MassHealth Overview and Services

Menu

MassHealth Overview

MassHealth helps adults with intellectual or developmental disabilities (IDD) and autism access the healthcare, therapies, and supports they need to live meaningful, connected lives in their communities.

MassHealth is the Massachusetts Medicaid health insurance program. It helps people with disabilities or low income pay for healthcare and related services. For adults with IDD, it often serves as the entry point to many other supports and services. Unlike a typical health insurance program, MassHealth also provides community-based services which are called “Long-Term Services and Supports.”  See LTSS in MassHealth here to learn more. 

MassHealth can cover…

  • Doctor visits and hospital care 
  • Prescriptions 
  • Therapy (occupational, physical, speech) 
  • Dental care 
  • Certain Over the Counter Drugs (but not covered if you also have Medicare) 
  • Home and Community Based Services which MassHealth terms as “Long Term Supports and Services” (noted in preceding paragraph) 

Types of MassHealth Plans

  1. MassHealth Standard provides the most access for persons with disabilities.  
  2. CommonHealth provides similar access as “Standard” but requires buying in, since it is for those adults with disabilities whose monthly income or assets exceed MassHealth thresholds. 
  3. MassHealth CarePlus is a specific, low-cost health insurance plan within MassHealth, primarily for low-income adults (ages 21-64) with incomes up to 133% of the Federal Poverty Level (FPL), offering essential medical, behavioral, vision, and hospital services, acting as a gateway to broader coverage or managing care for those with special needs without requiring extensive long-term support.   
  4. MassHealth Family Assistance is for adults with IDD who don’t qualify for MassHealth Standard and may be eligible for Family Assistance, which covers essential health care services, including doctor and hospital visits, therapies, prescriptions, dental and vision care, home health, mental health supports, preventive care, and emergency services. 

Types of Coverages within MassHealth Plans

Primary Care Clinician (PCC) Program (Traditional Medicaid) 

  • Core MassHealth coverage 
  • Provides a full range of medical and long-term support services for eligible residents, including people with disabilities 
  • This is the typical plan for persons who are eligible financially and with IDD and autism/DD 

Managed Care Plans 

Some people get their MassHealth benefits through private health insurance companies OR health care entities contracted with MassHealth.  MassHealth encourages these options. These plans coordinate care, make sure doctors and therapists are in-network, and manage certain behavioral health services. Some choose Accountable Care Organizations (ACO) or another managed care plan as they may have more flexibility or additional benefits. ACOs and Managed Care organizations are here. 

  • Accountable Care Organizations (ACO) – health entities contract with MassHealth to provide health and related services to a defined population  
  • One Care Program for beneficiaries combining Medicare and Medicaid – three insurance companies provide this option: Tufts Health Plan, Community Care Alliance, and United Healthcare Connected. 
  • Managed Care Organizations (MCO) – there are two: WellSense Essential MCO and Tufts Health Together. 

If you are enrolled in MassHealth Standard or CommonHealth, you can learn more about Long-term services and supports for adults with disabilities here.     

Getting Started: Confirm MassHealth Eligibility, Both Financial and Disability Status 

  • To receive LTSS, the individual must be enrolled in MassHealth Standard or CommonHealth. 
  • Apply for MassHealth Standard or confirm the adult’s current coverage status. There is a general application and a disability supplement. 
  • Adults with disabilities should apply at age 18, even if they were covered as a child. 
  • Get started or check eligibility: MassHealth Enrollment & Benefits 

You can apply in the way that works best for you. We encourage online applications as you can have all your back-up information on hand in case there are questions during the application process (always keep copies for yourself and for the future): 

  • By Phone:
    MassHealth Customer Service Center: 1-800-841-2900 (TTY: 711)
    MassHealth Enrollment Center: 1-877-MA-ENROLL (1-877-623-6765) 
  • By Fax: (857) 323-8300 

Need Help Applying?

You should be directed when applying online to the disability supplement application (which can’t be completed online).  Review the supplement which is here.  Always keep copies of important forms and back-up materials. The supplement is 16 pages, and it requires authorization to allow confidential information to be shared with MassHealth from the adult’s providers. It also has a page for the Authorized Representative of the adult. This is for family members or others filling out the page on behalf of an individual with disabilities. 

