New York
New York’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-III
- Rate updates
- Once a year
- Managed care (LTC)
- Yes
- Quality program
- Nursing Home Quality Pool
- Paid outside the rate
- Large
- Bed hold
- Leave only
- Published rates
- Rates and build‑ups
- Assisted living
- Limited
- Personal needs allowance
- $50 / month
Overview
- New York pays a price for the operating part of the rate and each home's own costs for the rest (10 NYCRR 86-2.40, since 1/1/2012).
- Operating = direct price + indirect price + a facility-specific 'non-comparable' amount.
- The direct and indirect prices are a 50/50 blend of the statewide mean and a peer-group mean (hospital-based or 300+ beds vs. freestanding under 300 beds).
- They come from 2007 cost reports and have never been rebased.
- Prices are wage-adjusted (50% the home's own wage factor, 50% one of 16 regional factors), and the direct price is multiplied by the home's Medicaid-only RUG-III case-mix index, frozen at July 2023.
- Capital is each home's actual cost from the cost report two years earlier, minus 5%.
- Add-ons are layered on top: dementia/behavior $8, BMI>35 $17, TBI $36, minimum wage, and the 1.5%, 1% and 7.5% across-the-board (ATB) increases.
- The cash receipts assessment (CRA) per diem (median about $17) is billed separately.
- The Jan 1, 2026 posted Medicaid rates (without CRA) cover 585 standard NF lines: median $275.33, range $161.15-$538.00.
- Regional medians are about $332 in NYC, $311 on Long Island and $234 upstate; ventilator units have a median of $654.
What matters in New York
- About 20% of base Medicaid pay arrives outside the posted rate, mainly up to $854.1M a year of ATB lump sums.
- Posted Medicaid rates omit the provider tax per diem (median about $17/day), which is billed under a separate rate code.
- Case mix is one home-wide RUG-III average, frozen at July 2023 until a PDPM (federal acuity) method is adopted.
- Managed care plans must pay at least the fee-for-service 'benchmark' rate, including capital and the tax per diem.
- The 70/40 law requires 70% of revenue on direct care and caps profit at 5%, with excess recouped.
- A 3.5 hours-per-resident-day staffing law (PHL 2895-b: 2.2 CNA, 1.1 licensed nurse), checked quarterly from PBJ, is enforced by fines, not built into rates.
- County-operated homes share a $500M-a-year UPL (federal ceiling) payment that private homes do not receive.
Frequently asked
Does New York's public Medicaid rate file show everything a nursing home is paid per day?
No. Posted rates omit the provider tax per diem, a median of about $17 per day, which is billed under a separate rate code.
Does a New York managed care plan pay less than the fee-for-service rate?
No. Plans must pay at least the fee-for-service benchmark rate, including capital and the tax per diem.
Does rising resident acuity increase a New York home's Medicaid rate?
No. Case mix is one home-wide RUG-III average, frozen at July 2023 since 4/1/2024 until a PDPM method is adopted.
Does New York require minimum nursing home staffing levels?
Yes. PHL 2895-b requires 3.5 hours of care per resident day, including 2.2 CNA hours and 1.1 licensed nurse hours, checked quarterly from PBJ data. It has been enforced by civil penalties since 4/1/2022 and is not built into Medicaid rates.
How much is paid outside the posted rate in New York?
Large, about 20% of base statewide (about 13% for a private home), mostly ATB lump sums and public-home UPL.
What does New York Medicaid pay on Medicare coinsurance days?
Full coinsurance for Original Medicare; 85% of cost-sharing for Medicare Advantage until 4/1/2027.
Does New York require a minimum share of spending on care?
Yes; 70% of revenue on direct care, 40% on resident-facing staff, with profit capped at 5%.
How is the New York nursing home provider tax charged?
6% of non-Medicare gross receipts, returned as a separate per diem that managed care must also pay.
How the rate is set
How the method got here
| Effective | From | To | Change | Headline | Source |
|---|---|---|---|---|---|
| 2012-01-01 | Operating rates from each home's own costs (2002 base year), with RUG-III case mix | Statewide pricing: 50% statewide / 50% peer-group prices from 2007 costs, wage-adjusted, with Medicaid-only RUG-III case mix; non-comparable and capital stay facility-specific | New York moved nursing home operating rates from each home's own costs to statewide prices, phased in over 5 years with caps on revenue loss (1.75% rising to 10%) that ended 12/31/2016. | Operating rates moved to statewide and peer-group prices | https://regs.health.ny.gov/content/section-86-240-statewide-p… |
| 2012-07-01 | Hospital and leave bed holds paid at 95% of the rate | Hospital bed hold at 50% (later only for hospice residents), leave at 95%, with day limits | New York sharply cut bed-hold pay for adults and later paid hospital-leave days only for hospice residents. | Bed-hold payments sharply reduced | https://regs.health.ny.gov/content/section-86-240-statewide-p… |
| 2021-07-01 | Case mix from January/July census picture dates, with a 5% cap on change | Case mix from all Medicaid assessments in the prior 6 months, no cap, with operator MDS certification | New York switched the case-mix index from a one-day census snapshot to an average of all Medicaid assessments. | Case mix moved to six-month assessment average | https://www.health.ny.gov/facilities/long_term_care/reimburse… |
| 2024-04-01 | Semiannual RUG-III case-mix updates | Case mix frozen at July 2023 until PDPM | After CMS dropped the RUG items from the MDS, New York froze each home's case-mix index at its July 2023 level until a PDPM method is in place. | Case mix frozen at July 2023 level | https://www.health.ny.gov/regulations/state_plans/status/ltca… |
Verified October 11, 2026
Cost basis
- Uses cost reports
Yes
- Cost report
NY RHCF-4 cost report for freestanding homes; RHCF-2 plus the parent hospital's institutional cost report for hospital-based homes. Certified annually under PHL 2805-e/2808-b.
