Health Coverage/Programs

MassHealth Programs:

There are several different types of MassHealth coverage, each with its own set of eligibility rules and benefits. Some individuals are subject to paying premiums and co-payments for programs. For information on applying to any of the MassHealth programs, call MassHealth Customer Service at 1-800-841-2900, or visit their website at www.mass.gov/masshealth.

  1. MassHealth Standard is the most comprehensive MassHealth program, providing a full range of health care benefits, with some limitations. MassHealth Standard covers the following services: inpatient hospital services and outpatient services such as hospitals, clinics, doctors, dentists, chiropractors, vision-care, prosthetics, family planning, nursing facility care, home health care, and transportation to appointments. It also covers adult day health; adult foster care; inpatient and outpatient mental health and substance abuse services; and well-child screenings (for children under age 21), including medical, vision, dental, and hearing tests, as well as shots and prescription and nonprescription drugs. Low-income children, pregnant women, families with dependent children, elders, and people with disabilities are eligible provided they are US citizens or qualified non-citizens.
  2. MassHealth Basic covers a wide range of health care services, including dental services, though not as many as MassHealth Standard. It does not cover adult day health, foster care, hospice, nursing facility services, or transportation, except for emergency ambulance services. Those eligible include individuals receiving Emergency Assistance to Elderly, Disabled, & Children (EAEDC) from the Department of Transitional Assistance, as well as individuals receiving services from the Department of Mental Health (DMH) who are long-term unemployed with income at or below 100% of the Federal Poverty Level (FPL).
  3. MassHealth Essential provides benefits, including dental services, slightly more limited than MassHealth Basic to individuals who are long-term unemployed and who are not otherwise eligible for MassHealth Standard or Basic coverage. Household income must be at or below 100% FPL and individuals must not be eligible for unemployment benefits.
  4. MassHealth Limited only covers emergency services, including labor and delivery, for certain low-income children, pregnant women, families with children, elders, and people with disabilities who are special status or undocumented aliens. People who apply only for MassHealth Limited are not required to provide a Social Security Number, nor will their information be matched to other federal and state agencies.
  5. MassHealth Family Assistance provides a similar range of benefits, including dental services, as MassHealth Basic, for certain higher-income children up to 300% FPL (or for special status children up to 200%); childless adults with income up to 200% FPL through premium assistance only; parents/caretakers of dependents with income up to 200% FPL; and persons with HIV/AIDS with income up to 200% FPL. This program either reimburses the cost of the insurance premium for families and childless adults who have employer-based health insurance or allows families to enroll in a health plan through MassHealth. US citizens, qualified non-citizens, and special status non-citizens are eligible.
  6. MassHealth CommonHealth offers health care benefits to adults and children with disabilities whose incomes are too high to be eligible for MassHealth Standard. Benefits offered are similar to those offered under MassHealth Standard. CommonHealth covers all long-term care needs except for nursing home facilities. There are no income limits or asset tests for CommonHealth coverage, but a premium payment applies on a sliding scale fee basis for those with higher incomes. Some members may have to pay a one-time deductible (spend down) depending upon income. Individuals who qualify for federal Qualified Disabled and Working Individual (QDWI) status may also receive benefits under MassHealth CommonHealth, while others who meet the working requirement must pay monthly premiums, but no deductible.
  7. MassHealth Prenatal provides immediate outpatient prenatal care including up to 60 days of routine prenatal office visits and diagnostic tests to pregnant women who have applied to MassHealth, but have not verified their income. Self-declared income must be at or below 200% FPL. If proof of income is not provided later within the time limits allowed, benefits will end after 60 days or when a determination of eligibility is made, whichever is sooner.
  8. MassHealth Senior Buy-In (QMB) is for certain Medicare beneficiaries whose assets are too high to qualify for MassHealth Standard, but whose income is less than or equal to 100% FPL. Countable assets must be $4,000 or less for an individual or $6,000 or less for a married couple living together. The program pays for Medicare premiums, as well as deductibles and coinsurance for both Medicare Part A and Part B.
  9. MassHealth Buy-In for Specified Low-Income Medicare Beneficiaries (SLMB) is for Medicare beneficiaries who do not qualify for MassHealth Senior Buy-In. This program is for individuals whose income is between 100% and 120% FPL. Countable assets must be $4,000 or less for an individual or $6,000 or less for a married couple living together. It pays only for the monthly Part B Medicare premium.
  10. MassHealth Buy-In for Qualifying Individuals (QI-1) is for certain Medicare beneficiaries who do not qualify for MassHealth Buy-In (SLMB). This program is for individuals whose income is between 120% and 135% FPL. Countable assets must be $4,000 or less for an individual or $6,000 or less for a married couple living together. It pays only for the monthly Part B Medicare premium.

