MASSHEALTH

MassHealth is a joint state and federal umbrella program that provides medical services for certain low to moderate income Massachusetts residents. Eligibility depends on meeting income guidelines as a percentage of the federal poverty level and on meeting other eligibility standards. There are several MassHealth programs described below.

MASSHEALTH STANDARD

MassHealth Standard is full Medicaid coverage, and offers the most comprehensive health care program covering a full range of benefits including:

• Hospital Visits
• Doctor visits
• Dental visits
• Lab Services
• OB/GYN & Women’s health services
• Well-child visits
• Prescription drug coverage
• Mental health services
• Substance abuse services

  

Eligible Groups	Income Limits
Pregnant Women	Doesn’t exceed 200% of poverty
Individuals under age 19	Doesn’t exceed  200% of poverty
Parents with children under age 19	Doesn’t exceed  133% of poverty
Individuals over age 65	Depending on income guidelines
Women diagnosed with breast or cervical cancer screened through the Women’s Health Network	Doesn’t exceed 250% of poverty
Individuals under age 21 and have aged out of foster care	No income limits
Individuals of any age living in a nursing home or other medical	No upper income limit but there is a required contribution to the costs of care based on income, and asset limits apply.

MASSHEALTH COMMONHEALTH

  

Eligible Groups	Income Limits
Individuals under age 19 with disabilities	No income limits
Working adults with a disability	No income limits
Nonworking disabled adults under age 65	No income limits

MASSHEALTH FAMILY ASSISTANCE

MassHealth Family Assistance offers coverage by combining several programs, there are two main types:

 Direct Coverage

  

Eligible Groups	Income Limits
Individuals under 19 who are uninsured	Doesn’t exceed 300% of poverty
Individuals under age 65 who are HIV-positive and uninsured	Doesn’t exceed 200% of poverty

Premium Assistance 

MASSHEALTH BASIC

MASSHEALTH ESSENTIAL

 
MassHealth Essential an extension of MassHealth Basic for long-term unemployed adults. This includes adults under age 65 who have been unemployed for 12 months or longer. It is also available for some adults under age 65 who are disabled and some adults over age 65.

This coverage type offers coverage to certain unemployed adults who are not eligible for MassHealth Basic by:

• Paying all of part of the cost of you other health-insurance premium
• Allowing you to enroll in a health plan through MassHealth if you do not have other health insurance

 

Eligible Groups	Income Limits
All	Doesn’t exceed 100% of poverty
Currently not working	No income limits
Individuals have not worked in more than one year or, have not earned enough to collect unemployment	No income limits
Individuals not eligible to collect unemployment benefits	No income limits

COMMONWEALTH CARE

Commonwealth Care provides affordable coverage to uninsured adults who are not otherwise eligible for MassHealth. Commonwealth Care is an option for those who earn above the gross family income guidelines required for MassHealth eligibility. Commonwealth Care is run by The Commonwealth Health Insurance Connector. The Connector offers Commonwealth Care health-insurance coverage through private insurance plans. A health plan includes a group of providers, hospitals, and other professionals who work together.

Commonwealth Care plans cover:

• Inpatient hospital services
• Outpatient services and preventive care
• Prescription drugs
• Inpatient and outpatient mental health and substance abuse counseling
• Dental services, including preventive and restorative procedures
• Vision services

  

Eligible Groups	Income Limits
Uninsured individuals that are not eligible for: MassHealth Children’s Medical Security Plan QSHIP And not offered insurance in which an employer pays at least 33% of cost of an individual premium, or 20% of the cost of a family premium.	Doesn’t exceed 300% of poverty
Individuals paying the full cost of insurance as self-employed	Doesn’t exceed 300% of the Federal Poverty Limit
Individuals using COBRA or in a waiting period for employer coverage	Doesn’t exceed 300% of the Federal Poverty Limit

QSHIP: QUALIFYING STUDENT HEALTH INSURANCE PROGRAM

CHILDREN’S MEDICAL SECURITY PLAN

The Children’s Medical Security Plan (CMSP) provides primary and preventive care for all children who are uninsured and are not eligible for MassHealth.

All children that are uninsured and not eligible for MassHealth qualify for The Children’s Medical Security Plan, regardless of citizenship or immigration status. Coverage depends on total family size and income.

