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Health Insurance

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This section covers four types of programs that help you get or keep health insurance while being employed:

Commonwealth Care

Commonwealth Care is a Massachusetts health insurance program for low- and moderate-income residents who otherwise don’t have health insurance. Commonwealth Care members receive free or low-cost health services through managed care plans provided by private insurance companies. Several health plans are available; each plan has different premiums.

Commonwealth Care is the result of comprehensive health reform legislation passed in Massachusetts in 2006. As a result, 97 percent of Massachusetts residents are now covered by health insurance, according to a study by the Urban Institute.

Eligibility

You may be eligible for Commonwealth Care if:

  • your family’s income before taxes meets the income guidelines for the program
  • you are uninsured
  • you are a U.S. citizen/national, or legal alien
  • you are age 19 or older (*persons under age 19 may be eligible for MassHealth benefits)

Benefits

The benefits of Commonwealth Care include regular check-ups, emergency treatment, prescriptions at your local pharmacy, vision care, and mental health or substance abuse treatment. Some members may also be covered for dental care.

Commonwealth Care is as simple as selecting your health plan and your doctor. Plans are offered by Boston Medical Center (BMC) HealthNet Plan, CelitCare Health Plan, Fallon Community Health Plan, Neighborhood Health Plan and Network Health.

To search plans, click here

Section 1619b

Section 1619(b) of the Social Security Act allows eligible individuals who are enrolled in SSI to continue Medicaid coverage when their earnings exceed the SSI eligibility. Although Section 1619(b) is essentially a continuation of Medicaid coverage, it is an SSI benefit.

Eligibility

To qualify for continuing Medicaid coverage, you must:

  • have been eligible for an SSI cash payment for at least one month
  • still meet the disability requirement
  • still meet all other non-disability SSI requirements
  • need Medicaid benefits to continue to work
  • receive gross annual earnings that are insufficient to replace SSI, Medicaid and publicly funded attendant care services.

If you are an SSI beneficiary and your earnings exceed the requirements for an SSI cash payment, you may be eligible for Medicaid if you meet the above requirements.

SSA uses a threshold amount to measure whether your earnings exceed your SSI and Medicaid benefits. This threshold is based on:

  • the amount of earnings that would cause you to become ineligible for SSI cash payments in Massachusetts
  • the average Medicaid expenses in Massachusetts.

If you are an SSI beneficiary and your gross annual earnings are higher than the threshold amount for Massachusetts, SSA can figure an individual threshold amount if you have:

  • Impairment-related work expenses; or
  • Blind work expenses; or
  • A plan to achieve self-support (PASS); or
  • Personal attendant whose fees are publicly funded; or
  • Medical expenses above the average State amount.

In 2010, the 1619(b) income threshold amount for SSI beneficiaries with disabilities in Massachusetts is $36,133.

For more information about 1619(b), visit the Social Security website

MassHealth/CommonHealth

MassHealth, the Massachusetts Medicaid program, offers comprehensive benefit plans for people with disabilities. The plans may be used alone or combined with other health insurance programs such as Medicare or health insurance offered by an employer.

The factors used to determine your MassHealth eligibility include:

  • household earned income – wages
  • unearned income – cash benefits from sources other than wages
  • employment status
  • whether the applicant has a disability

In certain circumstances, MassHealth will cover items that private health insurance will not cover such as personal care attendants, specialized wheelchairs and other necessary medical supplies. MassHealth may also cover the cost of private health insurance co-payments and/or private insurance premiums for individuals with disabilities.

Three MassHealth benefit plans for adults with disabilities are outlined below.

Eligibility Criteria MassHealth Standard CommonHealth Working CommonHealth Non-Working
Age 19-64 19 or older 19-64
Household Income At or below 133% federal poverty level Above 133% federal poverty level Above 133% federal poverty level
Work Status Could be working Working 40 hours or more each month or 240 hours in the previous 6 months Not working or working less than 40 hours each month
Disability Determined by Social Security (SSA) or MassHealth Determined by SSA or MassHealth Determined by SSA or MassHealth
Needs Test None None One time send down will apply
Premium None Based on family size & monthly household income Based on family size & monthly household income
Asset Test None None None
Redetermination Annually Annually Annually

For more information about plans, click here

To Apply for MassHealth, call MassHealth Customer Service at 1-800-841-2900 or visit mass.gov

When an application is submitted along with the necessary documentation, MassHealth renders a decision of approval with determination of benefit plan, denial or a request for additional information within 10 business days. All MassHealth decisions are in writing and come with the right to appeal.

Applicants with questions about their submitted application may call the MassHealth Enrollment Center at 1-888-665-9993 (TTY: 1-888-665-9997 for people with partial or total hearing loss)

Those with more general questions, applicants and members, should call the MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people with partial or total hearing loss)

Medicare

Medicare is a federally sponsored medical plan for individuals age 65 or older who have a qualifying disability or who have end-stage renal disease, or permanent kidney failure.

Medicare benefits are provided in four parts – A, B, C and D.

Part A helps pay for inpatient hospital care, some skilled nursing facilities, hospice care, and some home health care. Part A is premium-free for most people. Most beneficiaries pay a monthly premium to be covered by Medicare.

Part B helps pay for doctors, outpatient hospital care, and other care that Part A does not cover, such as physical and occupational therapy. There is a premium cost for Part B.

Part C allows various HMOs, PPOs and similar health care organizations to offer health insurance plans to Medicare beneficiaries. At a minimum, they must provide the same benefits that the Original Medicare Plan provides under Parts A and B. These organizations are also permitted to offer additional benefits such as dental and vision care. To control costs, Part C plans are allowed to limit a patient’s choices of doctors and hospitals to pre-selected networks. This can be a major disadvantage if a patient’s favorite doctor or hospital is not a member of a specified network.

Part D provides prescription drug benefits through various private insurance companies. Like Part B, most patients must pay additional monthly premiums each for prescription drugs. Premiums for Part D are different for every state, and often vary by company.

For more information about Medicare, click here.