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MassHealth (Medicaid)
Federal and state funded health insurance for very low to medium income people living in Massachusetts is available through the various programs of MassHealth. MassHealth can provide health care benefits directly or pay all or part of an individual or family’s health-insurance premium.
MassHealth Standard
This coverage type provides the most comprehensive benefits package of any MassHealth program-including durable medical equipment (DME)-for families, seniors, and individuals with disabilities under age 65 who meet eligibility guidelines. There is no asset test for most applicants (the exception is seniors, current and some former SSI recipients, and individuals requiring long-term care). This is also the only MassHealth coverage type that pays for long-term-care services.
Who is Eligible?
Children:
- Children under age one: up to 200% of the federal poverty level; no asset test.
- Children under age 19: up to 150% of the federal poverty level; no asset test.
Pregnant women and parents/caretakers:
- Pregnant women with income up to 200% of the federal poverty level; no asset test.
- Parents or other “caretaker relatives” living with their children under age 19: up to 133% of the federal poverty level. No asset test. (Note: Parents/caretakers over age 65 are also eligible for these benefits.)
- TAFDC (Temporary Aid to Families with Dependent Children) recipients automatically receive MassHealth Standard.
- Former TAFDC recipients: special income and asset rules under section 1931 of the Social Security Act allow adults who become ineligible for TAFDC cash assistance (“welfare”) to keep their MassHealth Standard benefits for up to 12 months after returning to work or getting a raise, regardless of their earnings.
Seniors:
- Seniors aged 65 and older and living at home: up to 100% of the federal poverty level, plus an asset standard of $2,000 or less for an individual, and $3,000 or less for a married couple living together.
People of all ages with disabilities:
- SSI (Supplemental Security Income) recipients automatically receive MassHealth Standard. An asset test applies.
- Disabled adults under age 65; up to 133% of the federal poverty level; no asset test. (MassHealth follows the federal standard for “disabled” and requires that the applicant have a mental or physical condition that prevents them from working for at least 12 months.)
- Former SSI recipients: Medicaid 1619b can allow disabled adults to keep MassHealth Standard indefinitely once they return to work. This enables people who need to cycle between SSI cash assistance and paid employment (depending on their ability to work) to seamlessly retain their MassHealth Standard insurance. To do so, they must not earn above a certain income limit, but continue to meet the SSI asset test and disability standard. Over income or can’t meet the asset test? MassHealth Standard or MassHealth CommonHealth may still be options. Learn more from Project Impact or BENEPlan; counselors are available.
People of all ages needing long-term care:
- Children under age 18 living at home with long-term care needs: a child’s eligibility can be determined without counting the income and assets of the parents through the Kaileigh Mulligan Program. Kaileigh Mulligan provides access to MassHealth Standard for severely disabled children who require a hospital or pediatric nursing-home level of care;
- Individuals of any age in need of nursing home care: there is no income limit, but there is a “patient-paid-amount,” plus an asset standard of $2,000 or less for an individual, and for married couples with one institutionalized spouse, the institutionalized spouse may keep $2,000 and the spouse at home may keep up to a certain amount according to certain rules.
- Seniors living at home with long-term care needs. There are 2 special MassHealth Standard programs designed to help adults live at home:
PACE (Program of All-Inclusive Care for the Elderly) for certain frail people age 55+. PACE integrates Medicare and Medicaid financing to provide community-based services for those who do not want to be admitted to a nursing home.
Medicaid Home and Community-Based Services Waiver for certain frail people age 60+. The “waiver” allows MassHealth Standard eligibility to be determined without counting the income and assets of the other spouse. For more information on these programs see Persons Living at Home Needing Long-Term-Care-Services at mass.gov.
What DME Services are Provided?
The following DME and AT related categories are “covered services” for MassHealth Standard members (See MassHealth provider regulations (PDF): 450 All Provider Manuals at this mass.gov web page):
- Durable medical equipment and supplies,*
- audiologist services [hearing tests],
- hearing aid services,**
- orthotic services,
- podiatrist services,
- oxygen and respiratory therapy equipment,
- prosthetic services,
- speech and hearing services,
- transportation services [to and from medical appointments]
- vision care [includes eyeglasses]***
*DME includes items such as wheelchairs and other seating and mobility equipment, medical and surgical supplies, hospital beds, and transfer devices and lifts.
** MassHealth does not pay for more than one hearing aid per ear in a 60-month period (5 years) without prior approval. See MassHealth provider regulations: 416 Hearing Instrument Specialist Manual at this mass.gov web page.
