Massachusetts
Massachusetts’s Medicaid agency and its state plan are the official source for these rules. This page summarizes them as researched in October 2026; check the state’s own documents, listed under Sources, before relying on them.
At a glance
- Rate method
- Statewide price
- Case-mix level
- Resident-level
- Classification
- PDPM
- Rate updates
- Once a year
- Managed care (LTC)
- Yes
- Quality program
- Quality rate adjustment
- Paid outside the rate
- Small
- Bed hold
- Hospital and leave
- Published rates
- Rates and build‑ups
- Assisted living
- Covered
- Personal needs allowance
- $72.80 / month
Overview
- MassHealth pays every home the same statewide prices, then adjusts them by percentages.
- The per diem = a nursing standard payment for the resident's PDPM nursing group (25 groups, $71.44 to $442.48 from 10/1/2026) + a flat operating payment ($128.14) + a home-specific capital payment (capped at $50).
- Nursing and operating are then moved up or down by percentage adjustments: High Medicaid share (+3/6/9%), quality (-7% to +6% in the 10/1/2026 file), the 75% direct-care spending test (up to -5%) and a maximum-change cap.
- Prices come from 2023 base-year costs plus a 7.04% inflation factor.
- In the 10/1/2026 file (330 homes), the median total rate is $313.11 for group K (LBC1), $225.74 for the lowest group (Y) and $607.16 for the highest (A).
What matters in Massachusetts
- Rates are paid per resident: each home has 25 posted rates, one for each PDPM nursing group, from about $200 to $836.
- 185 of 330 homes get a 3%, 6% or 9% High Medicaid boost for 70%, 75% or 90%+ Medicaid days.
- Homes must spend 75% of revenue on direct care. Those below lose 0.5% of rate per point short, up to 5%; 31 homes were cut on 10/1/2026.
- Staffing below 3.58 nurse hours per resident day cuts the rate by 0.5% to 3%, and by 8% at 3.00 or below from 10/1/2026.
- Provider tax $34.90 per non-Medicare day (7/1/2026); 87 homes with 87%+ Medicaid or nonprofit status pay $10.47.
- SCO and One Care plans pay long-stay nursing home care with no day limit and must pay at least MassHealth rates.
Frequently asked
Does Massachusetts pay one nursing home rate per facility or per resident?
Per resident. Each home has 25 rates, one per PDPM nursing group. Each MassHealth claim pays the rate for that resident's group from their latest OBRA MDS, so the posted rates are a menu, not one per diem.
How does Massachusetts penalize nursing homes for low staffing in Medicaid rates?
Two ways. Below 3.58 nursing hours per resident day, the quarterly rate is cut 0.5% to 3%, and 8% at 3.00 or below from 10/1/2026. Separately, spending under 75% of revenue on direct care cuts the next year's rate up to 5%.
Do Massachusetts Senior Care Options plans pay for long-term nursing home stays?
Yes. SCO, One Care and PACE cover nursing facility care with no time limit. The SCO contract sets a minimum fee schedule directed payment for Medicaid-covered nursing facility services, tied to the MassHealth rates.
How much is paid outside the posted rate in Massachusetts?
Small: a few location supplements ($2.97M North Adams, $3.8M Martha's Vineyard) and municipal-home CPE settlements.
What does Massachusetts Medicaid pay on Medicare coinsurance days?
Lesser of (MACPAC 2025 reading of 130 CMR 450.318): coinsurance is paid only up to the MassHealth rate net of Medicare's payment, usually $0 to the home.
Does Massachusetts require a minimum share of spending on care?
Yes: 75% direct-care cost quotient; 0.5% rate cut per point short, up to 5%.
How is the Massachusetts nursing home provider tax charged?
$34.90 per non-Medicare day (7/1/2026); $10.47 for nonprofit CCRCs, big nonprofit Medicaid homes or 87%+ Medicaid homes.
