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MassHealth (Medicaid) is what pays for nursing home and long-term care.  Applying for MassHealth can be a very time consuming process. Timing is critical in order to get coverage for the desired date. If you are financially eligible, you may go back for up to three months for retroactive coverage.

For a list of the documentation that you need to provide to us in order to prepare a MassHealth (Medicaid) Long-Term Care Application, Click Here

Frequently, entrance to a nursing begins after an elder has been hospitalized. If there is a three night stay in the hospital, the first part of the nursing home bill will be paid by Medicare. Medicare will pay for up to 100 days of nursing home care. Day 1 through 20 are paid in full and day 21 through day 100 are subject to a $164.50 per day co-payment. Many times other insurance, like Blue Cross Blue Shield/Medex will pay the co-payment. If you have a supplemental health insurance plan, you should call them and ask if they cover the skilled nursing home co-payment under Medicare. Medicare will pay for up to 100 days as long as the patient shows signs of improving. A steady or declining health status can immediately stop the Medicare benefits, at which time you either start privately paying or seek MassHealth (Medicaid) coverage.

If an elder enters a nursing home directly from home, they must either private pay or apply for MassHealth. If they have applied for MassHealth they are what we call, Medicaid pending. Although the nursing home may not bill for this period during which the application is pending, we in many cases calculate what we feel is going to be the patient paid amount and have the elder pay this amount monthly, until the application is approved.

The patient paid amount is the amount of the elders monthly income that will end up being paid to the nursing home for each month or part thereof that the elder is in the nursing home. In general this monthly amount is calculated by subtracting from the elder's MONTHLY GROSS INCOME, $72.80  (known as the personal needs amount) and any health insurance premiums for secondary health insurance, if any.

EXAMPLE: Tom is going to a nursing home. He has $800 per month social security and a pension. His gross monthly pension is $300 but he has $100 withheld for income taxes and $50 for health insurance. His monthly patient paid amount would be calculated as follows:


Gross Monthly Income:

Social Security                            $800

Pension                                       $300

Subtotal                                   $1,100


Personal Needs allowance    ($72.80)

Health insurance                        ($50)

Patient Paid Amount             $977.20


Married couples may keep up to about $120,000 in assets, if one spouse needs nursing home care to qualify for MassHealth. Single individuals are still subject to $2,000 in total assets.

Don't forget to check for life insurance. If an elder has a life insurance policy (or policies) and the total face value of those policies are more than $1,500, their cash surrender value is counted as an asset.

Once you look at the verification checklist available above, you need to get to work and start looking for all of the documents mentioned. Usually the most important things are the financial ones. MassHealth can ask for bank statements for the last five years. Any large deposit or withdrawal over $500 must be explained with documentation, also know as a verification. Some MassHealth workers are now asking for copies of EVERY check written for the last 5 years, regardless of the amount. They are looking for birthday gifts, Christmas gifts..., with the intent to disqualify the applicants for any gifts that they find that are dated after February 8, 2006.  

When looking for financial verifications, be sure to value all of the assets at the "Snapshot Date". This is the first date of constant institutionalization. For many, this is the day that they went into the hospital prior to entering the nursing home. For married couples this date is very important because it is the amount of assets on that date, that will determine whether or not they are over $120,000. What is important for single people is that they have less than $2,000 to be eligible for MassHealth.

For married couples who have one spouse in a nursing home, the planning gets a little more involved. For couples that have excess assets ( more than $120,000) our goal is to allow the spouse living at home to keep as much of those assets as possible. Historically, this meant that we would file for a hearing to allow her to keep additional assets in excess of what is allowed under the regulations. If we are unable to keep additional assets, something needs to be done with those excess assets or they will end up being paid to the nursing home.

Currently, for married couples, one of the most popular methods of protecting the excess assets involves the use of annuities. If you are married and have more than $120,000, an immediate annuity can help you get on MassHealth because, excess assets are being converted into income of the spouse that is living at home, and income of the spouse at home is disregarded for eligibility purposes. Lets say that you are married and have a home and $400,000. The asset limit is $120,000 and your have $280,000 too much to qualify. If the spouse at home purchased an annuity for $280,000, the money disappears and what you are left with it the spouse at home receiving monthly payments based upon a period not to exceed their life expectancy. The sick spouse gets to go on MassHealth and the sick spouses income gets paid to the nursing home. The healthy spouse gets to keep their home, $120,000 and the annuity payments. It's a pretty good deal.

Please be advised that there are many rules and exceptions to the rules that I have not mentioned in this introduction to MassHealth. The rules are constantly changing and when they change, there is no grandfathering. If you have an old trust that used to be fine and the law changes, the law will be applied retroactively, and that may produce unexpected results.

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