One of the most common questions families ask when considering skilled nursing care is: “How do we pay for this?” The costs of nursing home care can be significant, and understanding how Medicare and Medicaid nursing home coverage works in Massachusetts is essential for planning effectively. Unfortunately, these programs are complex, and misinformation is widespread. This guide provides a clear overview of what each program covers, how eligibility works, and what families need to know to navigate the process.
Medicare Coverage for Skilled Nursing Facilities
Medicare is the federal health insurance program for adults 65 and older and certain younger individuals with disabilities. While Medicare does provide coverage for skilled nursing facility care, it is more limited than many families expect.
What Medicare covers:
Medicare Part A covers skilled nursing facility care when all of the following conditions are met:
- The patient had a qualifying inpatient hospital stay of at least three consecutive days (not including the day of discharge)
- The patient is admitted to a Medicare-certified skilled nursing facility within 30 days of that hospital stay
- The patient requires skilled care — such as physical therapy, occupational therapy, speech therapy, or skilled nursing services — on a daily basis
- A physician certifies that skilled nursing care is medically necessary
How the coverage breaks down:
- Days 1 through 20: Medicare covers the full cost of skilled nursing care, including room, meals, nursing care, therapy, medications, and medical supplies
- Days 21 through 100: The patient is responsible for a daily coinsurance amount (in 2026, this is approximately $204.50 per day). Many patients have supplemental insurance or Medigap policies that cover some or all of this coinsurance
- After day 100: Medicare coverage ends. The patient is responsible for all costs
What Medicare does not cover:
This is the critical distinction that catches many families off guard. Medicare does not cover long-term custodial care — the ongoing assistance with daily activities like bathing, dressing, and eating that many nursing home residents need. If a resident no longer requires skilled services but still needs help with daily living, Medicare coverage will end even before the 100-day limit is reached.
Medicare coverage is designed for short-term rehabilitation and recovery, not for indefinite nursing home residence.
What Medicaid Covers in Massachusetts
Medicaid — known as MassHealth in Massachusetts — is a joint federal and state program that provides health coverage for individuals with limited income and assets. Unlike Medicare, MassHealth does cover long-term nursing home care, making it the primary payer for residents who need ongoing skilled nursing services.
What MassHealth covers in a nursing home:
- Room and board
- Nursing care
- Personal care assistance
- Medications
- Medical supplies and equipment
- Therapy services as needed
MassHealth covers the full cost of nursing home care for eligible individuals. There is no time limit on coverage, making it fundamentally different from Medicare’s limited benefit.
The financial reality:
MassHealth coverage for nursing home care is means-tested. This means eligibility depends on the applicant’s income and assets falling below specific thresholds. For many middle-income families, this means that private resources must be spent down before MassHealth coverage begins — a process that requires careful planning to avoid unnecessary financial loss.
Eligibility Requirements and Application Process
Qualifying for MassHealth nursing home coverage in Massachusetts involves meeting both medical and financial criteria.
Medical eligibility: The applicant must require a nursing facility level of care, as determined by a clinical assessment. This is typically established at the time of admission.
Financial eligibility for individuals:
- Income: Most income is applied toward the cost of care, with the resident retaining a small personal needs allowance (currently around $72.80 per month)
- Assets: Countable assets must generally be below $2,000 for an individual. Certain assets are exempt, including the primary residence (up to a specific equity value), one vehicle, personal belongings, and certain burial funds
Financial eligibility when a spouse remains at home: Massachusetts has specific protections for the community spouse (the spouse who does not need nursing home care):
- The community spouse may retain a portion of the couple’s combined assets, known as the Community Spouse Resource Allowance. In 2026, this amount can be up to approximately $154,140
- The community spouse may also retain a minimum monthly income allowance to ensure they can continue to support themselves
The five-year look-back period: MassHealth reviews all financial transactions made within the five years prior to the application date. Any gifts, transfers, or sales of assets for less than fair market value during this period may result in a penalty period — a stretch of time during which MassHealth will not cover nursing home costs. This is why advance planning with an elder law attorney is so important.
The application process: Applying for MassHealth nursing home coverage involves gathering extensive financial documentation, including bank statements, tax returns, property records, insurance policies, and records of any asset transfers. The application is submitted to the MassHealth enrollment center, and processing can take several weeks to several months.
Common Gaps in Coverage to Be Aware Of
Even with Medicare and MassHealth available, families should be aware of several potential gaps:
The Medicare-to-Medicaid transition. When Medicare’s skilled nursing benefit ends — either at 100 days or when skilled care is no longer required — there may be a gap before MassHealth coverage begins, especially if the application is still being processed. Families should begin the MassHealth application process early, even while Medicare is still covering the stay.
Supplemental insurance limitations. Medigap policies help with Medicare coinsurance during days 21 through 100, but they do not extend the 100-day benefit or cover long-term custodial care.
Spend-down requirements. Families with assets above MassHealth thresholds must spend down to qualify. Without proper planning, this can mean depleting savings that could have been protected through legal strategies like irrevocable trusts or spousal protections.
Private room availability. MassHealth covers semi-private rooms. If a family prefers a private room, the difference in cost may need to be paid out of pocket, depending on the facility’s policies and availability.
Prescription costs. While both Medicare and MassHealth cover medications, formulary restrictions and prior authorization requirements can create delays or require alternative medications.
How Southwood Helps Families Navigate Benefits
At Southwood at Norwell Nursing Center, we know that the financial side of nursing home care can feel as overwhelming as the medical decisions. Our admissions and social services team works directly with families to help navigate Medicare and MassHealth nursing home coverage, understand their benefits, and connect with resources that simplify the process.
We help families with:
- Understanding their Medicare benefit — including what is covered during a short-term rehabilitation stay and when the benefit may end
- MassHealth application support — guiding families through the documentation requirements and connecting them with elder law attorneys who specialize in MassHealth planning
- Benefit coordination — ensuring that Medicare, MassHealth, supplemental insurance, and any other coverage sources are properly coordinated to minimize out-of-pocket costs
- Financial planning referrals — connecting families with trusted elder law attorneys and financial advisors in the South Shore area who understand the specific rules and strategies relevant to Massachusetts families
We believe that every family deserves clear, honest information about the cost of care and the resources available to them. No one should have to navigate this process alone.
If you have questions about paying for skilled nursing care, or if you would like to tour Southwood at Norwell Nursing Center and learn about our services, call us at (781) 982-7450. Our team is here to help your family find a path forward with clarity and confidence.