Medicare

  1. Medicare is a federal health insurance program for seniors and people with disabilities who have contributed to the federal social security program while employed for a minimum number of years. It does not cover most long-term nursing home care, or longer-term home care services. It also does not cover certain routine services, including physical exams (except for a one-time only annual physical for new Part B members) or tests for vision and hearing.
    • Medicare Part A –Medicare hospital insurance that pays for inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care
    • Medicare Part B –Medicare medical insurance that helps pay for doctors’ services, some preventative care, outpatient hospital care, durable medical equipment, and some medical services not covered by Part A
    • Medicare Part C – Medicare managed care plan, see #13 for more details
    • Medicare Part D – Medicare prescription drug coverage benefit
  2. Medicare Part D (began January 1, 2006): Voluntary prescription drug coverage to supplement Medicare Part A and/or Part B beneficiaries. The coverage is provided by private plans, called Prescription Drug Plans (PDP), and beneficiaries choose a plan according to their medication needs and financial situation. PDP’s are either being attached to Medicare Advantage Plans or exist as stand-alone plans that supplement Medicare Part A and Part B coverage. Although PDP’s can create their own benefit design, it must be equivalent to the standard benefit, which requires beneficiaries to pay monthly premiums averaging $20 to $40 and a $265 deductible before prescription coverage begins. After paying the deductible, beneficiaries will pay 25% co-insurance until their prescription drug costs exceed $2,401. A coverage gap (also known as the “doughnut hole”) occurs between $2,401 and $5,451.25 where individuals must pay all drug costs themselves. After exceeding $5,451.25 in drug expenses, catastrophic coverage begins and members will be responsible for the greater of 5% co-insurance or $2 for generic/$5 for covered brand-name drugs (2007 figures; adjusted annually). Dual eligible beneficiaries can receive extra help in the cost-sharing requirements of Medicare Part D, and will be auto-enrolled in a PDP. Other Medicare beneficiaries with limited income and resources can receive extra financial assistance with their premiums and co-payments, but will have to apply for it. Although enrollment into Medicare Part D is voluntary, those who enroll after May 15, 2006 have to pay a cumulative penalty of 1% per month. For example, if a person chooses to enroll 3 years after the May 15, 2006 date, the penalty will be 36% of the Part D premium charged (36 months * 1%) for life. For comprehensive information about the Medicare Part D drug benefit call 1-800-633-4227 or www.medicare.gov. For information on how to apply for extra help paying for Medicare Part D premiums, deductible, and copayments call 1-800-772-1213 or www.ssa.gov/prescriptionhelp.
  3. Medicare Advantage Plans: Health plans offered by private managed care companies that contract with Medicare to provide Medicare Part A and B benefits. Medicare Advantage Plans are available with and without Part D prescription drug plans.
  4. Medigap is a private supplemental insurance policy that individuals may purchase to supplement services not covered by Medicare. In Massachusetts there are three levels of Medigap insurance policies offered, and each pays for different services, for varying costs. Some policies offer a choice of doctors or hospitals. Low-income individuals who cannot afford the cost of a Medigap plan may be eligible for supplemental coverage through MassHealth.