***Numerous restrictions apply to eyeglasses with regard to type that is reimbursable, replacement, repair, and spares. See MassHealth provider regulations: 402 Vision Care Manual at this mass.gov web page.
What DME Services are NOT Provided?
Routine periodic testing, cleaning, adjusting, and checking of the equipment. (Repairs and major maintenance services are provided if the equipment is medically necessary and reimbursable.)
DME or supplies considered “experimental,” unless the provider has secured prior approval.
Non-medical equipment or supplies, even if used for medically related purposes. Equipment primarily and customarily intended for non-medical purposes is not classified as medical equipment (for example, air conditioners or home modifications of any type are not reimbursable).
Items that are not both medically necessary and reasonable for treating your condition. For instance, an excessively expensive device will not be approved if a less costly alternative is medically appropriate and feasible. Items that cannot meaningfully improve your illness or injury also will not be approved. Additionally, items serving the same purpose as equipment you already have will not receive approval.
Accessory equipment for devices that are not reimbursable.
Hearing aids that fit entirely within the ear canal, rental of hearing aids, and personal FM systems.
How are DME Services Provided?
The process of obtaining necessary equipment through MassHealth can be complicated. Success largely depends on finding a medical equipment supplier able to provide the specific equipment you require and assist you in obtaining prior approval from MassHealth for its purchase (or rental). If enrolled in a managed care plan, you may need to begin with a preferred medical equipment supplier contracted with your Medicaid Managed Care Organization (MCO) or Senior Care Organization (SCO). Your primary care doctor’s office should help direct you.
It is very important to follow the prior approval process carefully, inform MassHealth of your current mailing address, retain all notices received, and cooperate with your equipment supplier to promptly respond to requests for additional information or documentation.
Here’s an outline of the process:
You identify a medical equipment supplier capable of providing the necessary equipment (your doctor’s office or an AT Regional Center might assist with this).
Your supplier evaluates your needs to determine precisely what equipment is required. The supplier may coordinate directly with your current medical providers (doctor, physical therapist, occupational therapist, etc.).
The supplier provides the cost for the item and helps gather letters from your medical providers supporting your need, as well as a prescription from your doctor (if you do not already have one).
The supplier submits a request for “prior approval” (also called “prior authorization”) to MassHealth. If enrolled through a Medicaid Managed Care Organization (MCO), such as BMC HealthNet, Fallon, Neighborhood Health Plan, Health New England, or Network Health, or a Senior Care Organization (SCO), the supplier will submit the request directly to the MCO’s or SCO’s health services department. This request must be submitted within 90 days from the prescription date or within 90 days of the requested delivery date of the equipment.
MassHealth reviews the request, usually through a consultant hired by MassHealth, who decides whether the equipment is medically necessary to treat or improve your medical condition and whether it represents the least costly, appropriate alternative. Additional follow-up questions may be asked of the supplier. MassHealth is required to provide a written decision within 14 days. In urgent cases (an emergency request), MassHealth must provide a decision within 3 days.
The written decision is sent to both you (the MassHealth member) and the supplier. MassHealth may approve, deny, or modify the request. Additional information from the supplier might be necessary to secure approval. It is the supplier’s responsibility to explain MassHealth’s decision clearly to you.
If MassHealth approves the request, the supplier arranges delivery of the equipment. According to MassHealth regulations, suppliers are responsible for providing all accessories necessary for initial set-up, delivering the equipment into your home and, if needed, into the specific room where it will be used, installing and setting up the equipment, instructing you in its safe use, making required adjustments for six months following initial service or providing a customized fitting during setup (depending on equipment type), and removing the equipment when service ends.
What if I Need to Appeal a Denial for DME?
Appeals are relatively common and worth pursuing. Often MassHealth needs better documentation of a consumer’s need for the equipment or some other additional information to approve the request.
If MassHealth denies your request you have 30 days to appeal the decision beginning from the date you receive the denial notice (assumed to be within 3 days of the date on the notice). See How to appeal a MassHealth denial from the Disability Law Center at www.dlc-ma.org. Note that even if your appeal time has expired, a request may be resubmitted with better documentation and an appeal may not be necessary.
If your MassHealth comes through a Managed Care Organization (i.e. Fallon, BMC Health Net, Neighborhood Health Plan, Network Health, Health New England), the Behavioral Health Partnership, or a Senior Care Organization (SCO), you will first need to appeal within your MCO or SCO’s internal grievance system before appealing to the MassHealth fair hearing system. MCOs and SCOs must follow a timely internal grievance process as dictated by MassHealth regulations (130 CMR 508.010). You may also ask for a fast review of your appeal if delay could seriously jeopardize your life or health or ability to recover. If you are appealing the discontinuation of DME services, MassHealth members should be able to have ongoing services continued during the grievance process.
