Healthcare coverage can be confusing, especially when terms like MassHealth and Medicaid seem to overlap but have distinct differences. At Casey Lundregan Burns, P.C., we understand the challenges Massachusetts residents face in sorting out these programs.
For three generations, our firm has helped individuals and families with estate planning, elder law, and healthcare coverage, including programs like MassHealth and Medicaid.
Today, we aim to clarify the similarities and differences between the two, ensuring you are informed and prepared to make the right decisions for your healthcare needs.
What Are Medicaid and MassHealth?
Medicaid is a joint federal and state program designed to provide healthcare coverage to individuals and families with limited income and resources.
Each state administers its Medicaid program under federal guidelines, giving states the ability to tailor certain aspects of eligibility and coverage.
In Massachusetts, Medicaid is referred to as MassHealth. This program offers a range of healthcare services, including medical care, prescriptions, long-term care, and support for individuals with disabilities.
However, the name MassHealth reflects the specific rules and regulations Massachusetts follows under the broader Medicaid umbrella. These include guidelines from federal laws like 42 U.S.C. §§ 1396 et seq. and state laws such as MGL c. 118E.
Differences Between Medicaid and MassHealth
While MassHealth operates under the Medicaid program, there are important differences in how eligibility, coverage, and processes are applied in Massachusetts compared to other states.
Income Limits
One of the key factors in qualifying for MassHealth is meeting income limits. Massachusetts uses a percentage of the Federal Poverty Level (FPL) to determine eligibility, with specific thresholds varying by group. For example:
- Adults aged 19–64: Income up to 138% of the Federal Poverty Level (FPL).
- Pregnant women: Income up to 200% of the FPL.
- Children under 19: Income up to 300% of the FPL.
These percentages often differ from other states’ Medicaid programs, making it important to check local guidelines.
Asset Limits
MassHealth also applies asset limits to certain groups, particularly those seeking long-term care coverage. For instance, individuals applying for nursing home care may be allowed up to $2,000 in countable assets, while married couples can retain higher amounts.
Coverage
MassHealth provides comprehensive coverage, including:
- Long-term care services like nursing home care.
- Community-based care for those who qualify.
- Transportation to medical appointments.
- Dental and vision services for eligible groups.
However, some states might exclude certain services, making Massachusetts’ program uniquely supportive in many areas.
Application Process
Applying for MassHealth requires completing detailed forms and providing documentation of income, assets, and medical needs.
Massachusetts also has additional requirements, such as verifying residency and compliance with federal guidelines. While the process can seem overwhelming, preparing all documents in advance can save time.
5-Year Look-Back Period
For those applying for long-term care under MassHealth, the 5-year look-back period is critical. This rule examines any gifts or transfers of assets made within five years of the application date.
If transfers are deemed improper, penalties may apply, delaying eligibility. The regulation governing this is outlined in 130 CMR 520.019(B), and careful planning can help mitigate potential issues.
Who Is Not Eligible for MassHealth?
Eligibility for MassHealth is restricted to those who meet specific income and asset criteria.
Individuals who exceed these limits, fail to meet residency requirements, or do not provide necessary documentation will not qualify.
MassHealth and Long-Term Care
MassHealth provides vital support for individuals needing long-term care, helping to cover the high costs of services like nursing home care and home- or community-based programs. These services are often essential for aging individuals or those with significant medical needs who require assistance with daily activities or medical supervision.
Planning for MassHealth eligibility well before the need for long-term care arises is critical.
The program enforces strict rules around income and assets, including the 5-year look-back period, which reviews financial transactions to ensure compliance with gifting and transfer regulations.
Without proper planning, applicants may face delays in eligibility or penalties, potentially leaving families burdened with the costs of care.
Additionally, it is important to understand estate recovery, where MassHealth may seek reimbursement for benefits paid by making claims against the recipient’s estate after their passing.
Recent changes to Massachusetts law (MGL c. 118E § 31) aim to clarify and streamline this process, but the implications remain significant for families.
Notable cases like Guilfoil v. Secretary of Health and Human Services and In the Matter of the Estate of Frances R. Mason highlight the importance of proactively addressing estate recovery during the planning process.
MassHealth vs. Medicare
Although MassHealth and Medicare are both essential healthcare programs, they serve different purposes and cater to distinct groups. Medicare is a federal health insurance program designed primarily for:
- Individuals aged 65 and older.
- People with certain disabilities.
- Those with end-stage renal disease requiring specialized care.
Unlike MassHealth, Medicare eligibility is not influenced by income or asset limits. Instead, it is based on age, disability status, or specific medical conditions, making it accessible to a broader group without financial criteria.
For individuals who qualify for both programs, known as “dual eligibility,” MassHealth plays an important role in supplementing Medicare coverage. This means MassHealth can help cover costs Medicare does not, such as copayments, deductibles, and services like long-term care.
Dual eligibility allows individuals to receive more comprehensive healthcare coverage, reducing out-of-pocket expenses and ensuring access to necessary care.
Understanding how these programs work together can make a significant difference for those managing both financial and medical concerns.
MassHealth and the Affordable Care Act
MassHealth is closely tied to the Affordable Care Act (ACA), commonly known as Obamacare.
Massachusetts’ healthcare system, known for its comprehensive approach to providing coverage for low-income residents, served as a blueprint for the ACA. The ACA expanded Medicaid programs nationwide, building on frameworks like MassHealth to improve access to essential healthcare services for millions of Americans.
Need Help with MassHealth Planning?
Understanding the differences between Medicaid and MassHealth is just one part of ensuring your healthcare needs are met. Planning for MassHealth eligibility and protecting your assets requires careful consideration.
At Casey Lundregan Burns, P.C., we can assist you with every aspect of MassHealth planning, from understanding eligibility requirements to preparing applications and safeguarding your assets.
Call us today at (978) 878-3519 or fill out our online contact form to schedule a consultation and learn how we can support you and your loved ones.
Disclaimer: The information in this post is not intended as legal advice or as a substitute for the particularized advice of counsel. For more information, please consult an attorney.