Medicaid Nursing Home Rates by State

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Indiana

Medicaid nursing facility payment · Hybrid · researched October 2026

Indiana’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

Hybrid

Case-mix level

Facility average

Classification

RUG-IV

Rate updates

Twice a year

Managed care (LTC)

Yes, ending

Quality program

Total Quality Score add-on and quality pool

Paid outside the rate

Large

Bed hold

Not paid

Published rates

Rates and build‑ups

Assisted living

Covered

Personal needs allowance

$52 / month

Overview

• Indiana is partway through a scheduled move from its old cost-based 'Legacy' system to a 'Prospective' price-based system (405 IAC 1-14.7-6).
• Each facility's per diem is a blend of the two: 67% Prospective / 33% Legacy for rates effective 7/1/2026, 83/17 on 1/1/2027, and 100% Prospective from 7/1/2027.
• Under the Prospective system, direct care is a statewide price (85th percentile of Medicaid-day-weighted costs) adjusted by the facility's Medicaid case-mix score.
• Facilities spending under that price keep a profit of up to 5%.
• Indirect care and administration are flat statewide prices (indirect $59.80, admin $33.74 for 7/1/2026).
• Therapy is paid at the facility's own cost, and capital is a fair-rental-value allowance capped at the statewide median.
• Add-ons for the quality assessment fee, transportation (NEMT), ventilator and dementia units come on top.
• Nearly every Indiana nursing home is licensed to a county hospital (488 of 497 rate-set facilities).
• Those 'non-state government owned' (NSGO) homes also get large Medicare-gap supplemental payments funded by county IGTs (intergovernmental transfers), which add roughly 35-45% on top of the base rate.

What matters in Indiana

• About 35-45% of base comes on top through county-hospital supplemental payments funded by intergovernmental transfers (IGT).
• 488 of 497 rate-set homes are licensed to county hospitals, so nearly all qualify for the Medicare-gap payment.
• Federal directed-payment limits (OBBBA, July 2025) put the county-hospital supplemental at risk; CMS capped SFY2026 payments at the Average Commercial Rate.
• Rates blend 67% price-based and 33% cost-based from 7/1/2026, becoming 100% price-based on 7/1/2027.
• On 7/1/2027 case mix moves from RUG-IV to PDPM nursing, and long-stay residents return from managed care to fee-for-service.
• Low-needs residents count at about 58% lower case-mix weight, pulling down the whole home's direct care rate.
• Bed hold is not paid for hospital or therapeutic leave, except for hospice residents.

Frequently asked

How are Indiana nursing homes licensed to county hospitals paid?

Only county-hospital-owned homes share a pooled Medicare-gap payment, funded by intergovernmental transfers. 488 of 497 rate-set Indiana homes are licensed to county hospitals, so nearly all qualify.

Does Indiana pay a separate rate for low-needs residents?

Not directly. Qualifying low-needs residents carry case-mix weights about 58% lower, which lowers the home's average and so its direct care rate for all Medicaid residents.

How much can an Indiana home lose if a state review finds its MDS assessments unsupported?

If over 20% remain unsupported, the aggregate rate is cut by a share of the Legacy administrative component: 7.5% for a first review, 10% for a second, 15% for a third and 25% for a fourth or later.

How much is paid outside the posted rate in Indiana?

Large, about 35-45% of base, from county-hospital supplemental payments of about $1.0-1.2B/yr.

What does Indiana Medicaid pay on Medicare coinsurance days?

Medicaid pays only when Medicare's payment is below the Medicaid rate, so usually $0; homes claim Medicare bad debt instead.

Does Indiana require a minimum share of spending on care?

No; under the price system, spending below the price lowers the rate, with profit capped at 5%.

How the rate is set

How the method got here

Verified October 11, 2026

Cost basis

Uses cost reports

Yes

Cost report

Indiana state-specific Nursing Facility Medicaid cost report (Myers and Stauffer .xlsm, V4 March 2026; Home Office cost report). Medicare 2540 cost report also required from Medicare-certified homes, used for the ancillary/indirect cost adjustments. Calendar-year fiscal periods required (BT2023116).

Base year and rebasing

Rebased every July 1. Since 7/1/2024 the rebase uses the most recent desk-reviewed or audited cost report with a fiscal year ending at least 18 months before the rate date (405 IAC 1-14.7-6(b)). For 7/1/2026 rates that means CY2024 cost reports. Before 7/1/2024, each facility rebased on its own fiscal-year schedule.

