The SHINE program
If you are uncertain about what health insurance coverage you have, or how to select the best plan for you, then you may contact the SHINE program.
The SHINE (Serving the Health Information Needs of Everyone) Program provides health insurance counseling services to elderly and disabled adults.
To reach a SHINE counselor, call:
Medicare is a federal health insurance program available to people with certain disabilities or who are aged 65 or older and eligible for Social Security or Railroad Retirement Benefits.
Medicare is Administered by the Centers for Medicare and Medicaid Services (CMS).
Medicare covers a LIMITED stay in a nursing home for skilled care when it is determined that the individual needs daily skilled nursing or rehabilitation services (such as wound care, injections, physical therapy, and so on) AND following a 3 day in-patient admission for a related illness or injury.
During a benefit period, Medicare pays for all covered services in a nursing home for 1 to 20 days, at a pre-determined rate in a semi-private room. For day 21 to a maximum of 100 days, Medicare pays for covered services except for a co-pay that is recalculated annually. (In 2018, it is $ 167.50 per day).
Individuals may carry supplemental Medicare insurance that covers some or all of the co-pay, sometimes called “Medigap” plans.
If it is determined that the individual no longer needs skilled assistance before the maximum number of 100 days, coverage stops at that time. If an individual disagrees with a Medicare decision, they may appeal the Medicare determination.
For assistance with Medicare appeals contact Livanta,1-866-815-5440.
For information about Medicare contact CMS at 1-800-MEDICARE or 1-800-633-4227.
When their financial resources are limited, residents living long term in a nursing home setting use a joint state and federal program, Medicaid.
Medicaid is a joint federal and state medical assistance program based on financial need that is administered in Massachusetts by the Division of Medical Assistance. In Massachusetts the Medicaid program, called MassHealth, provides coverage in a nursing home if an individual meets financial and other qualifying criteria.
Financially, an individual may have no more than $2,000 countable assets. If an individual has a spouse who remains in the community, the spouse at home is allowed to retain an amount of the combined countable assets and also a spousal allowance from their combined incomes.
Also, the individual must be assessed and determined to need long term care services provided in a nursing home setting.
An individual on MassHealth in a nursing home is required to pay the home a Patient Paid Amount (PPA) out of their monthly income for their stay, less a Personal Needs Allowance (PNA), which in 2018, is $72.80 per month. The PNA is for a resident to use for items not available at the home, such as clothing, hair styling or a favorite lotion. The home cannot charge personal laundry costs to the PNA.
The Nursing Home Reform Act (also known as OBRA, CFR 483) specifically forbids discrimination in treatment of residents and protects residents from fraudulent activities during admission. The home must have identical policies and practices regarding the provision of services, regardless of the source of payment. The home must not require another person to guarantee payment as a condition of admission or continued stay.
To apply for MassHealth, apply through a Regional MassHealth Enrollment Center. Information and applications are available at: MassHealth Enrollment Centers: 1-800-841-2900
Supplemental Security Income (SSI)
SSI is a federal financial assistance program administered by the Social Security Administration. Qualified individuals may use SSI to pay for a stay in a rest home.
Among other things, an applicant must meet age (65 or over) and/or disability criteria. Financially, a qualified applicant may not have more than $2,000 in countable assets, and if married, a couple may not have more than $3,000 in assets. In addition, the monthly income levels must be less than the SSI payment standard, recalculated annually.
People on SSI receive a personal needs allowance (PNA) to use for items not available at the home. SSI recipients are also automatically eligible for Medicaid to cover medical expenses.
To apply for SSI, contact the local Social Security Office,
If you have private insurance, review the policy carefully to determine if and for how long a stay in a nursing home may be covered. The Massachusetts Division of Insurance provides detailed information about insurance coverage in long term care. Contact them directly by calling (617) 521-7794.
Private pay contracts
If able, you may pay using your own resources for a stay in either a nursing or rest home.
You sign a contract specifying services you would receive in exchange for payment. The Attorney General Regulations in Massachusetts (940 CMR 4.00 – 4.11) detail protections for consumers in long term care facilities.
It is critical for someone paying privately to review their admission contract before signing it. The individual may also be required to disclose information about their financial status if they are paying privately.
The Veteran’s Administration (VA) provides limited nursing and rest home services to veterans through three programs:
- VA owned and operated nursing homes
- State veterans’ homes owned and operated by the state
- The community nursing home program
Each program has admission and eligibility criteria specific to the program. To find out if you are eligible for assistance, locate your city/town’s Veterans Agent through: