2015 Eligibility Guidelines forPublic Benefits Programs

PROGRAM / Monthly Income Limit / Annual Income Limit / Asset Limit
MassHealth (Medicaid), age 65+
100% Federal Poverty Level
Complete a MassHealth SACA-2 form / $1,0011 (individual)
$1,3481 (couple) / $12,0121 (individual)
$16,1761 (couple) / $2,000 (individual)
$3,000 (couple)
MassHealth (Medicaid), under age 65
133% Federal Poverty Level
Complete a MassHealth ACA-3 form / $1,3542(individual)
$1,8322 (couple) / $16,2482(individual)
$21,9842 (couple) / No Asset Test
Health Safety Net – Full Benefits
200% Federal Poverty Level
Assists with some services received at a
hospital or CommunityHealthCenter
Complete a MassHealth SACA-2 form / $1,962 (individual)
$2,655 (couple) / $23,544 (individual)
$31,860 (couple) / No Asset Test
Health Safety Net – Partial Benefits
400% Federal Poverty Level
No asset test
Will have deductible for services
Complete a MassHealth SACA-2 form / $3,924 (individual)
$5,310 (couple) / $47,080 (individual)
$63,720 (couple) / No Asset Test
CommonHealth
Must have a disability
Work at least 40 hours/month
If income is greater than 150% FPL, will have premium
Complete a MassHealth ACA-3 form / No Limit / No Asset Test
MassHealth for Caretaker Relatives
133% of Federal Poverty Level
Parent or caretaker of a child under 19
Complete a MassHealth ACA-3 form / $1,8322(family of 2)
$2,3112(family of 3) / $21,9842(family of 2)
$27,7322(family of 3) / No Asset Test

Medicare Savings Programs (MassHealth Buy-In)

Qualified Medicare Beneficiary (QMB)
100% Federal Poverty Level
Pays for B premium, A and B deductibles
and co-insurance.
Complete a SACA-2 form / $1,0011 (individual)
$1,3481 (couple) / $12,0121 (individual)
$16,1761 (couple) / $7,280 (individual)
$10,930 (couple)
Specified Low Income Medicare Beneficiary (SLMB)
120% Federal Poverty Level
Pays for Part B Premium.
Complete a SACA-2 form or Buy-in App / $1,1971 (individual)
$1,6131 (couple) / $14,3641 (individual)
$19,3561 (couple) / $7,280 (individual)
$10,930 (couple)
Qualified Individual - 1 (QI-1)
135% Federal Poverty Level
Pays for Part B premium.
Complete a SACA-2 form or Buy-in App / $1,3451(individual)
$1,8131 (couple) / $16,1401(individual)
$21,7561 (couple) / $7,280 (individual)
$10,930 (couple)

1Amount includes applicable $20 monthly disregard for unearned income

2Amount includes applicable 5% FPL disregard

Public Assistance Programs for Individuals Needing Assistance with Activities of Daily Living (ADLs)

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FOR SHINE COUNSELOR USE ONLYUpdated 2/20/15

PROGRAM / Monthly Income Limit / Annual Income Limit / Asset Limit
MassHealth Frail Elder Waiver Program for people aged 60 or older. Requires the need for a level of care equal to that provided in a nursing home. Must be ASAP client. If married will not count spouses income. Income can be up to 300% of federal SSI.
Complete a MassHealth SACA-2 form / $2,199(individual) / $26,388 (individual) / $2,000 (individual)
MassHealth PCA - for people aged 65 or older who need personal care attendant services.
133% Federal Poverty Level (can
qualify under Frail Elder Waiver Program)
Must need assistance with 2 ADLs
Complete a SACA-2 form & PCA form / $1,305 (individual)
$1,766(couple) / $15,660(individual)
$21,192 (couple) / $2,000 (individual)
$3,000 (couple)
Adult Foster Care Program – receive care provided by friend or eligible family member in home setting
Must be eligible for MassHealth Standard (can
qualify under Frail Elder Waiver Program)
Must meet clinical eligibility / $1,0011 (individual)
$1,3481 (couple) / $12,0121 (individual)
$16,1761 (couple) / $2,000 (individual)
$3,000 (couple)
LTC Medicaid – coverage for a long term care facility
Must meet clinical eligibility.
Disqualifying transfers of income or assets may impact eligibility.
Complete a MassHealth SACA-2 form and Long Term Care Supplement. / No Limit / $2,000 (applicant)
$119,220 (spouse)
Spouse may be able to keep some of applicant’s income (maximum of $2,981/mo.) or can appeal spousal asset limit in order to pay minimal household expenses.

Programs to Assist with Prescription Drug Costs

Full Extra Help (Low Income Subsidy)
135% Federal Poverty Level
Premium below benchmark paid
No deductible, copays $2.65 - $6.60
If income below 100% FPL, copays $1.20-$3.60 / $1,3451 (individual)
$1,8121 (couple) / $16,1281(individual)
$21,7441 (couple) / $8,780 (individual)
$13,930 (couple)
Partial Extra Help (Low Income Subsidy)
150% Federal Poverty Level
25-75% subsidy in premium below benchmark
$66 deductible, copays 15% / $1,4911 (individual)
$2,0111 (couple) / $17,8921 (individual)
$24,1321 (couple) / $13,640(individual)
$27,250 (couple)
Prescription Advantage (no enrollment fee)
300% of the Federal Poverty Level
Coverage gap assistance / $2,943 (individual)
$3,983 (couple) / $35,310 (individual)
$47,790 (couple) / No Asset Test
Prescription Advantage ($200 enrollment fee)
500% of the Federal Poverty Level
Catastrophic assistance / $4,904 (individual)
$6,638 (couple) / $58,850 (individual)
$79,650 (couple) / No Asset Test

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FOR SHINE COUNSELOR USE ONLYUpdated 2/20/15