How the rate is set
How the method got here
| Effective | From | To | Change | Headline | Source |
|---|---|---|---|---|---|
| before 2018 (date not confirmed) | Facility-specific cost-based per diems | Statewide standard payments: nursing price by management minute (MMQ) group, flat other operating price, home-specific capital | Massachusetts paid statewide standard prices built from industry median costs (base year 2007 by 2018), with nursing set by MMQ case-mix group. The exact start date was not confirmed. | Statewide standard payments with MMQ case mix | https://www.macpac.gov/publication/nursing-facility-payment-p… |
| 2020-10-01 | No direct-care spending or staffing rules in rates | 75% Direct Care Cost Quotient with rate cuts; 3.58 HPPD staffing minimum with a 2% quarterly cut (from 1/1/2021) | Massachusetts tied rates to spending at least 75% of revenue on direct care and to meeting 3.58 nursing hours per patient day. | Direct-care spending and staffing penalties introduced | https://www.mass.gov/regulations/101-CMR-20600-standard-payme… |
| 2023-10-01 | MMQ case-mix assessments (Management Minute Questionnaire) and monthly licensed nursing summaries | CMS OBRA MDS 3.0 assessments and the PDPM nursing group for FFS claims | MassHealth dropped its own MMQ assessment and began classifying residents for payment from MDS PDPM nursing groups. | MMQ replaced by MDS PDPM nursing classification | https://www.mass.gov/doc/nursing-facility-bulletin-201-update… |
| 2024-10-01 | MMQ-era nursing payment groups, 2007-based prices | 25 PDPM nursing-group prices rebased to 2019 costs (+23.5% CAF), with High Medicaid, quality and direct-care add-on percentages and a 130% gain cap | Nursing prices were re-set on the 25 PDPM nursing groups and rebased, with percentage adjustments layered on top. | PDPM nursing-group prices and percentage adjustments adopted | https://www.law.cornell.edu/regulations/massachusetts/101-CMR… |
Verified October 11, 2026
Cost basis
- Uses cost reports
Yes
- Cost report
Massachusetts Nursing Facility Cost Report filed with the Center for Health Information and Analysis (CHIA) under 957 CMR 7.00, plus realty company and management company cost reports and financial statements (101 CMR 206.08). State-operated homes file the CMS-2540.
- Base year and rebasing
Base year 2023 for nursing, operating and capital from 10/1/2025, kept for 10/1/2026 (101 CMR 206.03). Earlier base years: 2019 (rates from 10/1/2024) and 2007 (in the 2019 MACPAC entry). Rebasing is irregular and set by each year's budget/regulation, not a fixed cycle.
- Components
Component Method Notes nursing standard payment Statewide price for each of 25 PDPM nursing groups = a statewide nursing amount x the CMS PDPM nursing CMI, from 2023 base-year nursing costs + a 7.04% cost adjustment factor (10/1/2026). Range $71.44 (Y/PA1, CMI 0.62) to $442.48 (A/ES3, CMI 3.84). A Nursing Standard Payment Adjustment (hold-harmless) keeps a home's average nursing rate from falling. From 10/1/2026 it applies only to pediatric homes (1 home, +8.7%); in 2024-2025 it also covered High Medicaid (75%+) homes. operating cost standard payment Flat statewide price for all groups: $128.14 (10/1/2026), $127.26 (10/1/2025), $125.41 (10/1/2024). Covers dietary, laundry, housekeeping, plant, administrative and general, and similar costs. Pediatric homes get the greater of their own cost-based rate or the standard. capital payment Home-specific: allowable base-year (2023) capital costs + 6.65% CAF, divided by constructed beds x days x the greater of 90% or actual base-year utilization. Kept within 90%-150% of the prior capital rate, capped at $50.00/day. New, replacement or fully relocated homes since 10/1/2023 get a flat $50.00. 10/1/2026 file: median total capital $19.90/day (range $10.99-$50.00). percentage adjustments Applied to nursing + operating at every PDPM group: High Medicaid (+3/6/9%), quality (sum of three measures), DCC-Q penalty (0 to -5%), maximum change adjustment. The HPPD staffing penalty is recovered quarterly as an overpayment. 10/1/2026 file: total adjustments range -9% to +15% (median +3%). - Inflation
Cost adjustment factor (CAF) set in regulation each rate year: 7.04% from the 2023 base year for nursing and operating (10/1/2026); capital 6.65%. For state-operated homes, a composite of CMS nursing home without-capital market basket, regional health CPI and Massachusetts CPI (101 CMR 206.06(11)(b)).
