Overview of the Senior Care Options Program
Massachusetts’ Senior Care Options (SCO) is a voluntary healthcare program for seniors 65+ years old that coordinates Medicaid (MassHealth) and Medicare benefits. While the program was designed for persons who are “dual eligible” (eligible for both Medicaid and Medicare), persons do not have to be eligible for Medicare. Via SCO, medical services, such as physician visits, preventative care, and laboratory work, behavioral health services, and prescription drugs are covered. Nursing home care is also an available benefit, as are other long-term services and supports to prevent nursing home care and allow program participants to continue to live at home, the home of a relative, or another setting, such as assisted living or adult foster care. Available long term services and supports (LTSS) may include adult day care, personal care assistance, personal emergency response systems, respite care, and homemaker services.
Beneficiaries of the Senior Care Options Program receive their benefits via a single Medicaid plan provided by a managed care organization (MCO). Specific to SCO, it is called a senior care organization, which is essentially a private healthcare company. The senior care organization has a network of care providers and program participants receive services via these providers. A primary care provider (PCP) within the senior care organization is chosen by the program participant. The PCP works together with a team of other network providers, such as specialists, registered nurses, and a geriatric support services coordinator, to create an individualized care plan specific to the needs of the program beneficiary.
There are several senior care organizations from which a SCO program participant can choose. Note that the options may vary based on the area within Massachusetts in which a participant resides, as all senior care organizations may not service all areas of the state. Furthermore, this program is not available statewide. Persons who live in in Dukes and Nantucket Counties cannot access SCO.
Worth mentioning is that many long-term care Medicaid programs have a participant-directed option that allows beneficiaries to hire the caregiver of their choosing. This is not an option via Senior Care Options.
SCO is an entitlement program; meeting eligibility requirements equates to immediate receipt of program benefits. Put differently, the program does not limit the number of participant enrollment slots and there is never a waitlist for program participation.
Senior Care Options was established in 2004 and is part of a 1115(a) Medicaid demonstration program. In Massachusetts, the Medicaid program is called MassHealth. MassHealth Standard is the Medicaid program specific to persons 65 years of age and older.
Medicaid pays doctors, hospitals, and other providers in one of two ways, either “Fee-For Service” or “Managed Care”. Under Fee-For Service, Medicaid pays providers directly for each service they provide. Beneficiaries can receive services from any Medicaid-certified provider. Under Managed Care, Medicaid contracts with a Managed Care Organization (MCO). Medicaid pays the MCO a set amount for each beneficiary, rather than for each service provided. The MCO has a network of doctors, hospitals, and other providers and the MCO pays them. Beneficiaries must use providers within the network.
Benefits of the Senior Care Options Program
Via SCO, a program participant can receive all of their Medicare (Part A, Part B, and Part D) and Medicaid benefits. Benefits may vary slightly based on the Senior Care Organization from which benefits are received. Furthermore, an individual care plan determines which benefits, including long-term care services and supports / home and community based services, a program participant receives. Follows is a list of potential benefits.
– 24/7 Nurse Phone Line – for health questions and information
– Adult Day Care – may include dementia care
– Behavioral Health Services
– Care Coordination
– Companionship Services
– Dental Services
– Hearing Services / Hearing Aids
– Home Health Care
– Homemaker / Chore Services
– Hospice Care
– Laboratory Tests / X-Rays
– Medical Equipment / Supplies
– Medications – prescription and prescribed over-the-counter
– Mental Health Services
– Nursing Home Care
– Personal Care Assistance
– Personal Emergency Response Systems
– Preventative Care / Screenings
– Physician Visits
– Podiatry Services
– Rehabilitative Therapy
– Respite Care – to relieve a primary caregiver
– Transportation – non-emergency medical / non-medical services
– Vision Services / Eyewear
Eligibility Requirements for the Senior Care Options Program
The Senior Care Options Program is for MA residents aged 65+ who are eligible for MassHealth Standard, which is the MA Medicaid program for persons 65+ years old. Persons can be enrolled in both MassHealth Standard and Medicare, but do not have to be enrolled in Medicare. Persons who are only enrolled in Medicare are not eligible to participate in the Senior Care Options program. Applicants must live in a geographic region that offers SCO. The only areas of exclusion are Dukes and Nantucket Counties. Persons with end-stage renal disease, living in an intermediate care facility for the developmentally disabled, or is an inpatient in a chronic or rehabilitation hospital are not eligible for SCO. Additional eligibility criteria can be found below.
Financial Criteria: Income, Assets & Home Ownership
The applicant income limit is equivalent to 100% of the Federal Poverty Level (FPL), which increases annually in January. Effective March 2023 – February 2024, the income limit for a single applicant is $1,215 / month. Married couples, regardless of if one or both spouses are applicants, can have a monthly income up to $1,643.
The income limit rules vary slightly for applicants who require nursing home care and have a spouse living at home. In this case, the applicant spouse can have income up to $1,215 / month. The income of the non-applicant spouse is not counted towards the applicant spouse’s eligibility. Furthermore, the non-applicant spouse is entitled to a monthly Spousal Income Allowance, called a Monthly Maintenance Needs Allowance, from their applicant spouse. In 2023, the maximum amount that can be transferred to a non-applicant spouse is $3,715.50 / month.
In 2023, the asset limit is $2,000 for a single applicant. For married couples, the asset limit is slightly higher at $3,000.