Components

Component	Method	Notes
direct care (Prospective)	Statewide price set at the 85th percentile of Medicaid-day-weighted, case-mix-normalized direct care cost (CMI-adjusted part $143.80 plus non-CMI part $15.69 for 7/1/2026). The CMI-adjusted part is multiplied by the facility's Medicaid CMI. Facility gets the lesser of its own case-mix-adjusted cost plus 5% profit, or the price. Minimum occupancy 70%.	405 IAC 1-14.7-6(d)(1)(A), Tables D.1-D.4. Medical equipment rental above $1.50/day is excluded.
therapy (both systems)	Facility-specific Medicaid share of allowable therapy cost per patient day, no ceiling	Tables D.5-D.6 / E.5-E.6. Median facility $0.91/day; most homes near $0.
indirect care (Prospective)	Flat statewide price ($59.80 for 7/1/2026). Its percentile is reset each July 1 so that total Prospective spending equals what the Legacy system would have paid (budget-neutral). Minimum occupancy 85%.	Table D.7
administrative (Prospective)	Flat statewide price at the 50th percentile (Medicaid-day-weighted), $33.74 for 7/1/2026. Minimum occupancy 85%. Owner/related-party/management pay capped at $2.75/day, inflated from 1/1/2023.	Tables D.9-D.10
capital (both systems)	Fair rental value allowance (see capital) plus other capital costs per day at 95% minimum occupancy. Capped at 100% of the statewide median capital cost ($36.30 for 7/1/2026). Facilities below the median get 60% of the gap as profit, scaled by their quality score percentage.	Tables D.11-D.13 / E.12-E.14
Legacy system (33% weight 7/1/2026, ends 6/30/2027)	Cost-based with ceilings at the patient-day-weighted median. Direct care: facility cost x Medicaid CMI, profit 30% of the gap below 110% of median, capped at 120% of median. Indirect care: profit 60% of the gap below 105% of median, capped at 115%. Administrative: flat median price ($34.00). Capital is the same as Prospective. Includes a Quality Rate Add-on (avg $11.70 for 7/1/2026). Min occupancy 90% (>50 beds) or 85%.	405 IAC 1-14.7-6(e). Legacy medians for 7/1/2026: direct $114.12 per CMI point, indirect $66.74, admin $34.00, capital $36.30.

Inflation

CMS Nursing Home without Capital Market Basket (IHS Markit / S&P Global). Costs are inflated from the midpoint of the cost report period to the midpoint of the rate year (405 IAC 1-14.7-2(u), 14.7-6(d)(3)). RSMeans Construction Cost Index (Indiana cities) is used to inflate historical property cost for FRV.

Verified October 11, 2026

Case mix

System

RUG-IV

Applied at

Facility average

How it works

One rate per home: direct care x the home's Medicaid time-weighted average case-mix index, updated each January and July.

Classification

RUG-IV 48-group v1.03, nursing-only CMI set, scored from the Optional State Assessment (OSA). Moving to PDPM nursing component (10/1/2023 CMS weights, no low-needs groups, IPAs count), targeted 7/1/2027 (SFY 2028).

Applies to

direct care component (CMI-adjusted portion) in both Prospective and Legacy systems

Acuity measured from

Costs are normalized using the all-resident time-weighted facility CMI for the cost report period. Rates are then adjusted using the Medicaid-resident time-weighted CMI, built from the daily roster with index maximization, not picture dates. For SFY 2027 (both 7/1/2026 and 1/1/2027 rates) the Medicaid CMI uses MDS data from 9/1/2024-8/31/2025, weighted by Medicaid days.

Updated

Semi-annual (July 1 and January 1) since 7/1/2024; quarterly before that. For SFY 2027 the same CMI is held for both halves of the year.

Move to PDPM

Not yet on PDPM. Indiana kept RUG-IV by requiring the OSA after CMS dropped OBRA RUG support in Oct 2023. A 1/26/2026 Myers and Stauffer announcement targets PDPM (nursing component only) for 7/1/2027 rates. Preliminary informational PDPM rosters have been issued since 12/10/2025.

Verified October 11, 2026

Low-acuity residents

Yes, but it works through the facility's average case-mix score, not a separate per-resident rate. Under 405 IAC 1-14.6-7(h), carried into the current MDS & CMI Supportive Documentation Manual (eff. 10/1/2023) and used for 405 IAC 1-14.7 rates, a Medicaid resident counts as 'low needs' if all of these hold: (1) they fall in RUG-IV Reduced Physical Function group PB2, PB1, PA2 or PA1; (2) they are cognitively intact or mildly impaired (BIMS 10 or higher, or CPS 0-2); (3) they have no occasional, frequent or complete bowel incontinence (MDS H0400 on the federal assessment); and (4) they were not admitted to any Medicaid-certified NF before 1/1/2010. Those resident-days get a much lower case-mix index, about 58% below normal: PB2 0.70 to 0.29, PB1 0.65 to 0.28, PA2 0.49 to 0.21, PA1 0.45 to 0.19 (0.27/0.28/0.20/0.18 when the assessment is expired). These lower weights go into the facility's time-weighted Medicaid CMI, which pulls down the direct care component for the whole home. They do not go into the all-resident CMI used to normalize costs. Applies in both the Legacy and Prospective systems because both use the same Medicaid CMI. Effective date: added by rule filed 11/12/2009 (LSA #09-215, 20091209-IR-405090215FRA); the 1/1/2010 admission date grandfathers residents admitted earlier. The exact first rate date was not confirmed. Ends with PDPM: FSSA's 1/26/2026 announcement says low-needs groupings will not be carried into the PDPM system (targeted 7/1/2027). Sources: https://www.law.cornell.edu/regulations/indiana/405-IAC-1-14.6-7 ; MDS & CMI Supportive Documentation Manual eff. 10/1/2023, pp. 5-8.

