Healthcare and Related Services

This section summarizes public and private health insurance, as well as specialty services which advance independence in community living.

MassHealth (Medicaid)

MassHealth is Massachusetts’ Medicaid program, a federal-state partnership that provides essential health coverage for people with disabilities, as well as children and families with limited income. The federal Medicaid program has mandatory and optional benefits and Massachusetts covers both benefit categories. For a general introduction, see our MassHealth Overview.   

• Over-the-Counter (OTC) Medications: MassHealth may cover certain OTC medicines, though what’s covered can vary by managed care plan. Here’s an example from one of the plans.  Note: Those on MassHealth & Medicare do not have this coverage. 
• Premium Assistance: MassHealth may pay part or all of a family’s private health insurance premiums if you have children with disabilities who are eligible. Learn more here. 
• CommonHealth: This is a program for adults with disabilities who are working. It offers coverage similar to MassHealth Standard, helping people maintain health insurance while earning income. 

Medicare

Medicare is a federal health insurance program that provides important coverage, but it works differently than MassHealth. Persons with disabilities younger than 65 years may be eligible for Medicare if they’ve collected Social Security disability benefits for 24 months. Understanding Medicare is important for aging caregivers who are planning for the future. 

• Who Is Eligible for Medicare? 

Medicare provides health insurance for people who: 

• Are age 65 or older, or 
• Have a disability, or 
• Have end stage renal disease (ESRD) or ALS (Lou Gehrig’s disease) 

If an adult with a disability under age 65 is receiving Social Security Disability Insurance (SSDI) or survivor’s benefits, there is a 24-month waiting period before Medicare coverage begins. You can learn more about details on page 4 here.  

• Medicare does NOT cover all medical costs 

Medicare pays for many medical services, but it does not cover everything. It is best used with other coverage. Even with Medicare, you need additional insurance (called secondary or supplemental coverage) or private advantage plans to help with: 

• 20% coinsurance that Medicare doesn’t pay 
• Annual out-of-pocket medical costs 
• Prescription drugs (Part D) 
• Vision and hearing care 
• Dental care (often not covered by traditional Medicare) 

• Options to Supplement Medicare 

There are several choices to help fill the gaps in Medicare coverage.  For adults with disabilities, MassHealth is the most typical option: 

• Medicare Advantage Plans (Part C): These are private insurance plans that replace traditional Medicare and may include additional benefits like prescription drug, vision, or dental coverage. 
• Medigap (Supplemental Insurance): These plans help pay deductibles, coinsurance, and other costs that Medicare doesn’t cover. 
• MassHealth: For people who qualify, MassHealth can help with Medicare coinsurance and other out-of-pocket costs. 

Learn more about Medicare and purchasing other related insurance including advantage plans here.   Learn more about MassHealth here. 

Helpful Tips

• Compare Medicare and MassHealth: Medicare is federal health insurance; MassHealth is Massachusetts’ Medicaid program. They have different benefits and rules. Learn more about the differences here. 
• Plan Ahead: Knowing how Medicare works and how it fits with MassHealth or other insurance can help reduce gaps in coverage and avoid unexpected costs. 
• Federal Medicare information 
• See the MassHealth Overview 
• Get help through SHINE: SHINE (Massachusetts) provide free, unbiased guidance on Medicare coverage, plan choices, and managing healthcare costs. Learn more here. 

Private Insurance

There are many private insurance plans with monthly premiums. The most common private health insurance companies in Massachusetts are: 

• Blue Cross and Blue Shield of Massachusetts (BCBSMA) 
• Point32 Health (combined Tufts Health Plan and Harvard Pilgrim Health Care) 
• United Health Care 
• Other notable plans include Fallon Community Health Plan, Health New England, Mass General Brigham Health Plan, WellSense Health Plan, and Wellpoint. MassHealth offers a premium assistance plan if you have a family member with a disability in your plan and he/she is covered by MassHealth. 

Specialty Services and Resources

• Behavioral or Mental Health Crisis: Behavioral or mental health crises can occur unexpectedly and may require immediate, specialized support. Massachusetts has regional Community Behavioral Health Centers that provide urgent evaluation, crisis stabilization, and connection to ongoing supports. These centers are available for adults with intellectual or developmental disabilities as well as the broader community. Learn more here. 
• Applied Behavioral Analysis (ABA): ABA is a widely used approach for addressing challenging behaviors, teaching new skills, and supporting independence in people with disabilities. Many certified ABA clinicians provide services across Massachusetts. ABA can be used to support communication, social skills, daily living skills, and behavior management. Learn more about ABA here. One resource to locate an ABA provider in Massachusetts is here. 
• Allied Health Therapies: Allied health therapies help adults with disabilities advance, maintain, or regain functional skills across daily life, work, and community activities. These therapies are often part of a broader plan of care. are important in advancing skills or maintaining skills for adults with disabilities.  
• Physical Therapists (PT): Support gross motor skills, mobility, balance, and physical rehabilitation. 
• Speech-Language Pathologists (SLP): Support communication, language, social skills, and vocalization. 
• Occupational Therapists (OT): Focus on fine motor skills, daily living skills, work tasks, and participation in community activities. 
• Assistive Technology Professionals (ATP): Certified professionals who help individuals use technology to enhance communication, learning, and independence. It’s common for speech or occupational therapists to obtain this certification to provide integrated technology supports.  
• Search for professionals here or obtain a referral from your primary care physician or services provider.  

Resources for Information or Advocacy Regarding Health Benefits or Coverage

Families and caregivers often need support navigating health insurance, therapy coverage, and related benefits. The organizations below offer information, advocacy, and assistance. They can help families understand what services are covered, guide them through appeals or claims, and connect them to local providers and programs. 

• The Insurance Resource Center: Guidance on autism-related insurance coverage in Massachusetts. 
• Health Care for All: Support accessing health insurance, resolving coverage issues, and understanding benefits. 
• Health Advocates: Offers one-on-one advocacy for navigating complex health systems. 
• Independent Living Centers: Provide information, advocacy, and peer support for people with disabilities to access health, home, and community services. 
• Disabilityinfo.org: Provides easy-to-access information, resources, and referrals for people with disabilities and their families across the United States. 

Health and Specialty Tips for Families

• Know the difference: Medicare is federal; MassHealth is Massachusetts’ Medicaid program. They have different rules, benefits, and eligibility. 
• Plan Ahead: Understanding how Medicare, MassHealth, and any private insurance work together can prevent gaps and unexpected costs. 
• Use Specialty Services: ABA, allied health therapies (PT, OT, SLP, Assistive Technology), and behavioral supports help adults maintain or grow skills. 
• Access Crisis Support: Regional Community Behavioral Health Centers provide urgent evaluation and stabilization for behavioral or mental health crises. 
• Get Guidance and Advocacy: SHIP/SHINE, Autism Insurance Resource Center, Health Care for All, Health Advocates, and Independent Living Centers can help families navigate insurance, coverage, and local services.