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Rules for Massachusetts Medicaid

Medicaid is a state-operated, federally and state-funded health insurance program for low-income pregnant women, children, elderly and disabled individuals, women with breast or cervical cancer and individuals with HIV. The state of Massachusetts offers a variety of Medicaid programs under the MassHealth program.

  1. Residency

    • In order to receive coverage under MassHealth, you must be a U.S. citizen and a current resident of the state of Massachusetts. During the application process, you must provide a federal, state, or military-issued photo identification card, birth certificate and Social Security card to establish citizenship and residency.

    Income and Resources

    • You must meet income and resource limits to qualify for programs under MassHealth. Income limits vary significantly depending on family size, employment status and the type of health coverage. You typically must not exceed the resource limit of $1,500 to qualify for MassHealth. Resources include cash on hand, checking and savings accounts, stocks, bonds, IRAs, life insurance policies with a cash value, automobiles except for one that is excluded if it is used for transporting the recipient of Medicaid coverage, houses except for one that is excluded if it is the primary residence,

    Disabilities

    • If you are applying for MassHealth on the basis of disability, you must be able to provide proof of disability through medical records, statements from individuals familiar with your disability such as family members and former employers and other supporting documentation. The ability to complete daily living tasks, such as bathing, housekeeping and managing finances and the ability to obtain and maintain gainful employment, which is typically considered employment greater than 20 hours per week with a gross income of greater than $980 per month, are used to assess whether an individual is disabled. A Medicaid disability application requires listing previous jobs held, job duties at each employer and how the disability prevents returning to previous types of employment.

    Children and Elderly

    • Once an individual turns 19, he is no longer eligible for MassHealth based on his age alone. However, he may apply for MassHealth on the basis of disability or another qualifying factor. Elderly individuals must be at least 65 to qualify for MassHealth.

    Billing

    • Providers who accept Medicaid may accept only the approved reimbursement rate for consumers who receive Medicaid. The provider may not charge the consumer an additional amount after payment from Medicaid is received. The Center for Medicare and Medicaid Services (CMS) determines the maximum reimbursement rates for Medicaid services. Massachusetts determines the specific payment rates, which may be considerably less than the maximum reimbursement rates set forth by CMS, that providers receive for services billed to Medicaid.

    Prescription Drugs

    • The Massachusetts Office of Health and Human Services (OHHS) determines what prescription drugs are covered under Massachusetts Medicaid, including which prescription drugs require a prior authorization to be submitted by the prescribing physician prior to Medicaid coverage being approved. OHHS also sets quantity and dosage limits for covered prescription drugs. If a prescription exceeds the quantity or dosage limit, a prior authorization may need to be completed for coverage to be considered.

    Health Insurance Portability & Accountability Act (HIPAA)

    • HIPPA is a federal law that sets the guidelines for how protected health information (PHI) is shared between entities, such as hospitals, clinics, social service agencies, family members and others. Per HIPAA guidelines, you must complete an information release form and submit it to the provider for your medical records to be released to an outside entity. Providers who accept Massachusetts Medicaid must adhere to HIPAA guidelines or may risk losing the ability to provide Medicaid reimbursed services.

    Long-term Care

    • If you require care in a long-term facility, such as a nursing home, rehabilitation hospital or state psychiatric hospital, you may qualify for Massachusetts Medicaid. You must be 65 or older, or age 19 through 65 and disabled according to the Social Security Administration's (SSA) disability rules, or under the age of 19, meet citizenship requirements, be determined to require long-term care services after an assessment by MassHealth and your income and resources must fall under specified guidelines.

    HIV/AIDS

    • If you are HIV positive, you may qualify for MassHealth coverage. If you have dependent children, they may also be covered under your Medicaid policy. You must meet specific income requirements, including not exceeding $1,805 per month for an individual, $2,429 for a family of two, $3,052 for a family of three and $3,675 for a family of four. If your family size is larger than four, add $624 per each additional family member to determine the income limit.

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