Verified October 11, 2026

Capital

Fair rental value. Every facility gets the statewide median inflated historical property cost per bed (inflated from the later of 7/1/1976 or acquisition date by RSMeans) x its licensed NF beds x a rental rate. The rental rate is the 12-month average 10-year Treasury rate + 3%: 7.210% for 7/1/2026. Add other capital costs, divide by patient days at 95% minimum occupancy, and cap at 100% of the median capital cost ($36.30/day for 7/1/2026). There is no age factor today. Proposed SPA from 7/1/2027: a facility-specific FRV based on each building's weighted age, with renovations recognized via a Capital Additions Survey. The first survey is due 11/30/2026 (M&S announcement 9/8/2026).

Verified October 11, 2026

Budget adjustment factor

No across-the-board cut factor was found. There are two built-in budget-neutrality devices. (1) Each July 1 the Prospective indirect care price percentile is set so that total Prospective spending equals the Legacy system's estimated payments (405 IAC 1-14.7-6(d), Table D.7(G)). (2) The Legacy Quality Rate Add-on pool is held to SFY 2024 statewide spending. Late cost reports and audit noncompliance bring facility-specific per diem cuts of 1-10% (405 IAC 1-14.7-12).

Verified October 11, 2026

Add-ons and money outside the rate

Paid outside the posted rate

Level

large

Estimate

About 35-45% of base: NSGO supplemental (pooled Medicare-gap payment plus quality pool) of about $1.0-1.2B/yr against base Medicaid NF spending of about $2.6B/yr (Q4 SFY2026 alone was $306.2M; base derived from ~8.5M Medicaid days x ~$310 average rate).

Components

NSGO pooled supplemental (uniform % of Medicaid base payments, 42.3% interim Q4 SFY2026) blended with the legacy facility-specific UPL calculation; quality pool $37.96M Q4 SFY2026 (~$150M/yr, 12% of the pool); paid by FFS and the PathWays MCEs (SFY2025 SDP up to $180.7M for PathWays). Q4 SFY2026 total $306.2M across 522 provider lines.

Source

https://myersandstauffer.com/documents/IN/Long-Term%20Care/Nu…

Verified October 11, 2026

Payments by owner type

Applies

yes

Detail

The pooled Medicare-gap payment goes only to non-state government-owned (NSGO) homes; private homes share only in the quality pool. Because 488 of 497 rate-set NFs are licensed to county hospitals, nearly the whole market qualifies. IndyStar reported county-owned homes get about 36% more (+$108.30/day on a $297.42 base) and hospitals kept about 46% historically. For SFY2026 an Average Commercial Rate cap per quality tier cut 28 NSGO providers 1.0-3.5%.

Funding

IGT from the county hospital that holds the license (34.76% non-federal share). Private operators (e.g. Brickyard, Trilogy) run the homes as lessees or managers under the county-hospital license and receive part of the payment.

Source

https://myersandstauffer.com/documents/IN/Long-Term%20Care/Nu…

Verified October 11, 2026

Quality program

Program

Total Quality Score (TQS), Quality Program Manual v2 (rev. 3/2025). The TQS drives three payments: (1) the Quality Rate Add-on in the Legacy base rate; (2) a TQS percentage that scales the profit add-ons in both systems; (3) the Quality Pool of the supplemental payment (state directed payment through the PathWays MCEs plus FFS).

Funding

Base-rate add-on: budget neutral, because the value per quality point is set so total spending equals SFY 2024 Quality Rate Add-on spending (Manual Sec. 4). Quality Pool: a carve-out of the Medicare-gap supplemental pool, funded by county-hospital IGTs plus federal match. It was 10% of the pool in SFY 2025 and 12% in SFY 2026, planned to rise 2 points a year to 20%.

Size

Base-rate add-on: the 7/1/2026 Legacy add-on averaged $11.70/day (max $29.10, min $0.00). It carries only 33% blend weight, so it is about $3.9/day of the paid rate. Quality Pool: $37.96M for Q4 SFY 2026 (12% of a $316.3M quarterly UPL gap), about $150M/yr.

