Is MassHealth Medicare or Medicaid?

If you’re asking ‘is MassHealth Medicare or Medicaid?’ — the answer is straightforward: MassHealth is the Medicaid program in Massachusetts. It provides health coverage for over a million low-income residents, offering essential services like hospital care and more.

This article will guide you through the details of MassHealth, its comparison with Medicaid and Medicare, and what it means for Massachusetts residents.


Key Takeaways

  • MassHealth is a state-administered Medicaid extension in Massachusetts tailored to provide a broader range of healthcare coverage, including dental and vision, to over 1 million low-income residents, compared to standard Medicaid.


  • Medicare is a federal health insurance program for individuals 65 and older or certain disabled people, divided into four parts (A, B, C, and D) covering different healthcare services and funded through federal revenues, payroll taxes, and beneficiary premiums.


  • Massachusetts residents may be eligible for both MassHealth and Medicare, known as dual eligibility, offering comprehensive coverage by combining the benefits of both programs, and there are programs such as PACE and SCO specifically tailored for these dual-eligible individuals.

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Unveiling MassHealth: A Medicaid Extension in Massachusetts

MassHealth is a state-administered extension of Medicaid in Massachusetts, providing health insurance coverage to over 1 million residents, including low-income individuals, families, and seniors. The aim of this program is to provide vital medical care, such as hospital services, to individuals who might find it challenging to pay for it.

Thus, MassHealth serves as an indispensable lifeline for numerous Massachusetts inhabitants, guaranteeing access to necessary healthcare services.

Unveiling MassHealth: A Medicaid Extension in Massachusetts

Moreover, MassHealth doesn’t operate in isolation. Its rules and operations are shaped by federal guidelines, but it also offers additional benefits and coverage options tailored to Massachusetts residents. So, MassHealth is more than a localized version of Medicaid – it’s a program with its own distinct attributes and advantages.


Who Benefits from MassHealth?

The benefits of MassHealth extend to a wide range of people, including:


  • Children and parents of children
  • Pregnant women and unborn children
  • Elderly individuals
  • Disabled persons in need of general healthcare
  • Low-income families

MassHealth provides a broad safety net for Massachusetts residents.


The primary determinant for MassHealth’s financial eligibility is the Modified Adjusted Gross Income (MAGI) financial approach. This method calculates income based on IRS rules with certain adjustments. However, it’s not just about income.

Individuals must also possess assets totaling less than $2,000 to meet the criteria for benefits, and monthly premiums may apply to some individuals based on their income and eligibility category.


How Does MassHealth Compare to Standard Medicaid?

Although MassHealth operates under federal Medicaid guidelines, it’s not a carbon copy of the federal program. Instead, it provides additional benefits such as dental, vision, and transportation to medical appointments, among others, offering a wider range of coverage options.

Hence, MassHealth provides a more extensive program than standard Medicaid, guaranteeing that Massachusetts residents can access necessary care.

That said, the eligibility criteria for MassHealth and standard Medicaid are similar, determined primarily by income and assets rather than age. Furthermore, the cost-sharing under MassHealth may vary, as it encompasses a broader spectrum of healthcare benefits, including long-term care services, and offers various insurance plans with different cost-sharing arrangements.

Decoding Medicare: The Federal Health Insurance Program


MassHealth_logoWhile MassHealth is a state-administered program, Medicare is a federal health insurance program that is accessible to individuals aged 65 and older, as well as certain disabled persons.

Unlike MassHealth, which is aimed at low-income individuals and families, Medicare targets a different demographic, focusing more on age and disability status.



It also covers services like:

  • hospital stays
  • doctor visits
  • prescription drugs
  • preventive care
  • nursing home care (under specific conditions)


Medicare is administered by the Centers for Medicare & Medicaid Services, ensuring uniformity of the program across all states. It’s funded through several sources, including general federal revenues, payroll tax revenues, and beneficiaries’ premiums.

This underlines the contrasts between MassHealth and Medicare, going beyond coverage to include administrative structure and funding sources.