Verified October 11, 2026
Case mix
- System
PDPM
- Applied at
Resident-level
- How it works
'MassHealth uses each resident's PDPM nursing case-mix category, as determined by the MDS assessment, to establish payment rates for MassHealth nursing facility fee-for-service claims' (NF Bulletin 201, July 2026). The rate file posts 25 rates per home.
- Classification
CMS PDPM nursing component only (third HIPPS character, 25 groups A-Y), using CMS PDPM nursing CMIs (2026 weights in the 10/1/2026 table). PT/OT, SLP and NTA components are not used.
- Applies to
Nursing standard payment. Operating and capital are flat across groups, but the percentage adjustments scale both nursing and operating.
- Acuity measured from
Payment is per resident, not per home. Facility-average PDPM nursing case mix (calendar 2025 for 10/1/2026 rates) is used only to compute the hold-harmless and maximum-change adjustments. Assessments used: OBRA admission (or PPS 5-day), quarterly, annual, significant change and corrections. MDS must carry the MassHealth provider and member IDs; quarterlies are accepted within 21 days of the 92-day deadline.
- Updated
Per resident with each qualifying MDS assessment (at least quarterly). Prices reset each October 1.
- Move to PDPM
MMQ (Management Minute Questionnaire, state-specific minutes-based groups, six payment groups H-T in 2019) was replaced by MDS 3.0 OBRA assessments for FFS claims with service dates from 10/1/2023 (NF Bulletins 181/197/201; Monthly Licensed Nursing Summaries no longer required from 10/1/2023). Rates priced on 25 PDPM nursing groups appear in 101 CMR 206.04 from 10/1/2024 (2022 CMIs), with a hold-harmless for pediatric and 75%+ Medicaid homes and a 130% cap on gains versus the 9/30/2023 MMQ-based rate.
Verified October 11, 2026
Low-acuity residents
None found as a carve-out. Low PDPM nursing groups simply carry low nursing prices (10/1/2026: Y/PA1 $71.44, W/PA2 $77.20, versus $442.48 for A/ES3), but the same operating and capital payments apply. Separately, residential care (Level IV) beds in dually licensed homes get a flat $140.41 for nursing + operating (101 CMR 206.06(10)). That is a licensed bed type, not an acuity test. Checked: 101 CMR 206.00 (emergency 10/1/2026), 130 CMR 456.
Verified October 11, 2026
Capital
Home-specific prospective capital per diem from base-year (2023) allowable capital costs + 6.65% CAF, divided by beds at the greater of 90% or actual occupancy. Held within 90%-150% of the prior rate and capped at $50.00. New, replacement or relocated homes (on or after 10/1/2023) get a flat $50.00. Revised capital payments are available for approved DoN projects and room de-densification. No fair rental value system.
Verified October 11, 2026
Budget adjustment factor
No across-the-board cut. A Maximum Change Adjustment (101 CMR 206.06(15)) limits each home's new average rate to 90%-112% of its prior average (10/1/2026; 112% cap only in 2025; 130% cap in 2024). In the 10/1/2026 file 3 homes were cut by it (up to -2.5%). Rate updates follow each year's budget; the 10/1/2026 rate amendments cost an estimated $29.67M a year.
Verified October 11, 2026
Add-ons and money outside the rate
Paid outside the posted rate
- Level
small
- Estimate
Well under 5% of base. The location supplements ($2.97M North Adams + $3.8M Martha's Vineyard) total about $6.8M a year. Against an estimated $2.5B+ of MassHealth NF per diem spending (about 330 homes, median 72.5% Medicaid; spending estimated, not sourced), they are under 0.5%. The $25M RY2026 supplement (about 1%) ended 10/1/2026. Municipal-home CPE settlements are unquantified but limited to a few public homes.
- Components
North Adams supplement $2,973,456/yr; Martha's Vineyard $3,800,000/yr; municipal CPE (size not found); $25M statewide supplement in RY2026 only.