Paid as

Per-diem add-on on the Legacy base rate (ends 6/30/2027). The Quality Pool is a percentage increase on Medicaid base payments, paid as quarterly lump-sum interim payments by FFS and each MCE, reconciled after 6 months of run-out.

Measures

Measure	Source	Weight	How points are earned
Long-stay residents with one or more falls with major injury (QM 410)	MDS QM (CMS Care Compare)	100 of 625 points (16%)	0 points if worse than the national 40th percentile; full points at the 90th; linear between
Long-stay residents with pressure ulcers (QM 479 from 7/1/2025; high-risk QM 453 in SFY 2025)	MDS QM	100 points (16%)	national 40th to 90th percentile, linear
Hospitalizations per 1,000 long-stay resident days (551)	Medicare claims QM (CMS)	150 points (24%)	national 40th to 90th percentile, linear
Outpatient ED visits per 1,000 long-stay resident days (552)	Medicare claims QM (CMS)	150 points (24%)	national 40th to 90th percentile, linear
Total nurse staffing ratio: reported RN+LPN+CNA hours plus respiratory therapy hours, divided by case-mix nurse hours	PBJ (CMS Provider Info + PBJ employee detail)	125 points (20%)	Indiana 40th to 90th percentile, linear (SDP preprint: a 1.31 ratio = 90th percentile). Stale staffing data loses 20% of points per quarter of age

Scoring period

Scored twice a year. The July 1 TQS uses CMS files published the preceding January; the January 1 TQS uses files published the preceding July. QMs are four-quarter averages, so the underlying data lags the rate period by about 1-2 years. Each TQS applies to the next six-month rate period and the next two quarters of supplemental payments. Missing QMs get the statewide average points.

Payment formula

Base add-on: facility TQS x a statewide dollar value per point. The value per point is SFY 2024 add-on spending divided by the sum of (TQS x projected Medicaid days) across all NFs. There has been no floor or cap since 7/1/2024. This resolves the $18.45 vs $29.10 question: $18.45 was the SFY 2024 cap and no longer applies, and $29.10 is simply the top TQS x the value per point. Profit scaling: TQS 275-625 earns 100% of profit add-ons; 61-274 is proportional (100% + (TQS-275)/215); 60 or below earns 0%. Quality Pool: each TQS point earns a fixed % of the facility's Medicaid base rate (0.0257% per point in Q4 SFY 2026), applied through 26 tiers. In the SFY 2025 preprint the top tier was +2.578%, about 0.103% per tier. Since SFY 2026, each tier's total Medicaid plus supplemental payment is capped at the Average Commercial Rate.

Eligibility

All Medicaid-certified Indiana NFs, NSGO and private, earn a TQS and can get the base add-on and the Quality Pool. Only NSGO homes get the separate uniform-% pooled payment. No immediate-jeopardy or Special Focus Facility disqualifier was found in the manual.

Cadence

TQS is recalculated each Jan 1 and Jul 1. The base add-on is paid per day on claims. The Quality Pool is paid quarterly as interim payments, with final settlement about 6 months after the SFY ends.

Scores published

Yes. Per-facility TQS summary and support workbooks for each six-month period are posted at https://myersandstauffer.com/documents/IN/Long-Term%20Care/Nu… . Per-facility quality tier and pool dollars are in the supplemental payment workbooks (Tab 4A/4B).

Notes

From 7/1/2027 the base-rate Quality Rate Add-on ends and the TQS is used only for supplemental payments (Manual Sec. 4). The SFY 2024 method used a different 100-point scale (MDS QMs 60, survey 25, staffing 15; add-on $0-$18.45). Source: https://myersandstauffer.com/documents/IN/Long-Term%20Care/Nu…

Verified October 11, 2026

Provider tax

Charged

per non-Medicare day

Standard amount

$16.37 per non-Medicare patient day for private facilities with fewer than 62,000 annual census days (and NSGO facilities that became NSGO on or after 7/1/2003 with fewer than 62,000 days)

Tiers

Who	Test	Amount
>= 62,000 total annual census days (volume test on all days, not Medicaid days)	volume	$4.09 per non-Medicare day
NSGO (county-hospital) facilities that became NSGO before 7/1/2003	public	$4.09 per non-Medicare day
hospital-based NFs	hospital_based	exempt
qualifying CCRCs	ccrc	exempt
Indiana Veterans' Home	public	exempt

Lower for high-Medicaid homes

no

Returned in the rate

Medicaid rate add-on of QAF rate x non-Medicare days / total days (7/1/2026 avg $12.72/day, max $16.37); new providers get $12.20 until 6 months of census data. MCE claims don't offset the fee, so OMPP bills the uncovered QAF each July.