If your appeal through the MassHealth fair hearing system fails (the Board of Hearings), you may take your case to Superior Court. You should seek the assistance of a legal advocate. For advice and referral, contact the Disability Law Center at:
(617) 723-8455 / (800) 872-9992 Voice
(617) 227-9464 / (800) 381-0577 TTY
In western Massachusetts:
(413) 584-6337 / (800) 222-5619 Voice
(413) 582-6919 TTY
www.dlc-ma.org
MassHealth CommonHealth
This coverage type provides the same full range of DME benefits as MassHealth Standard. It is available for adults and children with disabilities who are not income-eligible for MassHealth Standard and have no private health insurance. There is no upper income limit or asset test for MassHealth CommonHealth, but members pay a premium or one-time deductible based on their gross family income and family size. The program, therefore, helps families of a range of incomes access insurance that covers durable medical equipment and other needed services. For children with disabilities living at home, this program is less restrictive than Kaileigh Mulligan (which requires a child need a nursing-home standard of care), but it is more expensive than Kaileigh Mulligan because it requires a premium.
Who is Eligible?
- A child with a disability* under age 18 whose family’s income is over the limit for SSI and MassHealth Standard;
- An adult with a disability* over age 18 who works an average of 40 hours or more per month and who has a gross income of above 133% of the federal poverty level (otherwise they are likely eligible for MassHealth Standard). This category can include seniors.
- An adult with a disability* under age 65 who has a gross income above 133% of the federal poverty level, and who does not meet the work requirement. They will need to meet a one-time deductible.
Again, there is no upper income or asset test to be eligible for CommonHealth. The higher a family or individual’s gross income, the higher their CommonHealth premium.
*MassHealth determines if you are disabled under state and federal law (generally the same as the SSI disability standard).
What DME Services are Provided?
How are DME Services Provided?
What if I Need to Appeal a Denial for DME?
The process is the same as for MassHealth Standard.
MassHealth Family Assistance
This coverage type provides access to health insurance by paying for part of your family’s private health insurance premium, or by enrolling you and/or your children in a MassHealth plan, or by purchasing your medical benefits directly. As result, DME benefits vary. MassHealth Family Assistance is available to income-eligible children, some working adults, and people who are under age 65 and HIV positive who cannot get MassHealth Standard or MassHealth CommonHealth. Families pay a low premium for each child enrolled in a MassHealth program (currently $12/month per child up to $84/month maximum for a family). Families with a parent or guardian enrolled in and paying a premium for Commonwealth Care do not have to pay a premium for their children on MassHealth.
Who is Eligible?
- Children ages 1 through 18 whose family income before taxes and deductions is no more than 200% of the federal poverty level. Certain children are eligible with income up to 300% of the federal poverty level.
- Working adults under age 65 whose family income before taxes and deductions is no more than 200% of the federal poverty level, and who are not eligible for MassHealth Standard or CommonHealth. They must also work for a qualified employer who participates in the Insurance Partnership or have employer-sponsored health insurance that meets basic-benefit level standards. They must also be willing to pay for part of the cost of their health insurance.
- People under age 65 who are HIV positive and are not eligible for MassHealth Standard or MassHealth CommonHealth, and whose family income before taxes and deductions is no more than 200% of the federal poverty level.
What DME Services are Provided?
DME benefits vary depending on the coverage you are able to get. If MassHealth Family Assistance provides you with premium assistance, your DME coverage will usually depend on the coverage provided by your private employer-sponsored health insurance (see Private Insurance). However, if you are HIV positive and MassHealth Family Assistance provides you with premium assistance for an employer group plan (or another source you are eligible for), MassHealth may also provide additional medical services not covered by your private health insurance.
If MassHealth Family Assistance purchases medical benefits directly or enrolls you or your child in a MassHealth plan, than the DME coverage provided is the same as what is provided with MassHealth Standard . However if medical benefits are purchased directly, these will not include transportation (to and from medical appointments) as a covered service.
How are DME Services Provided?
MassHealth and most private health insurance providers require prior approval for DME purchases. Your process for obtaining DME under MassHealth Family Assistance will be either the same process as required by MassHealth Standard (see the MassHealth Standard process) or the process required by your private insurance provider (as in the case of premium assistance).
