the home of a relative or caregiver, an adult foster care home or in congregate (shared) housing through one of three programs – Nursing Home / Institutional Medicaid, Home and Community Based Service (HCBS) Waivers or Aged Blind and Disabled (ABD) Medicaid.

Massachusetts Medicaid Long Term Care Programs

Nursing Home / Institutional Medicaid

Massachusetts Medicaid, which is called MassHealth, will cover the cost of long term care in a nursing home for eligible Massachusetts residents who require a Nursing Facility Level of Care. Nursing home coverage includes payment for room and board, as well as all necessary medical and non-medical goods and services. These can include skilled nursing care, physician’s visits, prescription medication, medication management, mental health counseling, social activities and assistance with the Activities of Daily Living (eating, bathing, moving, dressing, toileting).

Some of the things that MassHealth (Massachusetts Medicaid) won’t cover in a nursing home are a private room, specialized food, comfort items not considered routine (tobacco, sweets and cosmetics, for example), personal reading items, plants, flowers, and any care services not considered medically necessary.

Nursing Home Medicaid is an entitlement. This means that eligible Massachusetts residents who apply are guaranteed by law, aka “entitled,” to receive Nursing Home Medicaid benefits once their application has been approved.

Any MassHealth beneficiary who receives nursing home coverage must give most of their income to the state to help pay for the cost of the nursing home. They are only allowed to keep a “personal needs allowance” of $72.80 / month, as of 2023. This can be spent on personal items such as clothes, snacks, books, etc.

Home and Community Based Service (HCBS) Waivers

Home and Community Based Service (HCBS) Waivers will pay for long term care services and supports that help MassHealth (Massachusetts Medicaid) recipients who require a Nursing Facility Level of Care, but choose to remain living “in the community” instead of moving to a nursing home. The word “waiver” means something like voucher in this instance. Think of it as a voucher that will pay for long term care services for Massachusetts residents who live in their own home, the home of a loved one, an adult care home (adult foster care) or an assisted living residence.

Unlike Nursing Home Medicaid, Massachusetts HCBS Waivers are not an entitlement. Remember, entitlement means guaranteed by law. So, even if an applicant is eligible for an HCBS Waiver program in Massachusetts, they are not guaranteed by law to receive the benefits. Instead, there are a limited number of enrollment spots. Once those spots are full, additional eligible applicants will be placed on a waiting list.

Massachusetts residents can receive HCBS Waiver benefits through the Frail Elder Home & Community Based Services Waiver.

Frail Elder Home & Community Based Services Waiver (FEW)
Massachusetts’s Frail Elder Home & Community Based Services Waiver (FEW) provides long term care benefits to Massachusetts residents who require a Nursing Facility Level of Care but instead live in their own home, the home of a loved one, an adult care home (adult foster care) or an assisted living residence. While FEW will cover long term care services and supports in those settings, it will not cover room and board costs.

FEW benefits include supervision, meal delivery, home modifications, housekeeping, Personal Emergency Response Services and personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting). These benefits will be provided depending on the needs and circumstances of each individual.

FEW program participants also have the option of enrolling in MassHealth’s Senior Care Options (SCO), which uses one managed care plan to deliver all benefits – medical care, FEW benefits, behavioral healthcare, prescription medication, lab work, dental, vision, etc. FEW program participants who are also eligible for Medicare (dual eligible) can receive both their Medicaid and Medicare benefits through the SCO plan, although SCO applicants are not required to be Medicare eligible.

FEW has a limited number of enrollment sports (19,200 per year as of 2022). Once those spots are full, additional eligible applicants will be placed on a waiting list.

Aged Blind and Disabled Medicaid

Massachusetts’s Aged Blind and Disabled (ABD) Medicaid (which is also known as MassHealth Standard in Massachusetts) provides healthcare and personal service benefits to low-income Massachusetts residents who are aged (age 65+) or disabled and live in the community. ABD Medicaid can sometimes be referred to as regular Medicaid for seniors, but it should not be confused with the regular Medicaid that is available for low-income people of all ages.

ABD Medicaid is an entitlement, which means that anyone who meets the requirements is guaranteed by law to receive the benefits without any wait.

