When Medicaid in Massachusetts Will Pay for a Nursing Home?

In Massachusetts, Medicaid (called MassHealth) is a very common source of funding for long-term care, particularly for people who have used up their own assets to pay for home health care or a nursing home. In 2023, the average daily cost of a private room in a nursing home in Massachusetts was $480.

Private health insurance policies generally don't cover long-term care, very few people purchase private long-term care insurance policies, and Medicare coverage for long-term care services is very limited. Fortunately, Medicaid is there to pick up the tab for many people. In a recent year, MassHealth paid for nursing homes for approximately 60-70% of nursing home residents in Massachusetts.

There are many different ways to become eligible for MassHealth, and there are specific eligibility rules for long-term care services like nursing homes (rather than for doctors' appointments, hospitalizations, and so on, for people over 65). For application information, visit MassHealth online or by phone at 800-841-2900.

When a Nursing Home Is Medically Necessary in Massachusetts?

MassHealth will pay for a nursing home only when it is medically necessary. You must show MassHealth that you meet the "nursing facility level of care," meaning that you need the kind of care that can only be provided in a nursing home.

In Massachusetts, there are two ways to meet the nursing home level of care. First, you can show that you need at least one "skilled service" daily. Skilled services are usually provided by nurses. Examples of skilled services are injections, wound care, catheter care, and monitoring of unstable conditions.

The second way to meet the nursing home level of care is by showing that you have a medical or mental condition that requires a small amount of skilled nursing help but substantial assistance with activities of daily living. (Activities of daily living include bathing, dressing, toileting, eating, transferring, and mobility.) You must show that you need skilled nursing services at least three times a week.

What Is MassHealth's Income Limit for Nursing Homes?

If you're 65 or older, you can qualify financially for MassHealth if your income is at or below 100% of the federal poverty rate, or $1,255 per month in 2024. People who receive SSI already qualify to receive MassHealth.

If your income is above the limit but you need help with nursing home costs, you still might be able to qualify for Medicaid if you're already paying for a nursing home or have other significant medical expenses. A MassHealth worker will determine your "excess monthly income" to see if you qualify.

Excess monthly income is income left over after subtracting Medicare or other health insurance premiums, a personal needs allowance, and any spousal or family maintenance needs allowances. That amount, multiplied by six, is the "deductible" that you must meet in a six-month period to be eligible for MassHealth. You must show proof that your nursing home costs or medical expenses equal the required deductible amount. Once you show medical expenses that equal your deductible, then you're eligible for MassHealth for the entire six-month period.

What Is MassHealth's Resource Limit for Long-Term Care?

To qualify for any type of Medicaid coverage in Massachusetts, an individual applicant must have no more than $2,000 in resources. Resources are assets like money and property.

Some property doesn't count toward the resource limit. In Massachusetts, one car of any value is exempt, as long as a household member is using it. Personal belongings are also exempt. Your home is exempt up to an equity value of $1,071,000 (in 2024). You can exempt more equity if you have a spouse or a minor or adult disabled child living in the home.

Retirement accounts, stocks, bonds, certificates of deposit, life insurance policies with cash value, and bank accounts are all counted as resources.

What Is the Spousal Maintenance Allowance in Massachusetts?

If you have a spouse who is going to continue to live independently (meaning not in an institution, also known as a "community spouse"), then Massachusetts will allow you as a couple to keep more income and assets to support that spouse.

Your spouse will be allowed to keep some income each month, known as a monthly maintenance needs allowance. The amount will depend on how much income the community spouse has. As of January 2024, the minimum community spouse income allowance is $2,465 per month, and the maximum is $3,853.50 per month. If your spouse needs more income than the maximum allowed, you can request a hearing to ask for more.

If you and your spouse together have $154,140 or less in assets (as of 2024), then your spouse will generally be allowed to keep all of the assets. This amount is known as the community spouse resource allowance.

If you have more than $154,140 in assets, you'll be required to spend down your assets until you reach the $154,140 eligibility limit for a community spouse. If you need to be able to keep more than $154,140 in assets in order to support your community spouse while remaining eligible for Medicaid, you can request a hearing to request that this amount be raised. Also note that, effective as of 2024, the minimum community spouse allowance is $30,828.

How Much Is the Personal Needs Allowance in Massachusetts?

If you receive MassHealth and live in a nursing home, you will be expected to spend most of your income on your room, board, and medical care. Nursing home residents receiving MassHealth can keep only $72.80 per month as a personal needs allowance.

Read on to find out when MassHealth pays for assisted living facilities and home health care.

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