Source

https://www.law.cornell.edu/regulations/indiana/405-IAC-1-14.…

Verified October 11, 2026

Provider tax notes

Quality Assessment Fee (QAF), IC 16-28-15 / 405 IAC 1-14.7-11, per non-Medicare patient day. $16.37 for private facilities with fewer than 62,000 annual census days, and for NSGO facilities that became NSGO on or after 7/1/2003 with fewer than 62,000 days. $4.09 for facilities with 62,000+ days and for NSGO facilities that became NSGO before 7/1/2003. Exempt: hospital-based NFs, qualifying CCRCs, Indiana Veterans' Home. Returned as a Medicaid rate add-on of QAF rate x non-Medicare days / total days (7/1/2026 avg $12.72/day, max $16.37). New providers get $12.20 until 6 months of census data. Because MCE claims don't offset the fee, each July OMPP bills providers directly for the monthly QAF not covered by FFS claim volume. Part of the QAF funds quality initiatives.

Verified October 11, 2026

Supplemental payments

This is the dominant feature of Indiana NF payment: the county-hospital NSGO (non-state government owned) arrangement. County hospitals hold the license for nearly all Indiana nursing homes: 488 of 497 rate-set NFs are 'Government-County' in the 7/1/2026 Provider Index. Private operators (e.g., Brickyard Healthcare and Trilogy 'Health Campus' homes appear under county-hospital NSGO entities in the supplemental workbook) typically operate them as lessees or managers. The county hospital transfers the non-federal share via IGT. The state, and since 7/1/2024 the PathWays MCEs, then pays a supplemental payment that fills the gap between estimated Medicare payment (PDPM per diems) and Medicaid base payment. The hospital passes part of it to the operator. Size: Q4 SFY 2026 alone was $306.2M total supplemental across 522 provider lines: FFS $60.4M, Anthem $72.3M, Humana $77.7M, UHC $95.9M. IGTs were $106.4M (34.76% non-federal share). That annualizes to about $1.0-1.2B/yr against base Medicaid NF spending of roughly $2.6B/yr (derived: ~8.5M Medicaid days x ~$310 avg rate, LTCIS 7/1/2026). Structure since SFY 2025: a pooled payment (NSGO uniform % of Medicaid base payments, 42.3% interim in Q4 SFY 2026) plus a quality pool for both NSGO and private NFs (26 tiers). This is blended with the legacy facility-specific UPL calculation: 60% legacy / 40% pooled for PathWays in Q4 SFY 2026, phasing to fully pooled by SFY 2028. The PathWays portion is a CMS 438.6(c) state directed payment: SFY 2025 preprint IN_Fee_NF_New_20240701-20250630, approved 11/26/2024 for up to $180.7M ($117.6M federal). SFY 2026 approval was delayed about a year, partly over OBBBA (July 2025) SDP limits. It was approved with a condition capping each quality tier at the Average Commercial Rate. 3 NSGO tiers (28 providers) were cut by less than $1.2M total (M&S 9/24/2026). In April 2026, $462M owed to 496 homes was outstanding (Indiana Capital Chronicle). IndyStar (Mar 2025) reported county-owned homes get about 36% more (+$108.30/day on a $297.42 average base) and that public hospitals kept about 46% of $5.6B generated over 15 years. Per-facility calculation workbooks are posted at https://myersandstauffer.com/documents/IN/Long-Term%20Care/Nu…

Verified October 11, 2026

Other add-ons

Ventilator: $80 per eligible Medicaid ventilator-dependent resident day. Alzheimer's/dementia special care unit: $12 per eligible Medicaid resident day in the SCU. Both are resident-specific and need Schedule Z qualification (405 IAC 1-14.7-7; billed with revenue codes 199/193 per BT202380). NEMT add-on: $1.21 per Medicaid day for all NFs, because NFs pay for non-ALS/BLS transport. No COVID-era add-on remains (the COVID-19 Ready attestation add-on is archived).

Verified October 11, 2026

Units paid separately

No separate cost-based specialty unit system. Ventilator ($80/day) and Alzheimer's/dementia special care unit ($12/day) residents get resident-specific add-ons on the facility rate after Schedule Z approval (405 IAC 1-14.7-7). Children's (pediatric) nursing facilities (IHCP specialty 032) use a separate Legacy direct care table (Table E.2), with a profit add-on not scaled by quality score. State-owned NFs are rate-set separately and have their own Cumulative Rate Listing - State Nursing Facility. Traumatic brain injury facilities are not paid under the NF method (IHCP Therapy Services module). New providers get statewide Legacy medians plus 80% of median capital until they have a 6-month audited cost report (405 IAC 1-14.7-5).