In addition to medical care, MassHealth Standard can also provide non-medical long term care services and supports. Massachusetts Medicaid beneficiaries can receive these long term care benefits through a variety of programs:

• Adult Day Health (ADH) Program – provides nursing-home level care at adult day care centers across the state
• Personal Care Attendant (PCA) Program – pays for a part-time, in-home caregiver of the beneficiary’s choosing
• Adult Foster Care (AFC) Program – pays for a live-in caregiver in a private home
• Group Adult Foster Care (GAFC) Program – covers long term care in congregate living settings
• Senior Care Options (SCO) Program – coordinates care into a single Medicaid plan
• Program of All-Inclusive Care for the Elderly (PACE) – coordinates Medicaid and Medicare benefits into a single plan for dual-eligible applicants

Adult Day Health (ADH) Program
Massachusetts’ Adult Day Health (ADH) Program provides daytime care and supervision in adult day care centers to MassHealth Standard beneficiaries with long term care needs. ADH applicants are not required to need a Nursing Facility Level of Care, but they must need help with at least one of the Activities of Daily Living (mobility, bathing, dressing, eating, toileting) and/or require a skilled nursing service. Skilled nursing services can include intravenous feeding, jejunostomy feeding and regular oxygen administration. Behaviors that can be typical in people with Alzheimer’s disease and other related dementias (wandering, inappropriate language, physical abuse) may also meet the criteria of requiring a skilled nursing service, and some of the ADH day care centers have staff trained in Alzheimer’s / dementia care.

Adult Day Health (ADH) Program beneficiaries can live at home, the home of a relative, an adult foster care home or an assisted living residence. In addition to daytime supervision and required skilled nursing services, ADH benefits can also include case management, medication administration, therapies (physical, occupation, speech), transportation to and from the center and personal care assistance with the Activities of Daily Living, depending on the needs and circumstances of the individual and the capabilities of the adult day care facility.

The ADH Program, like MassHealth Standard itself, is an entitlement. This means that all eligible ADH applicants are guaranteed by law to receive benefits.

Personal Care Attendant (PCA) Program
Massachusetts’ Personal Care Attendant (PCA) Program will pay for up to 50 hours / week of in-home care and supervision for MassHealth Standard (Massachusetts ABD Medicaid) beneficiaries who live in their own home or the home of a loved one and require hands-on assistance with two of the seven following activities: mobility, bathing, dressing, eating, toileting, taking medication and passive range of motion exercises. In Massachusetts, a functional assessment is done by an occupational therapist or skilled nurse and signed by the applicant’s physician to determine if that level of assistance is required.

MassHealth Standard beneficiaries interested in the PCA program can contact a local personal care management agency to schedule an assessment. This assessment will also determine the number of hours of care the PCA Program will cover and which benefits will be offered. Available benefits include transportation, help with paperwork relevant to PCA services, and personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting) as well as essential household tasks (cooking, cleaning, laundry, shopping), medication administration and transportation to medical appointments.

Personal Care Attendant (PCA) Program participants can self-direct their care by choosing their own caregiver. This can include friends and certain relatives, like adult children and grandchildren, but not the beneficiary’s spouse. Program participants who are not capable of self-directing their own care can choose a surrogate to help manage their care. The surrogate can by anyone the PCA Program participant wants, including their spouse, but just not the person they hire as a caregiver. The state will provide a financial services company to manage some of financial aspects of being an employer, such as withholding taxes and issuing paychecks.

The PCA Program, like MassHealth Standard itself, is an entitlement. This means that all eligible PCA applicants are guaranteed by law to receive benefits.

Adult Foster Care (AFC) Program
Massachusetts’ Adult Foster Care (AFC) Program, which is also called Enhanced Adult Foster Care and the Adult Family Care Program, pays for a live-in caregiver who provides around-the-clock supervision, personal care and homemaker services for the MassHealth Standard (Massachusetts ABD Medicaid) beneficiary. AFC Program participants must live in a private home and need help with at least one of the Activities of Daily Living (mobility, bathing, dressing, eating, toileting). Behaviors that are common with Alzheimer’s disease and other related dementias (wandering, resisting care, being disruptive or abusive) are also taken into consideration when it comes to functional criteria for AFC Program eligibility.

The live-in caregiver for the Adult Foster Care (AFC) Program participant can be a friend or family member, such as an adult child, grandchild, niece, nephew or sibling, but the caregiver can not be program participant’s spouse. The caregiver can live in the home of the program participant, or the program participant can move into the home of the caregiver, and up to three AFC Program participants can reside in one home.

