Using a Disability Trust to Stay At Home
In addition to paying for nursing homes, sometimes MassHealth benefits can help you stay out of a nursing home. These programs can be complicated, and they require both medical and financial applications. Benefits don’t begin until both have been approved. A Disability Trust can help a person to qualify financially for these benefits programs.
The Frail Elder Waiver Program
One of the most important home-care options offered by MassHealth is the Frail Elder Waiver (FEW) program. This program may be available if you need enough care to be a candidate for nursing home care, but it is possible to meet your needs with extra care at home.
The FEW program requires you to create a viable plan for care in your home. Viable means that it is possible to care for you at home, within the financial limits that MassHealth is able to pay. The ASAP (Aging Services Access Point) will come to your home, evaluate you and your circumstances, issue a report, and make a decision about whether it is possible to care for you at home, based upon what amount of services MassHealth would be willing to pay for. Getting a positive decision is a critical first step.
The services that are available for home care include visiting nurses, personal care attendants, home health aides, Meals on Wheels and many, many other specific types of services. The ASAP is the hub for delivering all of these services. They know what is available, and can match your needs to the services that they can provide.
ASAPs are strong advocates for home care. They cannot, however, approve home care in every instance. If you would need round-the-clock nursing care (that is, more than just a home health aide), it may be simply too expensive to pay for that much home care. Unless you have other resources to fill the gaps, the FEW program won’t be enough to keep you at home.
If you have family or friends who can cover parts of your home care, it may become much easier to qualify for the FEW program. For instance, if the only help that you need during nighttime is something that family member or a home health aide can provide, MassHealth may be able to pay for that service as an FEW program benefit. But if you need a skilled nurse to be available to you at all times throughout the day and night, it is less likely that the FEW program would be able to provide that much skilled nursing care at home. You would probably have to go to a nursing home for that level of care.
To summarize, the criteria for the FEW program are—
- The ASAP determines that you are a candidate for a nursing home placement;
- It is medically (“clinically”) realistic that could remain at home with a combination of skilled and unskilled home care;
- You are financially eligible for MassHealth benefits,
Details about the income, asset and clinical eligibility rules for FEW benefits can be provided by a “SHINE” counselor (“Serving the Health Insurance Needs of Everyone”). SHINE counselors have offices in your local ASAP.
Program for All-inclusive Care for the Elderly (PACE)
The PACE program is a combined Medicaid-Medicare program that provides care at home through health maintenance organizations (HMOs) that are located in specific communities. Like the FEW program, PACE requires both financial and clinical eligibility. Unlike the FEW program, however, PACE is available (usually with a premium) to seniors with Medicare alone, i.e., who do not qualify for Medicaid. In the context of Disability Trusts, however, eligibility through Medicaid is the most relevant consideration.
The asset limits for PACE are the same as for all MassHealth long-term care benefits: $2,000 for an individual, $3,000 for a couple. Those with excess assets can meet the assets limit by establishing a Disability Trust for themselves, or for a disabled child or grandchild. For those age 65 or older, a Pooled Trust is the only Disability Trust option for meeting the asset standards for PACE.
The other eligibility criteria for PACE are that the person must be—
- Age 55 or older;
- Live in a geographical area that is served by a PACE provider; as of July, 2020, the list of communities served by a PACE provider is found here;
- Meet the income and asset limits for MassHealth;
- Meet the disability criteria for Supplemental Security Income (SSI); and
- Be willing to use the PACE provider for all medical care.
The income limits for PACE are based on the amount of the SSI federal benefit for the individual. In 2020, that amount is $2,349 ($783 x 3 = $2,349).
In addition to providing home care, PACE has contracts with a number of assisted living facilities for persons who cannot be maintained at home, or who cannot travel to Senior Centers or other programs for essential socialization and access to services.
Find more information about PACE on the state’s PACE information web page. For information about establishing a Disability Trust (individual or pooled), you will find additional information here, or you may contact Community Trust at (978) 775-3500.
Senior Care Options
Another program that combines Medicare and Medicaid coverage under a single health care provider is the Senior Care Options (or “SCO”) program. SCO plans are offered by independent HMO organizations, who are paid premiums by MassHealth and, for those who have it, Medicare. There are six organizations that operate SCO plans. In order to enroll, the individual must qualify financially for MassHealth.
Other criteria for enrollment are that the individual must be—
- age 65 or older;
- living at home or in a long-term-care facility;
- receiving income that is less than his or her necessary medical expenses;
- not diagnosed with end-stage renal disease; and
- living in an area served by a SCO plan.
Among other advantages, SCOs combines health services with social support services by coordinating care and specialized geriatric support services, along with respite care for families and caregivers. These services make them ideal for individuals and families hoping to avoid institutionalization in a nursing home. In addition, there are no copays for SCO members, which makes budgeting for home care easier and more predictable.
Disability Trusts are an important factor in planning for enrollment in a SCO. Significantly, since the program is open only to persons age 65 or older, the only Disability Trust option for such persons is a Pooled Trust. A senior may, however, may be able to establish an individual SNT prior to age 65, and to qualify for a SCO upon turning 65. Once established for an individual under the age of 65, and individual SNT does not become a disqualifying asset as a result of the beneficiary turning 65. At that point, however, the individual cannot add funds to the trust without incurring a MassHealth penalty.