Understanding Medicare Parts

Medicare is divided into four parts, each covering different aspects of health care and providing various medicare benefits:


  1. Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
  2. Part B is designated for doctor’s visits and other outpatient services.
  3. Part C, also known as Medicare Advantage, is an alternative to Original Medicare and includes all benefits and services covered under Parts A and B, and may also include prescription drug coverage.
  4. Part D provides prescription drug coverage.


Such segmentation enables Medicare to deliver an extensive array of services, ensuring that beneficiaries can access required care.

It’s significant to recognize that Medicare Part B enrollment isn’t obligatory. It’s considered optional coverage that’s available for individuals who qualify for Part A based on their work history. However, if one does not have sufficient work history, they can purchase Part B by paying a premium.


Medicare Eligibility Criteria

Eligibility criteria for Medicare are set based on factors such as:


  • Age
  • Employment history
  • Citizenship
  • Disability status


Although there are exceptions for certain medical conditions. For instance, US citizens aged 65 and older, as well as certain younger individuals with disabilities, meet the eligibility requirements for Medicare.


Is medicaid the same as masshealth



Additionally, individuals with end-stage renal disease can qualify for Medicare at any age if they, their spouse, or their parent (if they are a dependent child) have met the required work criteria. As for work history prerequisites, individuals are eligible for Medicare Part A without any premium if they have accumulated enough work history to earn a minimum of 40 credits, with one credit granted for every $1,410 earned, up to four credits per year.

In terms of disability status, it’s determined by the individual’s receipt of Social Security Disability benefits for a minimum of 24 months.

Distinguishing Between MassHealth and Medicare

Despite MassHealth and Medicare both aiming to provide health coverage, they display several prominent differences. For one, Medicare is a federal program designed for US citizens aged 65 and older, as well as some disabled individuals. On the other hand, MassHealth is a state-administered program specifically intended for low-income individuals and families.

This difference in target demographic is further reflected in their coverage scope. MassHealth provides coverage types such as Standard and CommonHealth, which encompass services that are not included in Medicare.

Conversely, Medicare provides coverage for specific services such as certain behavioral health services and other services not included in Medicare Part A or Part B, which are not covered by MassHealth.


Coverage Scope: What Each Program Offers

In terms of coverage, both Medicare and Medicaid and MassHealth each present distinctive offerings.


Medicare vs medicaid



MassHealth provides coverage for:


  • doctor visits
  • hospital stays, including hospital care
  • rehabilitation and therapeutic services
  • behavioral services
  • various types of long-term care services


It caters to a wide range of needs, ensuring that its beneficiaries have access to comprehensive health care.

In contrast, Medicare offers extensive coverage for a range of medical services, including:


  • inpatient hospital stays
  • care in skilled nursing facilities
  • hospice care
  • certain home health care
  • doctors’ services
  • outpatient care
  • medical supplies
  • preventive services
  • prescription drug expenses


However, when it comes to long-term care services, Medicare generally has limitations, with MassHealth offering more comprehensive coverage.


Funding and Costs: How Programs are Paid For

MassHealth and Medicare also differ in their funding mechanisms. While MassHealth receives funding from both state and federal sources, with the federal government contributing more than half of the cost, Medicare is a federal program funded through federal revenues, payroll taxes, and beneficiary premiums.

The cost structure of these government programs also varies. Here are some key points to consider:


  • MassHealth encompasses a broader spectrum of healthcare benefits, including long-term care services, and offers various insurance plans with different cost-sharing arrangements.
  • Medicare relies on federal revenues, payroll taxes, and beneficiary premiums for its funding.
  • Beneficiary premiums specifically contribute to 15% of the financing in the case of Medicare Part D.

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The Intersection of MassHealth and Medicare

Despite their clear differences, MassHealth and Medicare do overlap in certain areas. Some Massachusetts residents may be eligible for both MassHealth and Medicare, referred to as being “dual eligible”. This dual eligibility allows these individuals to access a wider range of healthcare services, combining the benefits of both programs.