Verified October 11, 2026
Payments by owner type
- Applies
yes
- Detail
(1) Homes owned and operated by a municipality can file a CPE request after their CMS-2540. EOHHS settles the gap between Medicaid interim payments and Medicaid allowable cost, and the municipality certifies it for federal match (101 CMR 206.06(1)). (2) State-operated homes are paid reasonable cost with final settlement (206.06(11)). Private homes get the standard prices only. The 2019 $3.80/day publicly operated add-on no longer appears. The number of municipal homes using CPE was not found.
- Funding
Certified public expenditures by the municipality (no IGT pool); state general funds for state homes.
Verified October 11, 2026
Quality program
- Active
Yes
- Program
Quality Adjustments, 101 CMR 206.06(2): percent increase or decrease applied to nursing and operating payments at each PDPM group. Rate year 2027 uses three measures.
- Funding
Inside the rate (plus and minus percentages within appropriated rate spending); no separate pool or new-money appropriation found. Not shown as budget neutral.
- Size
Not a pool. 10/1/2026 file: net quality adjustments from -7% to +6% of nursing + operating; median 0%.
- Paid as
Per-diem rate adjustment (percentage) for the whole rate year.
- Measures
Measure Source Weight How points are earned CMS Five-Star overall rating (as of April 2026) CMS Care Compare -2.5% to +2% 0 stars -2.5%; 1 star -2%; 2 stars -1%; 3 stars 0%; 4 stars +1%; 5 stars +2%. SFFs count as 1 star. DPH Nursing Facility Survey Performance Tool score (as of 4/1/2026) MA Department of Public Health -3% to +2% 108 or less -3%; 109-113 -2%; 114-118 0%; 119-123 +1%; 124+ +2%. Hospitalizations per 1,000 long-stay resident days, adjusted score (as of 6/1/2026) CMS claims-based QM -2% to +2% 1.33 or less +2%; 1.34-1.69 +1%; 1.70 0%; 1.71-2.13 -1%; 2.14+ -2%. - Scoring period
Scores as of April-June 2026 set the rate year starting 10/1/2026 (4-6 month lag).
- Payment formula
Sum of the three measure percentages, applied to nursing and operating standard payments.
- Eligibility
All homes paid under 101 CMR 206.00. SFFs are treated as 1-star.
- Cadence
Annual (October 1).
- Scores published
Yes in effect: each measure's percentage per home is a column in the 'Standard Nursing Facility Rates and Components' xlsx on the 101 CMR 206.00 page.
- Notes
Rate year 2025 (10/1/2024) used four measures: CMS achievement, CMS improvement, DPH achievement and DPH improvement (up to +2%/-3% each). Rate year 2026 replaced the improvement measures with hospitalizations. The 2019 compendium listed P4P as 'Reserved'.
Verified October 11, 2026
Provider tax
- Charged
per non-Medicare day
- Standard amount
Group I $34.90 per non-Medicare patient day, effective 7/1/2026 (AB 26-14). Was $24.16 from 1/1/2023 (101 CMR 512.04(5) as of 2023). Set yearly so collections equal 6% of class revenue (emergency amendment eff. 10/1/2026). Paid quarterly.
- Tiers
Who Test Amount Homes with Medicaid utilization of 87% or higher medicaid_utilization $10.47 per non-Medicare day (30% of standard) Non-profit homes with at least 39,000 annual Medicaid bed days volume $10.47 per non-Medicare day Non-profit continuing care retirement communities and non-profit residential care facilities ccrc $10.47 per non-Medicare day - Lower for high-Medicaid homes
yes
- Returned in the rate
Not as a separate add-on. The 2018-19 state plan paid a user-fee add-on for MassHealth's share, but current 101 CMR 206.00 has none and the 10/1/2026 components file has no user-fee column. The tax is presumably recognized only through base-year costs in the standard payments (not confirmed). The DCC-Q formula subtracts user fee expense from revenue. Group lists (7/1/2026-6/30/2028): 257 homes in Group I and 87 in Group II, reset every two years from April-March data.
Verified October 11, 2026
Provider tax notes
Nursing Facility User Fee (M.G.L. c. 118E s. 63; 101 CMR 512.00): $34.90 per non-Medicare patient day (Group I) and $10.47 (Group II, 30%) from 7/1/2026 (AB 26-14). Collections are set to equal 6% of class revenue. No separate user-fee add-on appears in current 101 CMR 206.00 or the 10/1/2026 rate components file.
