Medicare and Medicaid (Mass Health) Basics
In Massachusetts, Medicaid is Called Mass Health
There can be some confusion over the differences between Medicare and Medicaid. Medicare is a federal health insurance program in which most people enroll when they turn 65 years old. There are no financial qualification rules. Medicare has two primary parts: Part A and Part B.
Medicare Part A covers in-hospital care, extended care after a hospital stay, some home health care services, and hospice services. Medicare Part A will generally pay the full charge, except for some co-pay and deductible, and coverage is available for up to 90 days for a benefit period.
Medicare Part B covers doctor payments, medical tests, medical equipment, and outpatient physical and speech therapy.
Medicaid – Mass Health
Medicaid, or Mass Health as it is called in Massachusetts, is also a federal program, but unlike Medicare, each state is allowed to implement their own regulations on how the program is managed. Mass Health eligibility is determined after the proper application is submitted to the state. There are many Mass Health insurance programs available, from basic medical coverage to nursing home programs. An overview of all Mass Health programs is available online.
Nursing Home Payment – Medicare or Mass Health?
Medicare Part A will pay for a maximum of 100 days in a nursing home or rehabilitation center if both of the following conditions are met:
- The patient had been admitted to a hospital for at least three nights prior to being discharged to a nursing home; and
- The services being given to the patient are “skilled services.” Skilled services must be ordered by the doctor, given by or under the supervision of a professional (i.e. physical therapist, RN, occupational therapist, LPN, speech pathologist), and be the kind of service that can only be provided on an inpatient basis.
If both of these requirements are met, Medicare will cover the full cost of the stay in the nursing home or rehabilitation center for the first 20 days. From day 21 – 100 the patient is responsible for a co-pay amount. In 2016, the co-payment is $161 per day. Supplemental insurance may cover the co-payment.
Transitioning to Mass Health for Long Term Nursing Home Payment
After 100 days, or sooner if the nursing home determines that the patient is no longer eligible under the Medicare rules, the patient and their family will receive notice that Medicare will no longer pay for the nursing home. At that stage, there are essentially three choices: return home; private pay the nursing facility; or become eligible for Mass Health and submit a Mass Health application.
More information can be found online about Mass Health Long Term Care Information.