Choose Your Plan and Providers

  • Choose your coverage type after MassHealth member approval (see coverage types above). If an adult has a key physician (it may be a primary care doctor or a specialist), you may want to choose the coverage option that allows this professional to continue. You may still need to choose other health providers. Finding the right provider can take time, and different resources vary in usefulness. 
  • If you haven’t already, you need to identify the LTSS option(s) needed by the adult.  You can research this before approval of the application. 
  • The following may assist you with recommendations or referrals: 
  • Start with your DDS Area Office, which can be one of the most reliable sources for a local list of MassHealth LTSS providers 
  • Family Support Centers, accessed through DDS, can help families: 
  • Understand available services 
  • Connect with providers 
  • Navigate next steps and paperwork 

Choose Your LTSS

  • After determining which long-term services and supports would work best, an assessment for each service is required.  
  • Each LTSS service has its own clinical eligibility criteria, in addition to MassHealth eligibility until an Independent Assessment Entity is fully implemented.   
  • Assessments are handled differently for each LTSS service and are often completed by the service provider. 
  • MassHealth directly or through an intermediary then authorizes the services (Prior Authorization). 

Additional assistance can be found:  

  • Overview intended for agencies which has specifics on services – Pages 7-14 review the LTSS services. Page 19 for durable medical equipment and Page 24 for home health services.  
  • Independent Living Centers are nonprofit organizations that help adults with IDD and families access resources, complementing but not funding or managing DDS services. 
  • Having trouble accessing MassHealth, contact my ombudsman  

Key Takeaways

MassHealth is an option for all people with disabilities. It is a vital resource for adults with IDD and autism. It provides access to medical care, therapies, and community-based services, helping people live in their communities. MassHealth LTSS addresses gaps for individuals with disabilities who are unable fully access services from DDS. 

Tips for Caregivers

  • Know the basics: MassHealth eligibility is based on income, residency, and asset limits. 
  • Ask for help: DDS service coordinators, social workers, or support staff can assist with applications. 
  • Stay organized: Keep diagnoses, evaluations, and service records handy. 
  • Understand coverage: Know what your plan covers, what needs prior authorization, and review it yearly. 
  • Apply online when possible: Online applications can be saved and easily updated. 
  • Service access varies: Coverage includes many disabilities, but community-based services require meeting service-specific criteria. 

MassHealth Services

MassHealth Services  (LTSS)

MassHealth Long-Term Services and Supports (LTSS) help people with disabilities get the ongoing assistance they need to live safely, participate in daily life, and remain part of their community. These services go beyond doctor visits and hospital care, supporting everyday needs like personal care, skill-building, transportation, and safety, including: 

  • Activities of Daily Living (ADLs): bathing, dressing, toileting, eating, mobility
  • Instrumental Activities of Daily Living (IADLs): meal preparation, banking, shopping, laundry, housekeeping
  • Skilled medical care: nursing services, therapies, and health monitoring
  • Medical equipment and supplies: to support safety, mobility, and independence 

See the MassHealth Overview for information on eligibility and applying for MassHealth.   

Unless otherwise indicated, you must have MassHealth Standard or CommonHealth (a buy-in option for those whose income is too high) for LTSS, and you must be determined clinically eligible for each support or service you receive. Clinical eligibility is decided through providers and then approved through a prior authorization process at MassHealth’s Office of Long-Term Services and Supports (OLTSS) or a designated contractor.  Adults with disabilities should apply for MassHealth at age 18 to ensure access to these supports.   

Finding the Right Entry Point

You can locate LTSS services a number of ways: 

  • LTSS may begin through a Department of Developmental Services (DDS) area office referral.  Search for your area office by town/city.
  • Family or autism support centers can help to connect you to long term services.
  • Families often learn about services from PCA, AFC, or day habilitation providers or through a managed care program. 