AFC Program benefits include nursing oversight provided by a registered nurse, maintenance of wheelchairs and other adaptive equipment, and paying the live-in caregiver to provide 24-hour supervision, housekeeping, transportation, medication management, and personal care help with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting). While the AFC Program will pay for these benefits in a private home, it will not pay for the costs of living in the home (mortgage, rent, etc.) or food expenses.

The Adult Foster Care (AFC) Program, like MassHealth Standard itself, is an entitlement. This means that all eligible AFC Program applicants are guaranteed by law to receive benefits.

MassHealth Standard beneficiaries interested in the AFC Program should contact an adult foster care provider agency to complete and submit the MassHealth Adult Foster Care Primary Care Provider Order Form.

Group Adult Foster Care (GAFC) Program
Massachusetts’ Group Adult Foster Care (GAFC) Program provides long term care services and supports in group living settings for MassHealth Standard (Massachusetts ABD Medicaid) beneficiaries who are at risk of nursing home placement and need help with at least one of the Activities of Daily Living (mobility, bathing, dressing, eating, toileting). The group living setting may be an assisted living residence or subsidized group housing that is approved by MassHealth to provide GAFC Program benefits. Massachusetts uses the Minimum Data Set Version 2.0 form to conduct an assessment of the GAFC Program applicant and determine if the level of care requirement is met. This assessment also takes conditions commonly associated with Alzheimer’s disease and related dementias into consideration. To initiate this assessment, MassHealth Standard beneficiaries can contact Coastline Elderly Services at 508-999-6400 or 866-274-1643.

GAFC Program benefits include nursing oversight from skilled nurses, care management, 24/7 on-call access, transportation, medication management, meal prep, shopping, housekeeping and personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting). As mentioned above, the GAFC Program will pay for these services in an assisted living residence or subsidized group housing, but it will not cover the cost of room and board in those settings. However, there is a program called SSI-G (Supplemental Security Income – Category G) that provides funds to help cover the cost of GAFC room and board for low-income individuals.

The GAFC Program is an entitlement, which means that all eligible AFC Program applicants are guaranteed by law to receive benefits. However, there must be an available space (bed) in an assisted living residence or subsidized group housing that is approved by MassHealth to provide GAFC Program benefits for the applicant to enter the program.

Senior Care Options (SCO) Program
Through the Senior Care Options (SCO) Program, MassHealth Standard (Massachusetts ABD Medicaid) beneficiaries can receive all of their long term care services and supports, medical care, lab work, prescription drug coverage and behavioral health services through a single Medicaid plan provided by a managed care organization. These organizations, which are referred to as senior care organizations, are specifically designed for the SCO Program and have a network of care providers (including primary care providers) that will deliver all necessary services. SCO Program participants can choose from a variety of senior care organizations, although the SCO Program is not currently available in Dukes and Nantucket Counties. Program participants who are also eligible for Medicare can receive those benefits through the senior care organization, although SCO Program participants are not required to be enrolled in Medicare.

SCO Program participants can live at home, the home of a loved one, an assisted living residence or an adult foster care home. While the SCO Program will pay for benefits in those settings, it will not pay for room and board. In addition to care coordination and management, SCO Program benefits include 24/7 nurse phone line, adult day care, acupuncture, dental/hearing/vision and podiatry services, medical equipment, Personal Emergency Response Systems, hospice care, housekeeping assistance, transportation and personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting).

The Senior Care Options (SCO) Program is available to MassHealth Standard beneficiaries of all functional abilities, but they must need some functional help to receive long term care services and supports.

Program of All-Inclusive Care for the Elderly (PACE)
Massachusetts residents who are age 55 or older and have ABD Medicaid can coordinate their medical, social service and non-medical personal needs into one comprehensive plan and delivery system using the Program of All-Inclusive Care for the Elderly (PACE). PACE program participants are required to need a Nursing Facility Level of Care, but they must live in the community. Massachusetts’s PACE programs can be used by people who are “dual eligible” for Medicaid and Medicare, and it will coordinate the care and benefits from those two programs into one plan. PACE also administers vision and dental care, and PACE day centers provide meals, social activities, exercise programs and regular health checkups and services to program participants. Massachusetts’ PACE programs are located in Boston (Upham’s PLACE), East Boston (Neighborhood PACE), Cambridge (CHA PACE), Dorchester (Harbor Health Services), Lynn (Element Care), Worcester (Summit ElderCare), Holoyoke (Mercy LIFE MA) and Springfield (Serenity Care). More.

