When Medicaid Pays for Assisted Living or Home Health Care in Massachusetts

MassHealth (the Medicaid program in Massachusetts) will pay for some home health care services through various programs and, in some situations, part of the cost of assisted living facilities. (MassHealth also pays for nursing facilities. See our article on when MassHealth pays for nursing homes for more information.)

Assisted living facilities are generally less expensive and less medically intensive than nursing homes.

Home health care allows seniors to stay in their homes, and can include skilled nursing or therapy services, home health aide services like medication management or bathing assistance, and personal care aide services like meal preparation or cleaning.

MassHealth Coverage of Assisted Living Services

Most Massachusetts residents living in assisted living facilities pay their own costs. However, if you have little income and few assets, you might qualify for Medicaid programs that help pay for some of the costs of assisted living facilities.

If you receive MassHealth and need help with at least one activity of daily living, you may be eligible for a benefit called Group Adult Foster Care (GAFC). GAFC pays for personal care services for individuals living in GAFC-certified housing. Some assisted living facilities are GAFC-certified.

The State of Massachusetts licenses GAFC housing. You can find GAFC-approved housing near you by calling the Executive Office of Elder Affairs at 800-243-4636. GAFC doesn't pay for housing expenses (that is, room and board) in an assisted living facility, just medical and personal care expenses.

If you receive SSI and qualify for GAFC, you might qualify for a supplement called SSI-G, administered by the Social Security Administration. This subsidy program funds housing expenses at GAFC and assisted living facilities. But you need to make sure the facility you want to live in accepts GAFC and SSI-G, since not all do.

MassHealth Coverage of Home Health Services

If you already receive Medicaid through MassHealth, the program will pay for some home care services through its Personal Care Attendant (PCA) program.

To qualify for PCA services, you must have a disability or chronic condition that causes you to need help with two or more of the following activities of daily living: mobility, including:

• getting into or out of bed, or a chair or wheelchair
• taking medications
• bathing and grooming
• dressing or undressing
• range-of-motion exercises
• eating, and
• toileting.

In addition, your doctor must prescribe PCA services for you.

If you qualify, MassHealth will pay for a certain number of hours of PCA services for you each month, depending on your needs. You can either hire the PCA that you want or you can get help finding and supervising someone.

Medicaid Waiver Programs in Massachusetts

Another way to get home health services is through one of Massachusetts' Medicaid Home and Community-Based Services (HCBS) Waiver programs.

To qualify for one of MassHealth's HCBS programs, you must have income at or below 300% of the SSI Federal Benefit Rate, or $2,829 per month in 2024. You also must have less than $2,000 in assets and, if you're married, your spouse can have assets totaling not more than $154,140 (in 2024). If you have too much income, you can still qualify for MassHealth HCBS programs by first meeting a deductible.

To receive waiver services in Massachusetts, you must also show that you would be institutionalized in a nursing home if you weren't receiving home care services. To do that, you must show either that you need at least one skilled nursing or therapy service daily (such as help with injections, catheters, feeding tubes, or physical or occupational therapy) or that you need a nursing service at least three times per week, plus two "other" services. Other services can be additional nursing services or assistance with activities of daily living like bathing, dressing, toileting, getting in or out of a bed or chair, walking, or eating.

Massachusetts Frail Elder Waiver

If you meet the above financial and level of care requirements, you may qualify for Massachusetts' Frail Elder Waiver (FEW) program. To qualify, you must be 60 or over, but if you are under age 65 you must be disabled.

Eligible FEW program participants work with a case manager to develop a services plan based on how much help they need every month and with which tasks. Then MassHealth will pay for the cost of services to meet those needs, delivered in the participant's home or the home of a family member or caregiver.

Services provided under the FEW program include:

• personal care services
• housekeeping, chore, and laundry services
• home health and skilled nursing
• adult day programs
• grocery shopping and delivered meals
• transportation
• respite care, and
• accessibility adaptations to your home.

Community Choices Waiver Program in MA

If you meet the criteria for the FEW program but are at imminent risk of being institutionalized in a nursing home unless you receive help, you might qualify for the Community Choices program. You must have a serious condition evidenced by one of the following:

• a need for 24-hour supervision
• a significant cognitive impairment
• an inability to manage your medications
• frequent incontinence, or
• a need for daily assistance with activities of daily living.

You can show imminent risk of nursing home placement if any of the following are true:

• You actively sought nursing home placement within the last six months.
• You recently suffered a serious medical event or a significant loss of functional ability.
• You were discharged from a nursing home in the last 30 days.
• You lack supports that could keep you out of a nursing home.

If you qualify for Community Choices, you can receive case management services, nursing services, personal care services, skilled therapy services, changes to your home to make it more accessible, emergency response systems, home-delivered meals, adult day health care, respite care, and transportation.

To find out more about the Frail Elder and Community Choices Waivers, contact your local Aging Services Access Point (ASAP) or call 800-AGE-INFO to find the ASAP that serves your community.

Massachusetts Home Care Program

If you're 60 or older and your annual gross income is less than $33,659 ($2,805 per month), then you may qualify for Massachusetts' Home Care Program (HCP). You can also qualify for HCP if you're under 60 if you have a diagnosis of Alzheimer's Disease and need respite services.

The HCP will assign you a caseworker and evaluate your needs to create an individualized care plan. Depending on your needs, HCP can offer:

• personal care services
• home health services
• skilled nursing care
• adult day care
• homemaker services
• home-delivered meals
• transportation
• chore services
• adaptations to your home, and
• personal emergency response systems.

In the Home Care Program, you might be required to contribute a copayment, depending on your income. Individual copayments can range from $10-$141 per month.

If your annual income is too high to qualify for the HCP permanently, you still might qualify for "respite services" under the program. Qualifying respite services can be any of the HCP services, offered on a temporary basis.

PACE Programs in Massachusetts

In Massachusetts, Programs of All-Inclusive Care for the Elderly (PACE) operate in certain service areas throughout the state. To qualify for PACE, you must:

• be 55 or older
• live in an area served by PACE organizations
• meet the nursing home level of care, and
• be able to live safely in the community with PACE services.

If you don't qualify for MassHealth, you can pay for PACE services on your own.

PACE participants receive their services from an interdisciplinary team of professionals including physicians, nurses, and social workers, whose role is to coordinate individualized care and services to keep seniors in their own homes and communities.

If you receive MassHealth and participate in PACE, Medicaid pays for all of the services recommended by your care team. Services can include transportation, personal care services, home health services, skilled nursing, delivered meals, adult day care, and emergency response systems.

If you're interested in a PACE program, contact the program directly to apply. You can find a PACE organization in your community here.

Wanting to Move Out of a Nursing Home?

Massachusetts operates a program called the Money Follows the Person Demonstration (MFP Demo) to help people move out of institutions and into less restrictive settings. The MFP Demo is designed to provide support and connect members to home- and community-based services to assist in the transition from long-term facilities back into the community.

To qualify for the MFP Demo, a 65+ individual must:

• be an eligible MassHealth member or meet financial qualifications
• live in a qualified nursing facility or long-stay hospital at least 60 straight days, and
• transition to an MFP-qualified residence in the community or to your home.

For more information on the MFP Demo, call the MFP Project Office at 617-573-1647 or email [email protected].

_{Updated March 29, 2024}