Specific Long-Term Services and Supports Available Through MassHealth for Adults with IDD 

  • Personal Care Attendant (PCA)
    • What it is: in-home, hands-on assistance with daily activities such as bathing, dressing, toileting, eating, transfers, and mobility.
    • Eligibility: the member has a medical or mental condition that requires physical assistance with two or more of the following ADLs: mobility, including transfers; taking medications; bathing/grooming; dressing or undressing; range-of-motion exercises; eating; and toileting 
    • Key points: 
      • Consumer-directed (individual or designated surrogate directs care)
      • Family members may serve as PCAs in some situations (not guardians)
      • Authorized hours are based on an assessment of need 
  • Adult Foster Care (AFC)
    • What it is: daily, live-in support and supervision provided in a shared home. Caregivers receive a stipend. Monthly clinical or case management oversight is provided. 
    • Eligibility: the member has a medical or mental condition that requires daily hands-on (physical) assistance or cueing and supervision throughout the entire activity in order to successfully complete at least one of the following activities: bathing, dressing, toileting, transferring, mobility (ambulation), eating 
    • Key points: 
      • Caregivers often live in the home and may be family members. Some AFC agencies recruit non-related adults to provide support in their homes too.
      • Teens with disabilities may qualify for AFC if their family meets financial criteria (at 18 years, family criteria not applicable) 
  • Day Habilitation (Day Hab)
    • What it is: structured daytime programs focused on skill building, communication, independence, and community participation.  Includes allied health therapies and nursing.
    • Eligibility: determined by day hab provider and approved by MassHealth
    • Key points: 
      • Does not include community exposure
      • Typical attendance is five weekdays though some attend part-time due to other activities/services or health limitations. 
  • Adult Day Health (ADH)
    • What it is: a structured daytime program offering personal care, nursing oversight, meals, and social activities in a supervised setting. 
    • Eligibility: members with chronic medical or mental health conditions who require nursing care including assistance with one or more of the activities of daily living or at least one skilled service (licensed professionals).
    • Key points: 
      • Includes nursing and personal care 
      • Provides meals and social opportunities 
      • Can be used alongside PCA, AFC, or in-home supports 
  • Home Health Agencies (HHA)
    • What it is: skilled nursing, home health aide services, and therapies (physical, occupational, speech) provided in the home or community. Some agencies offer Continuous Skilled Nursing (CSN) for individuals with complex medical needs. 
    • Eligibility: physician referral after an in-person visit (physician’s order).  MassHealth approval needed if exceeding certain number of visits (depending on provider role) or medications prescribed. For CSN eligibility, typically for those with complex medical conditions, prior authorization by MassHealth is required, and must be under the care of a doctor.
    • Key points: 
      • May be short-term or ongoing 
      • Can be combined with PCA, AFC, Dayhab, or ADH but not during home health visit 
      • Available to MassHealth Standard, CommonHealth, Family Assistance, or CarePlus members who meet clinical criteria 
  • Durable Medical Equipment (DME)
    • What it is: medical equipment such as wheelchairs, walkers, hospital beds, shower chairs, and adaptive devices.
    • Eligibility: prescription and letter of medical necessity. Most DME must receive prior authorization. There are limits on supplies or replacement of equipment as dictated by MassHealth.
    • Key points:
      • Providers and prescribers are responsible for insuring that DME is based on medical and functional needs
      • Typically used alongside other LTSS 
  • Transportation
    • What it is: MassHealth transportation helps eligible members get to medically necessary appointments and authorized LTSS programs when they cannot use regular transportation.
    • Eligibility: requires medical prescription stating that the member can’t use public transit due to a disability or medical condition. Eligibility through options noted below.  The form is called PT-1 (prescription for transportation).
    • Key points:
      • Available to MassHealth Standard, CommonHealth, or CarePlus members who meet clinical criteria
      • Includes standard or wheelchair-accessible vehicles
      • Used for medical appointments
      • Online Transportation form 

Many adults with IDD receive community supports from both MassHealth LTSS and DDS depending on eligibility and the options available. 

Helpful Resources

Get the latest news directly to your inbox

Sign up for the latest news, events, and ways you can get involved with The Arc.

Name

By submitting your email you agree to The Arc terms