Verified October 11, 2026
Supplemental payments
(1) Certified public expenditures (CPE) for municipally owned and operated homes: the gap between Medicaid interim payments and CMS-2540 Medicaid allowable cost, certified by the municipality for federal match (101 CMR 206.06(1)). (2) North Adams area supplement: $2,973,456 shared by Medicaid days among homes within 17 miles of 71 Hospital Ave (since 10/1/2024). (3) Martha's Vineyard supplement: $3,800,000 for homes within 8 miles of the critical access hospital (from 10/1/2025). (4) $25,000,000 one-time statewide supplemental payment by Medicaid days (rate year 2026), removed 10/1/2026. (5) SCO minimum fee schedule directed payment for NF services (a floor, not extra money). No UPL/IGT pool for private homes was found.
Verified October 11, 2026
Other add-ons
Per-member, per-day add-ons for MassHealth-primary residents (101 CMR 206.10, 206.11, 206.15; rates from 10/1/2026): ventilator $343; communication-limited ventilator (e.g. ALS) $457; tracheostomy $220 (MDS O0100E1 required from 10/1/2026); transitional add-on $200 for the first 60 days after a hospital discharge; homelessness $200 for up to 180 days; temporary resident $130 ($250 under 22) for stays of 30 days or less from home; behavioral indicator $45 (MDS E0200/E0800/E0900 coded 2-3); SUD $45 (was $50); MOUD $100 (replaced the $200 SUD induction add-on 10/1/2026); bariatric $200 (BMI>40, was $300); dialysis $85 per treatment; complicated high-cost care (e.g. 1:1 staffing) at cost. Per home: kosher kitchen up to $5/day; multiple sclerosis homes $103.58/day. Add-ons are not billable on leave days.
Verified October 11, 2026
Units paid separately
(1) Pediatric NFs: own 2019 operating cost + A&G capped at the 85th percentile, with CAFs (3.68% operating, 3.14% capital for 10/1/2026); at least the operating standard. (2) State-operated NFs: reasonable cost via CMS-2540 with interim and final settlement. (3) Severe mental and neurological disorder programs: flat $486/day plus $150 high-cost add-on (101 CMR 206.11). (4) Residential care (Level IV) beds: $140.41 nursing + operating. (5) Contracted special programs (e.g. ventilator or brain injury contracts with EOHHS) are outside 101 CMR 206.00.
Verified October 11, 2026
Payment rules
Managed care for long-term care
- Status
yes
- Detail
SCO contract (eff. 1/1/2026) covers 'Skilled Nursing Facility/Nursing Facility Services' including the long-term custodial component: 'These services are not time limited for plan Enrollees.' SCO capitation uses Institutional Tier 1-3 rate cells keyed to PDPM nursing groups (Tier 3 = $10,096.69 per member per month, CCA 2026). Enrollment in SCO is voluntary. One Care and PACE also pay NF days. The user fee rule counts SCO/One Care/PACE non-skilled days as Medicaid days.
Verified October 11, 2026
Who pays
mixed: fee-for-service under 101 CMR 206.00 for most MassHealth nursing facility residents, plus voluntary integrated plans that pay NF care. These are Senior Care Options (SCO, 65+, six plans in 2026: CCA, Fallon, MGBHP, SWH, Tufts, UHC), One Care (duals 21-64 at enrollment) and PACE. ACO/MCO members are covered by FFS for long-term NF stays (add-on guidance sends ACO/MCO/SCO/PACE/One Care add-on questions to the plans). The FFS vs. plan share of NF days was not found.
Verified October 11, 2026
Managed care rate floor
Yes. SCO contract Appendix D, Exhibit 2 (Directed Payments effective 1/1/2026), item 6: 'Minimum fee schedule: Medicaid Covered Nursing Facility, Bariatric add-on, SUD add-on, Special Capacity add-on.' Plans must pay at least the MassHealth fee schedule for NF days. The same minimum-fee approach is assumed for One Care but was not checked. Source: https://www.mass.gov/doc/sco-contract-effective-january-1-202…
Verified October 11, 2026
Included in the daily rate
Per diem covers routine NF services (nursing, room and board, dietary, routine supplies, social and recreation services). Ancillaries are billed directly to the purchaser unless the home is in the Ancillary Pilot Program (101 CMR 206.03(2)); pharmacy, lab, x-ray and therapy by outside providers are billed separately under their own MassHealth rules. COVID-19 vaccine and antiviral administration are billable fee-for-service outside the rate. Detailed therapy and oxygen treatment were not confirmed.
