Medicare will pay some nursing home costs for Medicare beneficiaries who require skilled nursing or rehabilitation services. Individuals may qualify for up to 100 days of skilled nursing or rehabilitative care if he/she:
is over the age of 65 or disabled
has Medicare Part A benefits
has been hospitalized for at least three days prior to admission (except in certain Medicare managed care programs)
meets other program requirements
Medicare provides full coverage for the first 20 days. Coverage rules for 2017 require the beneficiary to contribute $164.50 a day for days 21 to 100. For more information about Medicare coverage, contact the Social Security Administration at (800) 772-1213 or www.ssa.gov.
Medicaid coverage – or MassHealth as it is called in Massachusetts - is available for individuals who have exhausted their own personal resources and require governmental assistance to help pay for nursing facility care. To qualify for MassHealth benefits, individuals must have no more than $2,000 in assets, excluding a house, a car and personal belongings. In the case of a married couple, assets are divided equally, with the at-home spouse allowed to keep up to $109,560 in assets and $2,739 in monthly income.
In determining MassHealth eligibility, the state Medicaid agency “looks back" or reviews the transfer of financial assets for the preceding 60 months with disqualification based on the amount of assets transferred. This “look-back” period can extend to 60 months for certain trusts.
Once an individual has qualified for MassHealth benefits, all but $72.80 of his or her monthly income is used to cover the cost of care, with MassHealth paying the difference between the individual’s income and the daily Medicaid nursing facility rate. The $72.80 is retained by the individual as a monthly "personal needs allowance" to pay for personal items he or she might need while in the nursing facility.
To be eligible for MassHealth benefits, an individual must have at least one nursing need and two additional nursing or Activity of Daily Living (ADL) needs. ADLs include eating, dressing, toileting, transferring and bathing. An individual applying for MassHealth benefits must be screened by one of the state’s Aging Service Access Points (ASAPs) or the hospital from which they are being discharged to ensure that they meet MassHealth clinical eligibility requirements and cannot be cared for in the community.
For more information about MassHealth eligibility, contact the MassHealth Customer Service Center at (800) 841-2900 or one of the following Medicaid Long Term Care Units:
Long Term Care Insurance:
In addition to Medicare and Medicaid coverage, long term care insurance policies are available to cover the cost of nursing facility care and other long term care services. A list of companies authorized to sell such policies in Massachusetts is available on the state Division of Insurance website or by calling (617) 527-7794.
As with all insurance products, the time to buy long term care insurance is before you need care; once care is required, the premiums are often too high to be affordable. In considering such policies, be sure that the type and amount of coverage you anticipate needing is provided, and that the premium is affordable.
The Division of Insurance website also includes a link which provides consumer information pertaining to long term care insurance.
Most people who enter nursing homes begin by paying for their care with their personal resources. After these savings and other resources are spent, many people who stay in nursing homes for long periods eventually become eligible for Medicaid.