Verified October 11, 2026

Payment rules

Managed care for long-term care

Status

yes_ending

Detail

PathWays for Aging (age 60+) since 7/1/2024; HEA 1277 moves long-stay residents back to fee-for-service on 7/1/2027

Verified October 11, 2026

Who pays

mixed: managed_ltss (Indiana PathWays for Aging, launched 7/1/2024 for Medicaid members age 60+; MCEs Anthem, Humana, UnitedHealthcare) plus fee_for_service for members under 60. HEA 1277 (signed 3/12/2026) moves long-stay nursing facility residents out of PathWays back to FFS effective 7/1/2027.

Verified October 11, 2026

Managed care rate floor

Yes. The FFS rate effectively sets MCE nursing facility payment. The IHCP Long-Term Care provider module (v8.0, published 5/12/2026) says 'The rates for NF services covered under a managed care program are equal to the reimbursement rates established for FFS Medicaid.' The Myers and Stauffer 7/1/2026 rate announcement says the blended rate 'has been communicated to Gainwell Technologies and to the Indiana Pathways for Aging Managed Care Entities for claims processing.' Supplemental payments are paid through the MCEs as a CMS-approved state directed payment (42 CFR 438.6(c) uniform percentage increase, separate payment term). Sources: https://www.in.gov/medicaid/providers/files/modules/long-term… ; https://myersandstauffer.com/documents/IN/Long-Term%20Care/An…

Verified October 11, 2026

Included in the daily rate

Included in the per diem: medical and nonmedical supplies, routine DME and its repairs, personal care items, and therapies. Therapy is paid through the facility-specific therapy component; NFs cannot bill therapy separately, and dual eligibles' therapy goes to Medicare as crossover. Low air loss mattresses, pressure support surfaces and oxygen concentrators are rental costs inside direct care (405 IAC 1-14.6-12). NFs must arrange and pay for non-ALS/BLS NEMT (ambulatory and wheelchair van) and get a $1.21/Medicaid-day add-on for it. Paid separately: outpatient and OTC drugs (billed by the pharmacy), prior-authorized nonstandard DME (billed by the DME supplier), physician visits (one per 27 days), and ALS/BLS ambulance. Lab and x-ray: costs appear in the cost report's ancillary cost centers, but whether they can be billed separately was not confirmed. Source: IHCP Long-Term Care module v8.0.

Verified October 11, 2026

Bed hold

Hospital stays

Not paid. The IHCP does not reimburse NF bed-hold days unless the member is under hospice care.

Leave days

Not paid (same rule). Revenue codes 180/183/185 are noncovered for NFs. The resident may choose to privately pay for a bed hold, and the facility may not set a minimum bed-hold charge.

Occupancy rule

n/a (no bed-hold payment)

Notes

Facilities must readmit to the first available semiprivate bed (42 CFR 483.12(b)(3)). ICFs/IID still get paid leave (hospital and 60 therapeutic days/yr), but NFs do not.

Source

https://www.in.gov/medicaid/providers/files/modules/long-term…

Verified October 11, 2026

Personal needs allowance

Per month

52

Effective

2002

Notes

IC 12-15-7-2: $52 monthly exempt. Not COLA-indexed.

Confidence

confirmed

Source

https://codes.findlaw.com/in/title-12-human-services/in-code-…

Verified October 11, 2026

Medicare coinsurance days

Method

lesser_of

Rule

Lesser-of. Per 405 IAC 1-18-2, IHCP pays a crossover claim only when the Medicare payment is less than the IHCP rate on file when the claim is processed, and a paid claim can be $0. The NF may not collect the unpaid coinsurance from the resident's personal funds, and the provider is pointed to Medicare bad debt (EOB 9004 RA as proof). Medicare Advantage: not stated in the LTC module. MA claims are processed as crossovers under the same rule (likely).

Effect

Usually $0, because Medicare's SNF payment almost always exceeds the Medicaid rate. The home claims the unpaid coinsurance as Medicare bad debt.

Confidence

confirmed

Source

https://www.in.gov/medicaid/providers/files/modules/long-term… (Medicare Crossover Payment Policy, p.19-20)

Medicare Advantage

lesser-of: IHCP Third Party Liability module (v7.2): crossover claims are claims for Medicare-covered services where 'the member's Medicare or Medicare Advantage Plan has made payment'. MA claims do not cross over automatically and are billed to IHCP with claim-filing code 16. The LTC module's Medicare Crossover Payment Policy (405 IAC 1-18-2) pays a crossover claim only when the Medicare payment is below the IHCP rate on file, and a paid claim can be $0. Lesser-of therefore applies to MA SNF cost-sharing by definition. There is no separate MA-only NF sentence.

Medicare Advantage source

https://www.in.gov/medicaid/providers/files/modules/third-par…

Verified October 11, 2026

Required care spending

Applies

no

Rule

No stand-alone spending requirement. Related cost cap (not counted as a spending rule): Cost-linked limit rather than a stand-alone spending floor: under the Prospective system a home gets the lesser of its own case-mix-adjusted direct care cost plus 5% profit, or the statewide price, so spending below the price lowers the rate. The Legacy system (33% weight through 6/30/2027) pays cost plus 30% of the gap below 110% of median. No recoupment rule found.