Verified October 11, 2026
Bed hold
- Hospital stays
Paid: MassHealth reserves the bed for up to 20 consecutive days per medical leave of absence (inpatient or observation stay) at the leave-of-absence rate of $80.10/day. Not paid if the hospital estimates the stay will exceed 20 days, or for a same-day return.
- Leave days
Paid: non-medical leave up to 10 days per 12-month period at $80.10/day.
- Occupancy rule
None found.
- Notes
The $80.10 leave rate is flat, not a share of the per diem, and add-ons are not billable on leave days. In 2019 medical leave was 10 days; it is now 20. Plans must at least match the MassHealth bed-hold policy (SCO contract).
Verified October 11, 2026
Personal needs allowance
- Per month
72.8
- Effective
Current per 130 CMR 520.026(A); the date of the last change was not confirmed
- Notes
MassHealth deducts $72.80 for the PNA. If the resident's income is below that, MassHealth pays up to $72.80 a month. SSI recipients: also $72.80. Not COLA-indexed in the rule.
Verified October 11, 2026
Medicare coinsurance days
- Method
lesser_of
- Rule
130 CMR 450.318(D): 'The MassHealth agency's crossover liability will not exceed (1) the member's liability including coinsurance, deductibles, and copayments ... (2) the maximum allowable amount payable under the MassHealth agency's payment methodology; or (3) the MassHealth agency's established rate for crossover payment.' Unlike other insurance (450.317), the text does not subtract the Medicare payment. Read literally, MassHealth pays Part A SNF coinsurance up to the MassHealth allowable. QMBs get Medicare cost sharing paid (All Provider Bulletin 386). Medicare Advantage cost sharing is not separately addressed. SCO/One Care duals have no crossover because the plan pays both parts. Re-checked 2026-10-11: 450.318 was last amended 6/16/2017 and is unchanged. MACPAC's 2025 compendium classifies this same text as 'lesser of', reading clause (2) as the MassHealth allowable net of Medicare's payment; the regulation itself does not say which. All Provider Bulletin 386 says only that providers bill MassHealth for 'any Medicare cost sharing amounts the state is responsible for covering'. No MassHealth bulletin or billing guide stating the NF Part A calculation was found, and the 4.19-B Medicare cost-sharing page could not be retrieved (mass.gov blocks automated access; no archived copy located).
- Effect
Lesser of: MassHealth pays the Part A day 21-100 coinsurance only up to the MassHealth allowable net of Medicare's payment, which for a nursing home is usually $0 because Medicare's payment exceeds the MassHealth per diem. Classification follows MACPAC's 2025 compendium reading of 130 CMR 450.318(D) (chosen 2026-10-12); the regulation text alone is ambiguous and the 4.19-B page was not retrieved.
Verified October 12, 2026
Required care spending
- Applies
yes
- Rule
Direct Care Cost Quotient (101 CMR 206.12; AB 26-21 eff. 10/1/2026): direct care expenses / total adjusted nursing revenue must be at least 75%. Expenses count nursing, aides, dietary, housekeeping, plant, social service and recreation (x1.5), behavioral health and similar staff, onsite clerical incl. administrator up to $200,000, and resident food and supplies. Revenue excludes user fee expense and Medicare ancillaries. Penalty: 0.5% cut to nursing + operating per point below 75%, max 5%; 5% if the final report is late. Measured on the prior calendar year from RY2027 (was fiscal year). Exempt: under 5,000 MA Medicaid days, or (from 10/1/2026) 4.00+ HPPD in all four quarters. 10/1/2026 file: 31 of 330 homes cut by 0.5%-5%. The 3.177% direct care add-on (2024-25) had to be spent on direct care pay.
