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

MassHealth will pay for some home health care services through various programs and, in some situations, part of the cost of assisted living facilities.

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. 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 also pays for nursing facilities. See our article on when MassHealth pays for nursing homes for more information.)

Medicaid 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 may qualify for 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 qualify 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.

Massachusetts licenses GAFC housing. You can find GAFC-approved housing in your area by calling the Executive Office of Elder Affairs at 800-243-4636. GAFC does not pay for housing expenses (that is, room and board) in an assisted living facility, just personal care expenses.

If you receive SSI and qualify for GAFC, you may 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.

Medicaid 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 Program. To qualify, 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, you doctor must prescribe personal care services for you. If you qualify, MassHealth will pay for a certain number of hours of personal care services for you each month, depending on your needs. You can either hire the personal care attendant that you want or you can get help finding and supervising someone.

Massachusetts Medicaid Waiver Programs

Another way to get home health services is through one of Massachusetts's Medicaid Waiver programs.

To qualify for one of MassHealth's Waiver programs, you must have income at or below 300% of the SSI Federal Benefit Rate, or $2,313 per month in 2019. You also must have less than $2,000 in assets. If you are married, MassHealth looks at only your individual income and assets, not those of your spouse. If you have too much income, you can still qualify for MassHealth Waiver programs by meeting a deductible.

To receive waiver services in Massachusetts, you must also show that you would be institutionalized in a nursing home if you were not receiving waiver 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's Frail Elder Waiver Program. To qualify, you must be 60 or over, but if you are under age 65 you must be disabled.

When you apply for the Frail Elder Waiver, an assessor from your local Aging Services Access Point (ASAP) will visit your home and decide how much help you need every month and with which tasks. Then MassHealth will pay for the cost of services to meet those needs every month. Services provided under the Frail Elder Waiver 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

If you meet the criteria for the Frail Elder Waiver Program, but you are at imminent risk of being institutionalized in a nursing home unless you receive help, you might qualify for the Community Choices Waiver 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 you:

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

If you qualify for the Community Choices Waiver Program, 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 has other Waiver programs for individuals with developmental disabilities and with traumatic brain injuries. For more information about those, contact MassHealth Waiver Information at 866-281-5602.

Home Care Program

If you are 60 or older and your annual gross income is less than $28,410 ($2,368 per month), then you may qualify for Massachusetts' Home Care Program (HCP). You can also qualify for HCP if you are 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 HCP, you may 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. Respite services are any of the HCP services, offered on a temporary basis.

Massachusetts's PACE ESP Programs

In Massachusetts, Programs of All-Inclusive Care for the Elderly Elder Service Plans (PACE ESPs) operate in certain service areas throughout the state. To qualify for PACE, you must be 55 or older, live in an area served by a PACE ESP, meet the nursing home level of care, and be able to live safely in the community with PACE ESP services. If you do not qualify for MassHealth, you can pay for PACE ESP services on your own.

PACE ESP 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 the PACE ESP Program, 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 are interested in a PACE program, contact it directly to apply. You can find a PACE program in your community here.

Wanting to Move Out of a Nursing Home?

Massachusetts has operated a program called the Money Follows the Person (MFP) demonstration to help people move out of institutions and into less restrictive settings. The MFP demonstration was 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.

The MFP Demonstration grant ended support for new transitions as of 2017, so individuals can no longer enroll to participate. Although the specific supports available through the MFP demonstration have ended, the grant continues to fund community-based services. Additionally, the HUD 811 Project Rental Assistance Program, a program related to the grant, continues to identify housing opportunities suitable for those leaving nursing and long-term facilities.

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

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