One of the most confusing issues, and fundamental questions, that people in the Commonwealth of Massachusetts have regarding medical care concerns the differences among Medicaid, Medicare and MassHealth. Most of this confusion stems from the name similarities Medicaid and Medicare, both of which are the federal programs available in each state. To add to this Medi-soup, and in true Commonwealth fashion, Massachusetts felt the need to add another agency name to the mix. This article will hopefully clear up some of this uncertainty.
What is MassHealth and What are the Benefits?
MassHealth is basically the consumer branch of the Massachusetts Department of Health and Human Services. In the words of its mission statement, MassHealth “provides comprehensive health insurance – or help in paying for private health insurance—to more than one million Massachusetts children, families, seniors, and people with disabilities.” In addition, MassHealth is the second largest insurer in the state. However this description of MassHealth sounds, the truth is that the question has no easy answer, since benefits and services under MassHealth are often changing with rising costs and changing client needs.
This system was used as a model for the nationwide healthcare plan known also as the “Patient Protection and Affordable Care Act” or “Obamacare.” In that sense it is a system that covers all insured persons within the state.
What is Medicaid and Who Gets It?
Medicaid is the federal government’s welfare, or safety net, plan for people who are without the necessary means to pay for essential medical care. The program provides emergency care to those who are without assets, but it also covers general care needed for certain vulnerable populations like children, parents of children, pregnant women and unborn children. The law generally requires that a person have less than $2,000 in assets if he is applying for Medicaid benefits due to lack of resources.
One of the main (and fastest growing) services administered by Medicaid provides for benefits to elderly individuals requiring long term care, specifically those who need 24 hour care in a nursing home. Because the cost of a nursing home in Massachusetts averages approximately $9,000 to $10,000 a month, most elderly individuals of modest means will qualify financially for long term care benefits under Medicaid fairly quickly. Of course, Medicaid planning addresses the asset and spending strategy that individuals and families can take prior to liquidating large amounts of money on the private payment of such care. In addition to the elderly, Medicaid can also provide coverage for disabled persons needing long term care.
Although Medicaid comes primarily from federal funds, one should remember that the program is administered by state agencies. In Massachusetts, that agency is of course MassHealth. And so people applying for MassHealth are in many cases also applying for Medicaid.
What is Medicare and When Do I Need It?
Medicare is described as a “social insurance program,” meaning in practice that its primary financing is obtained by a tax on all wages. About 2.9% of a person’s income will go towards this program via the payroll tax, and all legal U.S. citizens (having 5 years of residency) are entitled to the benefits after reaching the age of 65. Certain disabled persons qualifying for SSDI may also be covered. In this way the risk is spread across a diversity of the population.
The benefits under Medicare are divided into parts A through D. Part A (the primary part covered by the payroll tax) is used for hospital visits, while Part B is for Doctor’s visits. Anyone using Medicare for a hospital stay must show improvement, however, and this is usually where the most confusion between Medicare and Medicaid occurs.
The situation is usually a variation of the following: An elderly person falls and breaks a bone, and goes to the hospital for emergency treatment. After being treated, the hospital retains the patient until her condition is stabilized. The patient is then moved to a rehabilitation facility, many times a place that also treats persons for long term care. During the patient’s stay, several therapists work with her to improve mobility and other activities of daily living until the patient is capable enough to return home.
If the patient does not improve, then Medicare benefits can only continue for a certain period of time, usually up to 60 days per visit. After that time, the patient will need to pay either privately with her own funds, or will apply for Medicaid benefits if she has no assets.
Conclusion
So, just to summarize things for purposes of memory: MassHealth is the state administrator of Medicaid, Medicaid is the low income welfare system for people of limited resources, and Medicare is the social insurance that we’ll all receive when we reach a certain age.
For more questions about these programs, and specifically how to qualify for Medicaid for long term care under MassHealth, contact one of the MassHealth attorneys at our office.