Other Health Insurance Programs:

  1. Prescription Advantage: A prescription drug insurance program for Massachusetts residents age 65 and over, and younger, low-income individuals with disabilities. The Massachusetts Executive Office of Elder Affairs administers the program. With the introduction of the Medicare Part D prescription drug benefit on January 1, 2006, Prescription Advantage is a secondary payer providing financial assistance to supplement Medicare coverage. Prescription Advantage requires Medicare-eligible members to be enrolled in a Medicare prescription drug plan in order to receive its assistance. For members without Medicare, Prescription Advantage eligibility and benefits will remain the same.
  2. Children’s Medical Security Program (CMSP) is a health plan for children under the age of 19 who are not eligible for other MassHealth programs and do not have private health insurance coverage. The program covers primary and preventive services for children with any family income. The monthly amount a family pays for CMSP coverage is dependent on family size and income. The maximum prescription benefit is $200 a year.
  3. Commonwealth Care Health Insurance Program is a new program created by the health care reform bill. Commonwealth Care provides state-funded subsidies to low-income individuals to assist with the purchase of affordable private health insurance from Commonwealth Care health plans. To qualify, a person must have a household income at or below 300% FPL, not be eligible for MassHealth or Medicare, and have no access to employer-sponsored coverage or other subsidized government health insurance programs. Citizens, qualified aliens, and aliens with special status are eligible; undocumented aliens are not. Non-working individuals, the selfemployed, and employees from companies of any size are potentially eligible. Employees must either have no access to insurance or work for employers who contribute less than 33% (or less than 20% for family coverage) towards their insurance costs. Employees must also not have accepted any financial incentive from the employer to decline the employer’s coverage. Health plans offered through Commonwealth Care do not have deductibles. The amount of the premium subsidy is determined using an income-based sliding scale. For those whose incomes are not at or below 150% FPL, the subsidy will cover the full cost of the premium but individuals must pay co-payments for some services. Visit the Connector’s website at www.mahealthconnector.org or call 1-877-MA-ENROLL (1-877-623-6765) for more information.
  4. Healthy Start provides health insurance for low-income, uninsured pregnant women who are not eligible for MassHealth (except for MassHealth Limited) and have family income at or below 200% FPL. It also provides coverage for pregnancy-related primary and specialty care, labor and delivery, prescriptions, and several other health benefits.
  5. Insurance Partnership: The Insurance Partnership provides small businesses with partial subsidies to offset their costs of group health insurance purchased for employees between the ages of 19 and 64 earning at or below 300% FPL. The subsidy is available for both individual and family coverage. To participate in the Insurance Partnership, employers must have 50 or fewer employees or be self-employed, sponsor a comprehensive group health plan, and contribute at least 50% of the cost of the employees’ health insurance premium. Employees whose employer or family member’s employer has provided insurance coverage in the preceding six months for which the employee was eligible are excluded.
  6. Medical Security Plan: The Medical Security Plan (MSP) of the Division of Unemployment Assistance (DUA) provides either premium assistance or direct coverage for persons eligible for unemployment compensation in Massachusetts, or residents who either receive or are eligible to receive state unemployment insurance benefits. DUA contracts with Blue Cross Blue Shield to administer this plan, which provides either direct health coverage or premium assistance for COBRA, if that benefit is available to them. This plan is available to persons whose household income is at or below 400% of the federal poverty level. MSP Member Service Center: 1-800-914-4455
  7. Massachusetts HIV Drug Assistance Program (HDAP): A drug assistance program for Massachusetts residents with HIV with incomes at or under $50,000/year. HDAP is funded by the Massachusetts Department of Public Health and independently administered by the Community Research Initiative of New England. (1-800-228-2714)
  8. Prescription Assistance Programs: Various prescription discount programs offered by private for-profit and non-profit organizations that provide members with varying discounts on prescription drugs. Prescription Advantage: 1-800-243-4636, press 1 or TTY: 1-800-610-0241 or www.800ageinfo.com
  9. Commonwealth Choice is an employer-sponsored health insurance program administered by the Connector. Under Commonwealth Choice there are four levels of coverage offered to meet the needs of different individuals and their families including Premier, Value, Basic and Young Adult. To enroll into a Commonwealth Choice plan, members and/or employers must pay a monthly premium. Members also pay a co-payment. In addition there may be a deductible the member must pay out of pocket for services before the health plan begins paying.

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