Source

https://www.law.cornell.edu/regulations/indiana/405-IAC-1-14.7-6

Verified October 11, 2026

Occupancy rules

Applies

yes

Rule

Minimum occupancy used to compute per-day costs: Prospective direct care 70%, indirect care and administrative 85%, capital 95%; Legacy 90% (homes over 50 beds) or 85%. Homes below these levels have costs spread over the assumed days, lowering their rate. Statewide occupancy is about 73%.

Source

https://www.law.cornell.edu/regulations/indiana/405-IAC-1-14.7-6

Verified October 11, 2026

MDS accuracy penalties

Myers and Stauffer runs MDS case-mix reviews (405 IAC 1-14.7-12(g); MDS & CMI Supportive Documentation Manual). The primary sample is the greater of 30% of residents or 25 assessments, drawn 90% from Medicaid residents. If more than 20% are unsupported (the review changes the RUG-IV group), the sample expands by the greater of 20% of remaining residents or 10 assessments. If more than 20% are still unsupported, a corrective remedy cuts the aggregate rate by a share of the Legacy administrative component: 7.5% for the first review, 10% for the second consecutive, 15% for the third, and 25% for the fourth or later. Before 7/1/2024 the cuts were 15/20/30/50% of the admin component. Reviews exiting Apr-Sep take effect Jan 1; reviews exiting Oct-Mar take effect Jul 1. Lost reimbursement cannot be recovered. Separately, the Medicaid CMI is recalculated with the corrected assessments and applied going forward; there has been no retroactive recoupment since 7/1/2024. A validation improvement plan and an unannounced follow-up review are required. Delinquent assessments (ARD more than 113 days after the prior one) are counted as BC1 (CMI 0.43 per the manual's CMI table and 405 IAC 1-14.6-7; the manual's review-policy page says 0.45), or BC1-Low Needs (0.18-0.28) if they meet the low-needs criteria.

Verified October 11, 2026

Published rates and changes

How often rates change

A home's rate changes

semiannual

When

Jul 1 rebase; Jan 1 case-mix and quality update

Verified October 11, 2026

When rates change

Annual rebase July 1, with a semi-annual update January 1 (Medicaid CMI and TQS refreshed, other parameters held). Since 7/1/2024 rates are fully prospective: released about 45 days before the effective date (5/15 and 11/15), with no retroactive adjustments. Blend steps occur each Jan 1/Jul 1 through 7/1/2027. Supplemental payments are made quarterly as interim payments and settled after 6 months of claims run-out.

Verified October 11, 2026

Posted rates

Home-level rates published

Yes

Where

Myers and Stauffer Indiana Long-Term Care page (https://myersandstauffer.com/provider-resources/indiana/india…): Nursing Facility > Other Reports > Cumulative Rate Listing - Nursing, and Nursing Facility > LTCIS Reports > {year} > Provider Index Report

Format

pdf (Cumulative Rate Listing, 249 pages) and xlsx (Provider Index Report; LTCIS statewide cost summaries)

Cadence

Semi-annual (July 1 and January 1). Cumulative listing re-posted at each release (latest dated 5/16/2026).

History

Cumulative Rate Listing covers every rate effective date from 07/01/2020 to 07/01/2026, quarterly through 4/1/2024 then semi-annual. A separate archived listing covers 7/1/2019-6/30/2020. Provider Index Reports (xlsx) are posted for 1/1/2024 through 7/1/2026. Weighted median / statewide price tables go back to 10/1/2019.

Home identifier

Indiana Medicaid (IHCP) 9-digit provider number (e.g., 200289420) plus NPI in the Cumulative Rate Listing. The Provider Index uses provider number, name, county, chain name and NSGO entity. No CMS CCN; crosswalk via NPI.

Verified October 11, 2026

Rate build-ups

Published

Yes

Where

Myers and Stauffer Indiana LTC page > Nursing Facility > LTCIS Reports > 2026 (Provider Index Report). Also Supplemental Payment Program Documents, Nursing Facility Quality Score Reports, Fair Rental Value Allowance, and Tables (statewide prices, medians, rental rate, market basket).

What they show

Provider Index Report: one row per facility for both the Prospective and Legacy tabs. Shows NSGO entity, chain, org type, capital type, beds, occupancy, Medicaid utilization, facility-average and Medicaid CMI, direct care / therapy / indirect / admin / capital components, quality add-on (Legacy), assessment add-on, each system's rate, and the final blended case-mix rate. Supplemental workbook: per-facility Medicare per diem estimate, pooled %, quality tier, legacy UPL per diem, MCE split, and IGT amount. The full per-facility Medicaid Cost Profile (line-by-line ceilings and profit) goes only to the provider with the rate letter and is not posted publicly.

