Planning for Life

Should You Prepare a MassHealth Application Yourself? - Massachusetts

Posted by Harry S. Margolis on March 12, 2013

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By Harry S. Margolis

Whether you should prepare and file a MassHealth application by yourself or should hire help depends on answers to the following questions:

  • How complicated is the financial situation?

  • Are you applying for community or nursing home benefits?

  • How much time do you have available?

  • How organized are you?

MassHealth is the health care program for Massachusetts residents who do not have another form of insurance or whose insurance does not cover what they need, such as long-term care.  Many of our clients rely on MassHealth for assistance in paying for care at home or in nursing homes.

For people under age 65 and living in the community (at home), eligibility is based largely on income and the application process is not very complicated. Most people can apply on their own without assistance.

Matters get a bit more complicated for applicants age 65 and above and especially for those of any age who need nursing home coverage.

MassHealth applicants over age 65 are limited to $2,000 in countable assets. It's possible to transfer assets over this amount in order to become eligible, but seniors need to be careful doing so because they may need the funds in the future and if they move to a nursing home, the transfer could make them ineligible for benefits for five years.  Professional advice can be important because there is a confusing array of different MassHealth programs which may be of assistance in providing home care, each with its own rules.

All of that said, the application process itself is not so complicated for community benefits.  In short, those over 65 in many cases will need to consult with an elder law attorney for planning purposes, but they or their families may be able to prepare and submit the MassHealth application themselves.

(Click here to learn more about MassHealth community benefits.)

That is less true with applications for nursing home benefits.  This is because MassHealth subjects such applications to enhanced scrutiny, requiring up to five years of financial records and documentation of every fact. Any unexplained expense may be treated as a disqualifying transfer of assets and many planning steps, such as trusts, transfers to family members, and family care agreements, are viewed as suspect unless properly explained.  Finally, the process generally takes several months as MassHealth keeps asking questions and demanding further documentation of answers provided.

So, unless the person preparing the application is very organized and patient, or the applicant's financial situation is very simple, in most cases it makes sense to get help from people experienced in preparing MassHealth applications.  Clients generally have three choices: individual paraprofessionals, MediServices, or private attorneys.

  • Individual Paraprofessionals -- A number of individuals who have experience preparing applications for nursing homes or who had worked at MassHealth have created businesses assisting family members of nursing home residents in preparing applications.  These individuals have experience and can often be very helpful with the process. They are not, however, qualified to provide advice about protecting assets from having to be spent down on nursing home fees. (Also, I could not find them by searching on the Internet. They seem to do their marketing by word-of-mouth.)

  • Medi-Services -- Medi-Services, founded by elder law attorney Harley Gordon, is by far the largest company in Massachusetts assisting the preparation of MassHealth applications. Similar to individuals providing this service, Medi-Services can be very helpful in preparing the application and supporting material and doggedly bringing the process to its conclusion. They will not, however, provide long-term care planning advice. This is in part to make it clear that they are not a law firm, despite Attorney Gordon's involvement. Also, they are often brought into cases by the nursing homes themselves who have an interest in the resident paying out-of-pocket for as long as possible, since the MassHealth reimbursement rate is substantially lower than what facilities can charge on the private market.

  • Elder Law Attorneys -- Many elder law attorneys (including our firm) offer assistance with MassHealth applications as part of their services. This has several advantages, including expert advice on how best to qualify for benefits as early as possible, experience in dealing with the more difficult eligibility questions that often arise, and a high level of service through a long, grueling process. The one drawback of using an attorney rather than a lay service is that the fee is typically substantially higher. However, given the high cost of nursing homes, if the law firm's assistance can accelerate eligibility by even one month that will generally cover the fee. In addition, the payments are generally with funds that would otherwise be paid to the nursing home -- in other words, the funds will have to be spent in any event, whether for nursing home or legal fees.

In short, whether you need assistance and what assistance to seek in preparing an application for MassHealth benefits depends in large part on whether you are seeking community or nursing home coverage. It also depends on the time you have available and your level of organization.  Feel free to call us about this if you have any questions.

Also, click here to learn more about the MassHealth application process.

Topics: MassHealth planning, nursing homes

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