MASSHEALTH/MEDICAID

Medicaid is a health insurance and long-term care coverage program for low income and elderly Americans financed by the federal and state governments.

Each state establishes and administers its own Medicaid program and determines the type, amount, duration and scope of services covered within broad federal guidelines. States must cover certain mandatory benefits and may choose to provide other optional benefits. Medicaid is also the primary means of payment for nursing home services in the United States.

The Massachusetts Medicaid program is MassHealth, which provides health insurance or help in paying for private health insurance to more than a million Massachusetts children, families, seniors and people with disabilities.

What caregivers need to know about MassHealth

To qualify for MassHealth, a person must be a resident of Massachusetts, along with belonging to one or more of the following categories:

• A family living with children under the age of 19 years
• A pregnant woman with or without children
• A person who is long-term unemployed
• A disabled person
• An adult who is working for a qualified employer
• A person who is HIV positive
• A child under the age of 19 years
• An adult caretaker relative living with children under 19 years of age when neither parent is living in the home
• A person who is elderly (65 or older)
• A woman with breast or cervical cancer
• A person in need of long-term care
• A young adult under age 21 who was in the care and custody of the Department of Children and Families (DCF/DSS) on his/her 18th birthday

In most cases, financial eligibility requirements must also be met to qualify for MassHealth.

MassHealth Standard covers a wide range of medical care, including a number of benefits of particular interest to caregivers

• adult day health services
• home health services
• personal care attendant program
• transportation services
• long-term care in a medical facility (nursing home, hospital, etc.)
• hospice services
• medical equipment and supplies

Related information and additional web resources

• Official Medicaid site – More information about Medicaid can be found on this government site, which also has a section dedicated to information on the Massachusetts program.
• MassHealth page – The state’s official website provides in-depth information about the MassHealth program.
• Help by phone – You can also call 1-888-665-9993 for more information about the MassHealth program and 1-800-841-2900 for customer service. TTY users should call 1-888-665-9997 for general information.
• Online applications – You can apply online to MassHealth or submit a Senior Medical Benefit Request for long-term care.
• Downloadable guide [PDF] – MassHealth also offers a guide for seniors and persons of any age needing long-term care services that can be downloaded.

MassHealth checklist

Here is list of items and information you should have ready before applying for MassHealth:

• Proof of income: from pensions or retirement funds
• Proof of any income from rental property
• Proof of expenses from rental property
• Your Medicare card
• Copy of any long-term insurance policies
• Copies of your bank passbook and/or current account statements within the last 45 days or three months if you want Mass Health to for your medical expenses for that time period
• Information about the account balances of any bank accounts, certificates of deposit, checking, savings, credit unions, NOW, money market or personal needs allowance accounts
• Copy of the first page of any life insurance policy. If the total face value of any of the policies exceeds $1,500 per person, you’ll need a letter from the insurance company showing the current cash surrender value of the policy (except for term policies)
• If you have stocks, bonds, mutual funds, securities or assets held in a safe deposit box, collect proof of current value (except cash). If you have these types of assets, you will be referred to a lawyer to work on your Mass Health application
• Copies of a contract used to purchase any annuity
• Copies of any contract you signed with an assisted living facility
• Copies of the deeds, tax bills and proof of amount owed on any property you own
• Copies of the registration for any vehicle you own and proof of the outstanding loan balance. For mobile homes, provide a copy of the bill of sale
• Copy of any prepaid burial plan or trust, insurance policy or burial only account
• Copy of any trust documents, amendments, documents showing financial activity and a schedule of beneficiaries
• Copies of immigration cards

MassHealth Releases “Restructuring” Plan

On April 14, 2016, the $15.4 billion MassHealth program announced a major “restructuring” campaign designed to create “a sustainable, robust” health care program for its 1.8 million members. This process is the culmination of roughly a year of “intensive design and stakeholder engagement,” according to state officials.

MassHealth accounts for almost 40% of the Commonwealth’s budget. The Administration of Governor Charles Baker has made overt moves to swap out the current fee-for-service payment model, which they says results in “fragmented, siloed care,” and replace it with a managed care delivery system experiment which places large hospital and physician networks, known as “Accountable Care Organizations (ACOs),” in control of funding.

The instrument to make this change is a large federal 1115 waiver to support MassHealth restructuring. Financing for the current waiver ends June 30, 2017 with $1 billion in federal support. State law (Chapter 224) requires MassHealth to adopt alternative payment methodologies for promotion of more coordinated and efficient care. ACOs would represent for MassHealth a more “integrated” model of care. In ACO models, the health care providers are accountable for the cost and quality of care.

At the center of the “restructuring” plan are the ACOs. To be an ACO, providers must show they can coordinate care and partner with Community Partners, including primary, specialty, behavioral, acute, and community-based care. The ACO must have relationships with other providers to coordinate/ integrate care effectively. ACOs will be able to choose to create an integrated ACO/MCO entity or enter into ACO contracts with other MCOs; some ACOs may choose to contract directly with MassHealth.

MassHealth’s timeline calls for pilot ACOs to launch by the end of calendar 2016, with a full roll out of ACOs, BH/LTSS Community Partners and DSRIP by October 2017.

In the LTSS field, the focus is on the relationships between the new ACOs and the new “Community Partners.” (CPs). The ACO plan calls for increased LTSS integration and linkages to social services in ACO models through “explicit requirements for partnering with LTSS Community Partners.” The state will encourage ACOs to “buy” LTSS care management expertise from existing community-based organizations, like the 26 statewide Aging Services Access Points (ASAPs) vs. “building” their own assessment and care coordination capacity. MassHealth plans to invest in infrastructure and capacity to overcome fragmentation amongst community-based organizations.

MassHealth is not requiring ACOs to partner with CPs, but instead trying to use financial incentives to make this happen.

For more information about the MassHealth restructuring, see the full story at Mass Home Care.