Verified October 11, 2026
Occupancy rules
- Applies
yes
- Rule
Capital cost is divided by beds x days x the greater of 90% or actual base-year utilization, so homes below 90% lose part of their capital (101 CMR 206.05(1)(b)). The kosher add-on uses the greater of actual days or 96%. The Low Occupancy Adjustment (-1% to -3% of nursing + operating below 88%/84%/80%, eff. 10/1/2022) appears in the 10/1/2024 rule but is 'Reserved' from 10/1/2025.
Verified October 11, 2026
MDS accuracy penalties
MassHealth audits every home's MDS twice a year at random (NF Bulletin 201, July 2026): high-PDPM assessments, behavioral-add-on assessments, 100% of significant change assessments and upward modifications for claims since 10/1/2023. Unsupported coding requires a correcting MDS with the lower PDPM nursing HIPPS code, plus overpayment recovery, corrective action plans, DPH referral or sanctions. Unsupported behavior coding claws back the behavioral add-on. No fixed percentage penalty threshold was found.
Verified October 11, 2026
Published rates and changes
How often rates change
- A home's rate changes
annual
- When
Each October 1, prices, CAFs, capital, quality, High Medicaid and DCC-Q adjustments are reset by emergency regulation. A resident's payment changes whenever a new qualifying MDS assessment changes their PDPM nursing group. The HPPD staffing penalty is applied quarterly as an overpayment recovery.
Verified October 11, 2026
When rates change
Rate year October 1 - September 30 (e.g. RY2027 began 10/1/2026 by emergency adoption filed 9/25/2026, hearing 11/13/2026). The user fee resets each July 1; HPPD penalties are quarterly; capital revisions take effect on request or on the bed change date.
Verified October 11, 2026
Posted rates
- Home-level rates published
Yes
- Format
xlsx (also pdf for some years)
- Cadence
Annual (October 1), plus mid-year corrections when issued.
- History
The regulation page posts the current and prior rate year (10/1/2025 and 10/1/2026). Older years were not found on the page.
- Home identifier
DPH ID, FACNO, MassHealth Provider ID (e.g. 110188395A) and facility name; no CCN or NPI.
Verified October 11, 2026
Rate build-ups
- Published
Yes
- What they show
'Standard Nursing Facility Rates and Components': per home, the total rate for each of 25 PDPM groups and Level IV; nursing standard and hold-harmless adjustment by group; operating; capital payment and adjustment; kosher, MS and other add-ons; Medicaid %; High Medicaid %; each quality measure %; DCC-Q score and adjustment %; total adjustment $ by group; rate before and after the maximum change adjustment.
- Format
xlsx
Verified October 11, 2026
Recent changes
| Effective | Change | Headline | Direction | Size | Source |
|---|---|---|---|---|---|
| 2023-10-01 | FFS nursing home payment classification moved from the state MMQ to CMS MDS 3.0 PDPM nursing groups, with MDS audits of claims from this date. | Case mix moved from MMQ to MDS PDPM | structural | https://www.mass.gov/doc/nursing-facility-bulletin-201-update… | |
| 2024-02-02 | New bariatric add-on of $300 per member per day for MassHealth residents with BMI over 40 needing two-person assistance. | Bariatric add-on of $300 per day created | increase | $300/day per qualifying resident | https://www.law.cornell.edu/regulations/massachusetts/101-CMR… |
| 2024-10-01 | Rates rebased to 2019 costs with a 23.5% CAF and 25 PDPM nursing prices. Added High Medicaid (+7%/+9%), quality (-/+), and a 3.177% direct care add-on to be spent on direct care pay. Gains capped at 130% of the prior rate; capital capped at $50. | Rates rebased onto PDPM with Medicaid and quality adjustments | increase | operating standard $125.41; CAF 23.50% on 2019 base | https://www.law.cornell.edu/regulations/massachusetts/101-CMR… |