Format

xlsx

Example file

https://myersandstauffer.com/documents/IN/Long-Term%20Care/Nu…

Verified October 11, 2026

Recent changes

Verified October 11, 2026

Assisted living

Medicaid assisted living

Covered

yes

Program

Assisted Living service under the Indiana PathWays for Aging 1915(c) waiver (age 60+, managed care) and the Health & Wellness 1915(c) waiver. 2026 state law directs FSSA to seek a dedicated 1915(c) Assisted Living waiver (6,500 slots to move from PathWays).

What is paid

Services only (personal care, home and community assistance, attendant care, medication oversight, transportation, programming, 24-hour staff). Room and board is participant-paid; the resident keeps a $52/month PNA and the provider may bill room and board up to the federal SSI maximum.

Rate

3 levels, effective 2025-08-01: daily $101.98 / $112.13 / $132.06; monthly $3,028.81 / $3,330.26 / $3,922.18 (HCPCS T2031)

Limits

Waiver slots; Assisted Living reserve capacity referral process (eff. 2025-07-01); waiver waitlists exist

Source

https://www.in.gov/medicaid/providers/files/modules/ompp-hcbs…

Verified October 11, 2026

Sources

1. 405 IAC 1-14.7-6 Rate calculation (Prospective and Legacy systems, blend table) · regulation
2. 405 IAC 1-14.7-2 Definitions (inflation factor, rental rate) · regulation
3. 405 IAC 1-14.7-5 New provider reimbursement · regulation
4. 405 IAC 1-14.7-7 Additional reimbursement (vent, SCU, NEMT) · regulation
5. 405 IAC 1-14.7-11 Quality assessment fee · regulation
6. 405 IAC 1-14.7-12 Rate reductions and settlements · regulation
7. Indiana SPA 23-0011 (Attachment 4.19-D, new NF reimbursement system, approved 2/27/2024) · state plan
8. CMS approval + 438.6(c) preprint IN_Fee_NF_New_20240701-20250630 (PathWays NF SDP) · agency page
9. IHCP Provider Reference Module: Long-Term Care Facility Services v8.0 (5/12/2026) · agency page
10. Myers and Stauffer Indiana Long-Term Care page (rate setting contractor) · agency page
11. M&S announcement: NF Medicaid rates effective 7/1/2026 (67/33 blend) · agency page
12. M&S announcement: SFY 2027 Medicaid rates and PDPM implementation (1/26/2026) · agency page
13. M&S announcement: Fair Rental Value Allowance Calculation (9/8/2026) · agency page
14. M&S announcement: Q4 SFY 2026 interim supplemental payment / ACR reduction (9/24/2026) · agency page
15. M&S announcement: PathWays-only supplemental payment calculations Q1-Q3 SFY 2026 (7/2/2026) · agency page
16. Provider Index Report, rate effective 7/1/2026 (per-facility components, Prospective + Legacy) · rate file
17. LTCIS Report 7/1/2026 Prospective (statewide cost/stat summaries by org type) · rate file
18. Cumulative Rate Listing - Nursing (all facilities, 7/1/2020-7/1/2026) · rate file
19. Medicaid Day-Weighted Statewide Price table · rate file
20. Weighted Median table (Legacy) · rate file
21. Rental Rate Index table · rate file
22. Pooled Supplemental & Quality Payment workbook, SFY 2026 Q4 · rate file
23. Quality Program Manual v2 (rev. 3/2025) · agency page
24. MDS and Case Mix Index Supportive Documentation Manual (eff. 10/1/2023) · agency page
25. Nursing Facility Total Quality Score Summary & Support, 7/1/2026 rate year Q3 (per-facility TQS) · rate file
26. 405 IAC 1-14.6-7 Case mix index (incl. subsection (h) low-needs CMIs for PA1/PA2/PB1/PB2) · regulation
27. IHCP OMPP HCBS Waiver module: Indiana PathWays for Aging (PRPR10021 v2.2, June 2026) · agency page
28. Medicare crossover / coinsurance rule · regulation
29. Medicare crossover rule · regulation
30. Personal needs allowance · regulation
31. FSSA, Nursing Facility Reimbursement Topics - Indiana PathWays (3/5/2024 slides, via LeadingAge Indiana) · secondary
32. Indiana Capital Chronicle: Providers wait for hundreds of millions in delayed Medicaid payments (4/8/2026) · secondary
33. Skilled Nursing News: At least $2.6B diverted from county-owned nursing homes in Indiana (IndyStar summary, 3/18/2025) · secondary
34. IHCA: Gov. Braun signs HEA 1277 (3/12/2026) · secondary

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