Being dual eligible offers extensive healthcare coverage and facilitates the coordination of care for individuals who meet the criteria for both MassHealth and Medicare programs. This guarantees that these individuals receive optimal healthcare, customized to their unique needs.


Navigating Dual Eligibility

For individuals eligible for both MassHealth and Medicare, understanding dual eligibility can yield extra benefits and cost savings.

These individuals receive most of their fundamental medical services through Medicare, with MassHealth offering long-term services and supports. MassHealth also assists in covering the out-of-pocket costs for dual-eligible members, providing added financial relief.

Furthermore, the expenses of healthcare coverage for MassHealth and Medicare beneficiaries are combined when serving dual eligible members, with contributions from both MassHealth and Medicare.


Masshealth vs medicaid



This cost amalgamation guarantees comprehensive healthcare coverage for dually eligible individuals, with Medicare handling most preventive, primary, and acute health care services, and Medicaid taking care of long-term services and supports.


MassHealth Members with Medicare

MassHealth members with Medicare have access to a range of programs that combine benefits from both programs. These include PACE, Qualified Medicare Benefit, and Senior Care Options, each offering unique benefits tailored to the needs of these members.

For example, the Senior Care Options (SCO) program integrates MassHealth and Medicare funding to provide extensive healthcare coverage for seniors.

The Qualified Medicare Benefit program provides financial assistance to disabled individuals with low income, covering their Medicare premiums if they satisfy the income requirements for MassHealth. Lastly, PACE offers a comprehensive array of medical and social services tailored to eligible elderly participants, achieved through the integration of Medicare and Medicaid benefits.

Additional Health Coverage Options in Massachusetts

Other health coverage options exist for Massachusetts residents who may not qualify for MassHealth or Medicare. One such option is the Massachusetts Health Connector, the official health insurance marketplace for the state.


Masshealth and medicare dual eligible



This offers residents and small businesses the opportunity to:


  • Browse and purchase health and dental coverage
  • Compare different plans and prices
  • Access financial assistance programs
  • Enroll in coverage


The Massachusetts Health Connector provides another avenue for access to healthcare.

To be eligible for the Health Connector, one must:


  • Be a resident of the state
  • Be a U.S. citizen, a ‘lawfully present’ non-citizen, or a permanent resident
  • Have an income that is no more than 500% of the federal poverty level for their family size


The expenses for private health insurance, such as Health Connector plans, vary depending on the type of plan and the insurer, offering flexibility in terms of cost.


In conclusion, understanding the differences and intersections between MassHealth and Medicare is crucial for Massachusetts residents seeking healthcare coverage. While MassHealth is a state-administered program focusing on low-income individuals and families, Medicare is a federal program targeting seniors and disabled persons.

However, some residents may be eligible for both programs, offering them a wider range of healthcare services. Furthermore, Massachusetts offers additional health coverage options, such as the Health Connector, ensuring that all residents have access to the healthcare they need.

Frequently Asked Questions



→  Is MassHealth part of Medicaid or Medicare?

Yes, MassHealth is part of Medicaid, as both programs are combined in Massachusetts to form a single program providing health insurance for low to moderate income residents.


→  Will MassHealth pay my Medicare?

If you have MassHealth, it may pay your Medicare Part B premium, Part D coverage, and help with co-payments to doctors and hospitals. Additionally, MassHealth may also help pay your Medicare Part A premium if applicable.


→  What is Medicare?

Medicare is a federal health insurance program available to individuals aged 65 and older, as well as certain disabled persons. It provides coverage for hospital stays, doctor visits, and other medical services.


→  What other health coverage options are available in Massachusetts?

In addition to MassHealth and Medicare, Massachusetts provides other health coverage options like the Health Connector, the state’s official health insurance marketplace. These options can help individuals find suitable coverage for their needs.

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Russell Noga
( Medicare Expert )

Russell Noga is the CEO of ZRN Health & Financial Services, and head content editor of several Medicare insurance online publications. He has over 15 years of experience as a licensed Medicare insurance broker helping Medicare beneficiaries learn about Medicare, Medicare Advantage Plans, Medigap insurance, and Medicare Part D prescription drug plans.