Eligibility Criteria For Massachusetts Medicaid’s Long Term Care Programs

To be eligible for Massachusetts Medicaid, which is called MassHealth, a person has to meet certain financial requirements and functional (medical) requirements. The financial requirements vary by the applicant’s marital status, if their spouse is also applying for Medicaid, and what program they are applying for – Nursing Home / Institutional Medicaid, Home and Community Based Service (HCBS) Waivers or Aged Blind and Disabled (ABD) Medicaid, which is also called MassHealth Standard in Massachusetts.

MassHealth Nursing Home Medicaid Eligibility Criteria

Financial Requirements
Massachusetts residents have to meet an asset limit and an income limit in order to be financially eligible for nursing home coverage through MassHealth (Massachusetts Medicaid). For a single applicant in 2023, the asset limit is $2,000, which means they must have $2,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the red box below for more details), and there are other non-countable assets like funeral trusts and Medicaid-approved annuities. The 2023 income limit for a single applicant is $1,215 / month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc. COVID-19 stimulus checks and Holocaust restitution payments are not considered income. However, MassHealth beneficiaries who reside in nursing homes are only allowed to keep $72.80 / month of their income as a “personal needs allowance” and must give the state the rest to help offset nursing home costs.

For married applicants with both spouses applying, the 2023 asset limit for nursing home coverage through MassHealth (Massachusetts Medicaid) is $3,000 combined, and the income limit is $1,643 / month combined. For a married applicant with just one spouse applying, the 2023 asset limit is $2,000 for the applicant spouse and $148,620 for the non-applicant spouse, and the income limit is $1,215 / month for the applicant. The income of the non-applicant spouse is not counted.

MassHealth applicants are not allowed to give away their assets in order to get under the asset limit. To make sure they don’t, Massachusetts has a “look-back” period of five years. This means the state will look back into the previous five years of the applicant’s financial records to make sure they have not given away assets.

Functional Requirements
The functional, or medical, criteria for nursing home coverage through MassHealth (Massachusetts Medicaid) is needing a Nursing Facility Level of Care (NFLOC), which means the applicant requires the kind of full-time care that can only be provided in a nursing home. To determine if this level of care is needed for Medicaid purposes, Massachusetts uses the Comprehensive Data Set, which takes into consideration the applicant’s cognitive functioning as well as their ability to complete the Activities of Daily Living (mobility, bathing, dressing, eating, toileting).

Massachusetts Home and Community Based Service (HCBS) Waivers Eligibility Criteria

Financial Requirements
Massachusetts residents have to meet an asset limit and an income limit in order to be financially eligible for Home and Community Based Service (HCBS) Waivers. In Massachusetts, the HCBS Waiver is called is called the Frail Elder Home & Community Based Services Waiver (FEW). For a single applicant in 2023, the asset limit for the HCBS Waiver in Massachusetts is $2,000, which means they must have $2,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the red box below for more details), and there are other non-countable assets like funeral trusts and Medicaid-approved annuities. The 2023 income limit for a single applicant is $2,742 / month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc. COVID-19 stimulus checks and Holocaust restitution payments are not considered income.

For married applicants with both spouses applying, the 2023 asset limit for HCBS Waivers in Massachusetts is $3,000 combined, and the income limit is $2,742 / month per spouse, for a total of $5,046 / month combined. For a married applicant with just one spouse applying, the 2023 asset limit is $2,000 for the applicant spouse and $148,620 for the non-applicant spouse, and the income limit is $2,742 / month for the applicant. The income of the non-applicant spouse is not counted.

MassHealth applicants are not allowed to give away their assets in order to get under the asset limit. To make sure they don’t, Massachusetts has a “look-back” period of five years. This means the state will look back into the previous five years of the applicant’s financial records to make sure they have not given away assets.

Functional Requirements
The functional, or medical, criteria for Home and Community Based Service (HCBS) Waivers through MassHealth (Massachusetts Medicaid) is needing a Nursing Facility Level of Care (NFLOC), which means the applicant requires the kind of full-time care that can only be provided in a nursing home. To determine if this level of care is needed, Massachusetts uses the Comprehensive Data Set, which takes into consideration the applicant’s cognitive functioning as well as their ability to complete the Activities of Daily Living (mobility, bathing, dressing, eating, toileting).