What if I Need to Appeal a Denial for DME?
If your insurance comes from a private insurance provider, you will need to follow that provider’s internal grievance procedures to appeal. Otherwise, the appeals process is the same as it is for MassHealth Standard.
MassHealth Basic
This coverage type provides access to insurance for long-term unemployed adults who are active clients of the Department of Mental Health (or on a waiting list for DMH services). Benefits are also available to individuals or members of a couple who are getting Emergency Aid to the Elderly, Disabled and Children (EAEDC) cash assistance (EAEDC is a state-funded cash assistance program similar to the federal SSI program). If you are eligible, MassHealth Basic pays for all or part of your private health insurance premium or purchases your medical benefits directly if you do not have other health insurance available to you. MassHealth Basic provides a leaner version of MassHealth insurance benefits (as compared with MassHealth Standard), but it does include DME. Private insurance purchased through MassHealth Basic premium assistance may or may not cover DME.
Who is Eligible?
- Individuals or members of a couple who are receiving EAEDC cash assistance.
- Unemployed adults who are active clients (or on the waiting list for services) with the Department of Mental Health and who:
- are not enrolled in college with access to insurance through the college or university;
- are not eligible for unemployment benefits;
- have not worked in more than one year, or if so, have not earned enough to collect unemployment benefits;
- are not married to a spouse who works more than 100 hours/month.
- have a gross monthly family income of no more than 100% of the federal poverty level.
What DME Services are Provided?
If you have no access to private health insurance, MassHealth Basic directly purchases medical benefits, including DME services, through a Managed Care Organization (MCO) plan. The coverage for DME is the same as with MassHealth Standard, except that transportation to and from medical appointments is not a covered service. If MassHealth Basic provides you with premium assistance, your DME coverage will depend on the coverage provided by your private health insurance (see Private Insurance).
Note: people on EAEDC can get fast access to the EAEDC medical benefit before they are enrolled in Basic, but DME coverage is not provided. Once an EAEDC recipient is enrolled with a Managed Care Organization (MCO), they get the full Basic benefit package, including DME.
How are DME Services Provided?
MassHealth and most private health insurance providers require prior approval for DME purchases. Your process for obtaining DME under MassHealth Basic will be either the same process as required by MassHealth Standard (see the MassHealth Standard process) or the process required by your private insurance provider (as in the case of premium assistance).
What if I Need to Appeal a Denial for DME?
If your insurance comes from a private insurance provider, you will need to follow that provider’s internal grievance procedures to appeal. Otherwise, the appeals process is the same as it is for MassHealth Standard.
MassHealth Essential
This coverage type provides long-term unemployed adults who are not eligible for MassHealth Basic (adults who are not clients of the Department of Mental Health, and not EAEDC cash recipients) with an even leaner version of MassHealth insurance benefits. Almost no DME equipment or services are covered. The program functions like MassHealth Basic; if you are eligible, it will pay for all or part of your private health insurance premium or purchase your medical benefits directly if you do not have other health insurance available to you.
Who is Eligible?
Adults under age 65 who
- have a gross family income of no more than 100% of the federal poverty level;
- are currently unemployed, have not worked for more than one year, or if they have worked, have not earned enough to collect unemployment;
- are not eligible for MassHealth Basic; or
- have an immigrant status that prevents them from getting MassHealth Standard, are long-term unemployed and disabled by MassHealth guidelines, and have a gross family income of no more than 100% of the federal poverty level.
What DME Services are Provided?
- Prosthetic and podiatrist services (but not the purchase of the equipment).
What DME Services are NOT Provided?
- DME equipment and supplies,
- audiologist services,
- hearing aids,
- orthotic services,
- oxygen and respiratory therapy equipment,
- transportation services, and
- vision care.
What if I Need to Appeal a Denial for DME?
If your insurance comes from a private insurance provider, you will need to follow that provider’s internal grievance procedures to appeal. Otherwise, the appeals process is the same as it is for MassHealth Standard.
Contact:
MassHealth Customer Service Center (for benefits, general eligibility, and enrollment information)
(800) 841-2900
(800) 497-4648 TTY
MassHealth Enrollment Center (for the status of your medical benefit request or member eligibility)
(888) 665-9993
(888) 665-9997 TTY
www.mass.gov/masshealth
Health Care For All (HCFA) is a non-governmental organization that answers questions about healthcare in Massachusetts.
HCFA’s Health Helpline: (800) 272-4232
www.hcfama.org