| 2025-10-01 | Rebased to 2023 costs (nursing +6.163%, operating +6.31%). High Medicaid tiers set at 3/6/9% (from 70%). Quality measures changed to CMS stars, DPH score and hospitalizations. HPPD penalty made tiered (0.5%-3%). The low-occupancy cut and the 3.177% direct care add-on were removed. Added a one-time $25M statewide supplement and a $3.8M Martha's Vineyard supplement; gains capped at 112%. | Rates rebased to 2023 costs; $25M supplement | increase | $25,000,000 statewide supplemental; operating $127.26 | https://www.mass.gov/doc/standard-payments-to-nursing-facilit… |
| 2026-07-01 | User fee raised to $34.90 per non-Medicare day for Group I and $10.47 for Group II; group assignments reset for 7/1/2026-6/30/2028. | Nursing facility user fee raised to $34.90 | cut | $34.90 / $10.47 per non-Medicare day (was $24.16 / $7.25 in 2023) | https://www.mass.gov/regulations/101-CMR-51200-nursing-facili… |
| 2026-10-01 | 7.04% CAF on nursing and operating (operating $128.14; top group $442.48). New 8% cut for homes at 3.00 HPPD or below. Homes at 4.00+ HPPD are exempt from the DCC-Q cut, and DCC-Q moves to a calendar year. Bariatric add-on cut to $200, SUD to $45, MOUD add-on of $100 replaces SUD induction. The $25M supplement ended; the maximum change band is now 90-112%. | Rates up 7.04%; tougher staffing penalty | increase | $29,670,000 estimated annual fiscal impact | https://www.mass.gov/doc/notice-of-final-agency-action-publis… |
Verified October 11, 2026
Assisted living
Medicaid assisted living
- Covered
yes
- Program
Group Adult Foster Care (GAFC), a MassHealth state plan service (130 CMR 408.000) delivered in assisted living residences and supportive or subsidized housing. Also covered by SCO and One Care plans (minimum fee schedule directed payment), plus assisted living under the ABI-RH 1915(c) waiver for brain injury.
- What is paid
Services only: ADL/IADL help by direct care workers, nursing oversight and care management. Room and board are paid by the resident; any SSI state supplement for assisted living was not confirmed.
- Rate
GAFC $50.00 per diem (H0043), 101 CMR 351.00 emergency adoption filed 9/25/2026. AFC Level I $54.37, Level II $91.31.
- Limits
No enrollment cap found for GAFC (state plan service; requires clinical eligibility and a physician order). Waiver slots apply for ABI-RH.
Verified October 11, 2026
Sources
- 101 CMR 206.00 Standard Payments to Nursing Facilities - emergency adoption filed 9/25/2026 (eff. 10/1/2026) · regulation
- 101 CMR 206.00 Standard Payments to Nursing Facilities (effective October 1, 2025) · regulation
- 101 CMR 206.00 regulation page (downloads: rates, components, bulletins) · agency page
- Notice of Final Agency Action, 101 CMR 206.00 (published 9/30/2026) · agency page
- Standard Nursing Facility Rates and Components (effective October 1, 2026) · rate file
- Standard Nursing Facility Rates (effective October 1, 2026) · rate file
- Administrative Bulletin 26-21: Nursing Facility Direct Care Cost Quotient (eff. 10/1/2026) · agency page
- Nursing Facility Rate Add-Ons Billing Guidance (effective 10/1/2026) · agency page
- Nursing Facility Bulletin 201: FFS Payments and MDS 3.0 Assessments (July 2026) · agency page
- 101 CMR 206.00 as of 10/1/2024 (LII mirror: 206.03, 206.04, 206.06, 206.10, 206.12, 206.13) · regulation
- 101 CMR 512.00 Nursing Facility User Fees - page, emergency adoption filed 10/1/2026, AB 26-14 (eff. 7/1/2026), Group List 7/1/2026 · regulation
- 101 CMR 512.04 Calculation of User Fee (2023 text, LII) · regulation
- 130 CMR 456.000 Long Term Care Services (Transmittal NF-64, 9/08/2025) · regulation
- 130 CMR 450.318 Payment Limitations on Medicare Crossovers · regulation
- 130 CMR 520.026 Long-term-care General Income Deductions (PNA) · regulation
- SCO Contract effective January 1, 2026 (CCA): covered NF services, Appendix D capitation and directed payments · agency page
- 101 CMR 351.00 Rates for Certain Adult Foster Care Services (emergency adoption filed 9/25/2026) · regulation
- MACPAC Nursing Facility Payment Policies compendium (2019 baseline) · secondary
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