Massachusetts Aged Blind and Disabled Medicaid Eligibility Criteria

Financial Requirements
Massachusetts residents have to meet an asset limit and an income limit in order to be financially eligible for Aged Blind and Disabled (ABD) Medicaid, which is also called MassHealth Standard in Massachusetts. For a single applicant in 2023, the asset limit is $2,000, which means they must have $2,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the red box below for more details), and there are other non-countable assets like funeral trusts and Medicaid-approved annuities. The 2023 income limit for a single applicant is $1,215 / month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc. COVID-19 stimulus checks and Holocaust restitution payments are not considered income.

For married applicants, the 2023 asset limit for MassHealth Standard is $3,000 combined between the two applicants/spouses, and the income limit is a combined $1,643 / month combined. These limits are used for both married couples with both spouses applying for MassHealth Standard and married couples with only one spouse applying.

While Massachusetts has a “look-back” period of five years for Nursing Home Medicaid and Home and Community Based Service Waivers applicants to make sure they don’t give away their assets to get under the limit, there is no “look-back” period for ABD Medicaid/MassHealth Standard applicants. However, MassHealth Standard applicants should be cautious about giving away their assets. They might eventually need Nursing Home Medicaid, or an HCBS Waiver, and those programs will deny or penalize the applicant for giving away assets.

Functional Requirements
The functional requirements for Massachusetts Aged Blind and Disabled (ABD) Medicaid, which is also called MassHealth Standard, are being disabled, blind or aged (65 or over). MassHealth (Massachusetts Medicaid) will conduct an assessment of ABD Medicaid applicants and their ability to perform Activities of Daily Living (mobility, bathing, dressing, eating, toileting) to determine the kind of long term care services the beneficiary needs and the state will cover.

Applying For Massachusetts Medicaid Long Term Care Programs

The first step in applying for MassHealth (Massachusetts Medicaid) Long Term Care coverage is deciding which of the three coverages discussed above you or your loved one wants to apply for – nursing home, Home and Community Based Service (HCBS) Waivers or Aged Blind and Disabled (ABD) Medicaid, which is also called MassHealth Standard.

The second step is determining if the applicant meets the financial and functional criteria, also discussed above, for that Long Term Care program. Applying for MassHealth when not financially eligible will result in the application, and benefits, being denied.

During the process of determining financial eligibility, it’s important to start gathering documentation that clearly details the financial situation for the MassHealth applicant. These documents will be needed for the official Medicaid application. Necessary documents include five years of quarterly bank statements from all accounts; the most recent monthly or quarterly statements from all investments, IRAs, 401Ks, annuities and any other financial accounts; a letter from the Social Security Administration showing the applicant’s gross Social security income and deductions; tax forms to verify income streams including wages, pensions, royalties and interest; lists of items of any trusts; proof life insurance (if the applicant has any) and a list of beneficiaries; Power of Attorney documentation.

After financial eligibility requirements are checked and double checked, documentation is gathered, and functional eligibility is clarified, Massachusetts residents can apply for Medicaid by downloading this “Application for Health Coverage for Seniors and People Needing Long-Term Care Services” and mailing it to the MassHealth Enrollment Center, Central Processing Unit, P.O. Box 290794, Charlestown, MA, 02129, or by faxing it to the MassHealth Enrollment Center at 617-887-8799. Individuals can also drop off their completed applications at the MassHealth Enrollment Center at The Schrafft Center, 529 Main Street, Suite 1M, in Charlestown. Massachusetts residents can also apply in person at any of these six enrollment centers.

Choosing a Massachusetts Medicaid Nursing Home

After an applicant has been approved for nursing home coverage through MassHealth (Massachusetts Medicaid), they need to choose which Medicaid-approved nursing home they will live in. Even though Medicaid nursing home coverage is an entitlement, MassHealth will only cover stays and care in approved nursing homes. Massachusetts residents can find and compare nursing homes in their area using this state Health and Human Services webpage, or by using Nursing Home Compare, which is a federal government website that has information about more than 15,000 nursing homes across the country. All of the nursing homes on this site are either Medicaid- or Medicare-approved.