As with income, the asset rules are different for applicants who require nursing home care. If both spouse are applicants, each spouse can have up to $2,000 in assets. If only one spouse is applying, the applicant spouse can keep up to $2,000 in assets and the non-applicant spouse is entitled to a higher amount of the couple’s assets. This is called a Community Spouse Resource Allowance, and in 2023, allows the non-applicant spouse to keep 50% of the couple’s assets, up to $148,620. If 50% of the couple’s assets falls under $29,724, the non-applicant spouse can keep all of the couple’s assets, up to $29,724. This is in addition to the $2,000 the applicant spouse can retain.
Some assets are not counted towards Medicaid’s asset limit. These generally include an applicant’s primary home, household furnishings and appliances, personal effects, and a vehicle.
Depending on the avenue of entrance into the Senior Care Options Program, there may be a Medicaid Look Back Period. This is a period of 60-months immediately preceding one’s Medicaid application date in which Medicaid checks to see if assets were given away or sold under fair market value. Doing so violates Medicaid’s Look-Back Rule and results in a Penalty Period of Medicaid ineligibility. It is thought that the Look Back Period is only relevant for persons who require nursing home care or are accessing SCO via the Frail Elder Waiver.
The home is often the highest valued asset a Medicaid applicant owns, and many persons worry that Medicaid will take it. Fortunately, for eligibility purposes, Massachusetts Medicaid considers the home exempt (non-countable) in the following circumstances.
– The applicant lives in the home or has “Intent” to Return home, and in 2023, their home equity interest is no greater than $1,033,000. Home equity is the current value of the home minus any outstanding mortgage. Equity interest is the portion of the home’s equity value that is owned by the applicant.
– A spouse lives in the home.
– The applicant has a child under 21 years old living in the home.
– The applicant has a blind or permanently and totally disabled child living in the home.
Learn more about the potential of Medicaid taking the home here.
Medical Criteria: Functional Need
While Senior Care Options serves seniors of all functional ability, persons who require long-term care must have a functional need for such care. It is thought that most of these benefits require the program participant need assistance with a minimum of one of their Activities of Daily Living (ADLs). ADLs include transferring from the bed to a chair, dressing, bathing, mobility, eating, and toileting. One’s cognitive functioning, such as short-term memory and decision making ability, is also commonly considered and is relevant for persons with Alzheimer’s disease or a related dementia. A greater level of care, a Nursing Facility Level of Care (NFLOC), is required for nursing home care. The ability / inability to complete daily living activities and one’s cognitive functioning are also considered, though the need for assistance must be more crucial. For persons entering the SCO program via the Frail Elder Waiver, a NFLOC is also required. A functional needs assessment will be completed to determine if one meets the functional need for long term care. A diagnosis of dementia in and of itself does not mean one will qualify functionally.
Qualifying When Over the Limits
Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for Massachusetts Medicaid / MassHealth. There are a variety of planning strategies that can be used to help persons who would otherwise be ineligible to become eligible. Some of these strategies are fairly easy to implement, and others, exceedingly complex. Below are the most common.
While MassHealth has a Spenddown Program (a 6-month recurring deductible) that permits Medicaid applicants to spend “excess” income on medical expenses in order to meet Medicaid’s income limit, SCO prohibits persons from qualifying via this avenue.
When persons have assets over the limits, Irrevocable Funeral Trusts are an option. These are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Another option are Medicaid-Compliant Annuities that turns countable assets into a stream of income. There are many other options when the applicant has assets exceeding the limit.
Inadequate planning or improperly implementing a Medicaid planning strategy can result in a denial or delay of Medicaid benefits. Professional Medicaid Planners are educated in the planning strategies available in Massachusetts to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. Some of these planning strategies, like Medicaid Asset Protection Trusts, violate Medicaid’s 60-month Look Back Rule, and therefore, should be implemented well in advance of the need for long-term care. However, there are some workarounds, like the “Half a Loaf” strategy, and Medicaid Planners are aware of them. For these reasons, it is highly suggested one consult a Medicaid Planner for assistance in qualifying for Medicaid when over the income and / or asset limit(s). Find a Medicaid Planner.
How to Apply for the MassHealth Senior Care Options Program
Before You Apply
Prior to submitting an application for the Senior Care Options Program, applicants need to ensure they meet the eligibility criteria. Applying when over the income and / or asset limit(s) will be cause for denial of benefits. The American Council on Aging offers a free Medicaid eligibility test to determine if one might meet Medicaid’s eligibility criteria. Take the Medicaid Eligibility Test.
As part of the application process, applicants will need to gather documentation for submission. Examples include copies of Social Security and Medicare cards, previous bank statements, proof of income, and copies of life insurance policies, property deeds, and pre-need burial contracts. Unfortunately, a common reason applications are held up is required documentation is missing or not submitted in a timely manner.
To apply for SCO, one must apply for MA Medicaid / MassHealth. To apply for MassHealth, seniors must complete the Application for Health Coverage for Seniors and People Needing Long-Term Care Services, which can be found here. The completed application can be mailed, faxed, or dropped off at the MassHealth Enrollment Center. The fax number and addresses are on the application.
Persons already enrolled in Medicaid can contact a Senior Care Organization, which will assist the individual in the enrollment process. Persons call also call MassHealth Senior Care Options at 1-888-885-0484.
Approval Process & Timing
The Massachusetts Medicaid / MassHealth application process can take up to 3 months, or even longer, from the beginning of the application process through the receipt of the determination letter indicating approval or denial. Generally, it takes one several weeks to complete the application and gather all of the supportive documentation. If the application is not properly completed, or required documentation is missing, the application process will be delayed. Based on federal law, Medicaid offices have up to 45 days to review and approve or deny one’s application (up to 90 days for disability applications). Despite the law, applications are sometimes delayed even further.