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MassHealth Nursing Facility Coverage Types

A range of medical services, other benefits, or both is available to members who meet specific eligibility criteria.
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Overview

MassHealth coverage types include the following:

  • Standard,
  • CommonHealth,
  • CarePlus,
  • Family Assistance,
  • Limited,
  • Fee for Service (FFS),
  • Buy-In,
  • Health Safety Net (HSN),
  • Senior Care Options (SCO),
  • One Care,
  • Program of All-inclusive Care for the Elderly (PACE), and
  • Accountable Care Organization (ACO).

Sometimes these coverage types are combined. The scope of services or covered benefits for each coverage type is found at 130 CMR 450. To understand the categorical requirements and financial standards that must be met to qualify for a MassHealth coverage type, see 130 CMR 505.

Information on MassHealth coverage types that cover Nursing Facility services

 

Room/Board

Medicare co-insurance

Nursing Facility Rate Add-Ons

Standard (FFS)

Yes

Yes

Yes

CommonHealth (FFS)

Yes

Yes

Yes

Buy-In

No

No

No

Family Assistance*

Yes

No

Yes

CarePlus

Yes

No

Yes

Limited

No

No

No

HSN

No

No

No

SCO

Yes

Does not apply

Yes

PACE

Yes

Does not apply

No

One Care

Yes

Does not apply

Yes

Accountable Care Partnership Plans (ACOs)/Managed Care Organizations (MCOs)

Yes, for the 1st 100 days of admission

Does not apply

No

Primary Care ACOs/Primary Care Clinician Plan

Yes, for the 1st 100 days of admission

Does not apply

Yes

*Family Assistance covers both short term and long term nursing facility stays  

Download a printable PDF of the table

One Care, PACE, and SCO Plans and Coverage

MassHealth members enrolled in either a One Care, PACE, or SCO Plan must receive all health-care services from the plan’s network. The only exception is emergency situations. For this reason, it is important to always check the Eligibility Verification System (EVS) before providing services to verify if a MassHealth member is enrolled in One Care, PACE, or SCO. If a member is enrolled in One Care, PACE or SCO, you should contact the specific plan in which the member is enrolled before providing services.

One Care Plans and Coverage                   

Enrollment into One Care is voluntary, and once enrolled, a member may disenroll any month of the year. Enrollment is open to MassHealth Standard members who:

  • are between the ages of 21 and 64, at the time of enrollment;
  • have a disability;
  • have Medicare Parts A and B;
  • qualify for Medicare Part D (drug coverage);
  • have MassHealth Standard or MassHealth CommonHealth;
  • do not have private health insurance (like health insurance from your job);
  • do not take part in a Home and Community-Based Services (HCBS) waiver; and
  • live in an area covered by a One Care plan.

SCO Plans and Coverage

Enrollment in this managed care program is voluntary, and once enrolled, a member may disenroll any month of the year. Enrollment is open to MassHealth Standard members who:

  • are 65 or older; 
  • live at home or in a long-term-care facility (member cannot be an inpatient at a chronic or rehabilitation hospital or reside in an intermediate care facility for people with intellectual disabilities);
  • are not subject to a six-month deductible period under MassHealth regulations;
  • do not take part in a Home and Community-Based Services (HCBS) waiver except the Frail Elder Waiver (FEW); and
  • live in an area served by a SCO plan.

Current SCO Plans

Additional Resources

The Program of All-inclusive Care for the Elderly (PACE) and Coverage

The Program of All-inclusive Care for the Elderly (PACE) is administered by MassHealth and Medicare to provide a wide range of medical, social, recreational, and wellness services to eligible participants. The goal of PACE is to allow participants to live safely in their homes instead of in nursing homes.

To enroll in PACE you must: 

  • be 55 or older;
  • live in the service area of a PACE organization;
  • be certified by the state as eligible for nursing home care;
  • be able to live safely in the community;
  • agree to receive health services exclusively through the PACE organization; and
  • meet the Social Security Act Title XVI disability standards, if 55 through 64 years of age.

Current PACE Plans

Additional Resources

ACO/MCO Plans and Coverage

Accountable Care Organizations (ACOs) 

ACOs are groups of doctors, hospitals, and other health care providers who give coordinated, high-quality care to MassHealth members. This way, MassHealth members get the right care at the right time.  

There are two types of ACOs members can enroll in: Accountable Care Partnership Plans or Primary Care ACOs. In both, ACOs are led by providers, not just administrators. Primary Care Providers (PCPs) are at the center of the member’s care. Providers work with members directly and know their needs. PCPs will have a bigger part in working with members to make decisions about care in an ACO than in other types of health plans.  

There are two types of ACOs. 

  • Accountable Care Partnership Plans  
  • Primary Care ACOs  

Accountable Care Partnership Plans 

In this type of ACO, a network of PCPs works with just one MCO to create a full network that includes PCPs, specialists, behavioral health providers, and hospitals. PCPs plan and coordinate care to meet the needs of the member. 

Primary Care ACOs 

In this type of ACO, a network of PCPs has joined together into an ACO to provide integrated and coordinated care for members. The ACO contracts directly with MassHealth and uses the MassHealth provider network of specialists and hospitals. Members who enroll in a Primary Care ACO receive behavioral health services through the Massachusetts Behavioral Health Partnership (MBHP).  

MCO and PCC Plans

  • MassHealth continues to offer Managed Care Organizations (MCO) and the Primary Care Clinician (PCC) Plan to its members.  

Managed Care Organizations (MCOs)

  • MCOs are health plans run by insurance companies. These plans provide care through their own provider network which includes PCPs, specialists, behavioral health providers, and hospitals. Care coordinators are employed by the MCO. 

Primary Care Clinician (PCC) Plan

  • In the PCC Plan, primary care providers are called primary care clinicians (PCCs). The MassHealth network of PCCs, specialists, and hospitals delivers services. The Massachusetts Behavioral Health Partnership (MBHP) provides behavioral health services.

Accountable Care Organizations (ACOs)

Primary Care ACO Plans

Managed Care Organizations (MCOs)

After 100 Days of Coverage

MassHealth Standard/CommonHealth/Family Assistance (FFS) Services in a Nursing Facility

After 100 days in a nursing facility, MassHealth members will be transferred from their plan to MassHealth fee-for-service to keep receiving Nursing Facility Services.

Note: Members who also receive Chronic Disease Rehabilitation Hospital (CDRH) Services will be transferred after 100 days of combined CDRH and Nursing Facility Services.

MassHealth Members covered by either an ACO Model "A" or MCO plan: Requests for Level of Care for continued nursing facility stays should be submitted to ASAP agencies when notice is received from health plans that the members Health plan benefits are ending.

CarePlus Services in a Nursing Facility

If during the 100 days, the MassHealth member is receiving CarePlus services and becomes eligible for another MassHealth coverage type (e.g., MassHealth Standard or CommonHealth), the nursing facility coverage may be extended beyond 100 days.

Note: Admission in a Nursing Facility and a CDRH will be treated as one admission. In those cases, 100 days of combined Nursing Facility and CDRH services is covered.

Date published: April 3, 2024

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