Certain income groups may have to pay premiums:

• No premiums are charged children in families with income under 200 percent of poverty
• Monthly premiums for children in families with income between 201 and 200 percent of poverty are $7.80 per child up to $23.40 family maximum
• Monthly premiums are $33.14 per family, for families with  income between 301 and 400 percent of poverty
• Monthly premiums are $38.99 per child  for families with income over 400 percent of poverty
• CMSP also charges copayments of $2–8 depending on the service and the family income.

For inpatient hospital care and emergency services (CMSP only covers primary and preventive care):

• Families eligible for CMSP with income at or under 200 percent of poverty are eligible for full Health Safety Net benefits at hospitals and community health centers
• Families eligible for CMPS with income between 200-400 percent of poverty are eligible for partial health safety benefits
• Children ineligible for MassHealth based on their immigration status with income less than 150 percent of poverty will receive CMSP plus MassHealth Limited for emergency and inpatient services.

CMSP benefits cover:

• Dental up to $750
• Prescription drugs up to $200
• Mental health and substance abuse up to 20 visits
• Durable medical equipment up to $200 along with outpatient office visits and immunizations

HEALTHY START

Healthy Start covers prenatal care and 60-day postpartum care for pregnant women.

Benefits:

• Pregnancy-related primary and specialty visits
• Outpatient behavioral health, up to 10 visits
• Pregnancy-related radiology and laboratory services
• Amniocentesis
• Prescribed durable equipment, up to $300
• Home nursing postpartum visits
• Office visits, including family planning
• Postpartum obstetric and gynecological care
• Prescription drugs with $3-4 copayments
• Medical nutritional therapy

Eligibility:

• Uninsured pregnant women, or underinsured with health insurance that does not cover all medically necessary pregnancy-related care
• Gross income cannot exceed 200 percent of poverty for a family size that includes the fetus.
• Not eligible for any other MassHealth coverage type, other than MassHealth Limited
• There is no citizenship of immigration status requirement but women must be Massachusetts residents

HEALTH SAFETY NET (FREE CARE)

The Health Safety Net is a program for Massachusetts residents who are not eligible for health insurance or can't afford to buy it. The goal of the Safety Net is to make sure that all Massachusetts residents can get health care when they need it, regardless of income. The Health Safety Net (Free Care) pays for medically necessary services at Massachusetts community health centers (CHCs) and hospitals.

You must go to a Massachusetts community health center for Health Safety Net benefits.

HSN Benefits for emergency/ inpatient medical care are limited to:

• Emergency, urgent or maternity care
• Need for hospitalization
• There is no community health center within 5 miles
• Specialty or complex care not available at a community health center

MEDICAL SECURITY PROGRAM

The Medical Security Program (MSP) is a health care plan for low and moderate-income Massachusetts residents who are getting unemployment insurance benefits. MSP benefits end when unemployment insurance benefits end. The MSP has two options:

Direct Coverage: If you cannot continue your previous health plan, or if you did not have health insurance, the MSP offers direct coverage for you and your family.

Premium Assistance: If you had health insurance before you lost your job and can continue that coverage, the Medical Security Plan will help pay for your insurance premiums.

You may be eligible for MSP if:

• You are a Massachusetts resident
• You receive Massachusetts unemployment insurance benefits
• You worked for a Massachusetts employer

INSURANCE PARTNERSHIP

Insurance partnership makes health insurance more affordable for qualified small businesses and their employees. The insurance partnership is a program of the Massachusetts Executive Office of Health and Human Services. The goal of the Insurance Partnership is to reduce the number of uninsured residents in Massachusetts.

MEDICARE

Medicare is a Health Insurance Program for people age 65 or older, some disabled people under age 65, and people of all ages with End-Stage Renal Disease (permanent kidney failure treated with dialysis or a transplant).

You may qualify for Medicare if:

• You are 65 years or older, are a citizen or permanent resident of the United States and you or your spouse worked for at least 10 years in Medicare-covered employment
• You are under 65 years old you may qualify if you have a disability
• Have End-Stage Renal Disease (any age)

PRESCRIPTION ASSISTANCE

Pharmacy Assistance programs:
Call the Mayor's Health Line at 617-534-5050 for a list of pharmacy assistance programs that are currently available. Programs vary by eligibility.

If you need more information or to start the application process, call the Mayor's Health Line at (617) 534-5050 where trained staff can help you determine which program is best for you and your family. The Health Line offers application assistance directly over the phone for the programs described on this page.