Whether you should prepare and file a MassHealth application by yourself or should hire help depends on the 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 assisted living facilities or nursing homes.
For people under age 65 who are 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 over—especially for those of any age who need continuing care, whether at home, in assisted living, or in a nursing home.
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 when considering 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.
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.
On the other hand, community benefits after age 65 for people who need long-term care can be quite complicated. In large part, this is because such benefits comes under half a dozen separate programs, each with its own eligibility rules and services it covers.
(Click here to learn more about MassHealth community benefits.)
Nursing Home Coverage
The process of applying for nursing home benefits is more difficult 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, it often 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 with 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 former 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. Also, they are often brought into cases by the nursing homes themselves, which 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 the opportunity to receive 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, payments are generally made 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 services or to cover 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.