- Base year and rebasing
Operating prices use 2007 calendar-year costs (direct, indirect, non-comparable) and 2009 cost reports for the wage equalization factors (86-2.40(d),(h),(n),(w)). They have not been rebased since prices began on 1/1/2012. 86-2.40(ac)(3) lets the Commissioner update the base year 'periodically', but that has not been done. Capital is re-based every year on the certified cost report from two years earlier (2026 capital = 2024 cost report).
- Components
Component Method Notes direct Price = 50% statewide mean + 50% peer-group mean of 2007 allowable direct cost per day (after the 'allowable costs percent reduction', 9.49% from 2017). Multiplied by the direct wage factor (50% facility, 50% regional; 16 regions) and by the Medicaid-only RUG-III case-mix index divided by the 2007 all-payer index. Cost centers: nursing administration, activities, social services, transportation, PT/OT/speech, central supply, pharmacy, RHCF (nursing). Therapy is in the direct price. Median Jan 2025 direct (non-Medicare-eligible) = $150.85 (range $76-$313). indirect Price = 50% statewide + 50% peer-group mean of 2007 indirect cost per day, times the indirect wage factor. Not case-mix adjusted. Covers administration, fiscal, plant (excl. utilities and taxes), housekeeping, laundry, dietary, medical records. The 2017 regulation table shows $64.52 (hospital-based/300+ beds) and $57.18 (<300 beds) before the wage factor. Median Jan 2025 indirect = $58.21. non-comparable Each home's own 2007 allowable cost per day for lab, radiology, inhalation therapy, podiatry, dental, psych, medical director, utilities, real estate taxes and pharmacy overhead. Median Jan 2025 $9.57/day. capital Each home's actual cost (see capital field), cut 5% since 4/1/2020. An extra 10% cut ran 4/1/2024-3/31/2026 and was ended by the SFY2027 budget. Median Jan 2025 capital $19.57/day (range $4-$170). per diem add-ons and ATB increases Fixed dollar add-ons, weighted by the share of residents who qualify: dementia/behavior ($8), BMI>35 ($17), TBI extended care ($36). Also a minimum-wage adjustment. The 1.5% 'transformation', 1% (4/1/2022) and 7.5% (4/1/2023) ATB increases are added as dollar per diems on the operating component. A negative bed-hold savings adjustment and the 2% quality penalty are subtracted. Itemized in the 'Misc Per Diem' backup file. cash receipts assessment (CRA) add-on Pass-through per diem that repays the Medicaid share of the 6% assessment, reconciled to actual. Billed under a separate rate code. Median $17.15/day (2023 CRA, in the Jan 2025 benchmark). - Inflation
No general inflation trend has been applied to adult nursing home operating prices in recent years; recent rate letters mention trend factors only for pediatric homes. Increases have come instead through legislated ATB percentage increases (1% in 2022, 7.5% in 2023) and lump sums. The 2012-2017 regulation tables were trended year by year through the 'allowable cost percent reduction'.
Verified October 11, 2026
Case mix
- System
RUG-III
- Applied at
Facility average
- How it works
Each home's direct price is multiplied by its average Medicaid-only RUG-III case-mix index, so all its Medicaid residents get one rate. By statute that index is frozen at its July 2023 level (PHL 2808(2-c)(a)(ii)(B); SPA 24-43) until a PDPM method is fully in place.
- Classification
RUG-III, using CMS groups with weights re-costed to New York wages and the 1995-97 time study ('NY RUG-III'). Extra aide minutes are added: +30 for Impaired Cognition A, +40 for Impaired Cognition B, +25 for Reduced Physical Functions B.
- Applies to
Direct component only. Specialty units and facilities (AIDS, vent, pediatric, TBI, behavioral, neurodegenerative) are not case-mix adjusted.
- Acuity measured from
Medicaid-only residents (Medicaid as primary payer). Since July 2021 there are no census picture dates. The index averages ALL Medicaid assessments sent to CMS in the prior 6 months (Apr-Sep for January rates, Oct-Mar for July rates), and the 5% cap on changes was removed. An operator must certify the MDS data are accurate. Late certification can draw up to $2,000/day, and DOH then uses the prior index. Homes also flag dementia, BMI, TBI and specialty status on the state's Health Commerce System (HCS) file; these flags drive the add-ons.
- Updated
Semiannual (January and July) by regulation, but frozen at July 2023 since April 1, 2024.
- Move to PDPM
In progress, not implemented. DOH hired Myers and Stauffer (4/15/2024), and CMS approved the MDS data use agreement on 11/19/2024. Only about 30% of 2022-24 OBRA assessments produced a full PDPM HIPPS code, so DOH required three extra MDS items (I0020, J2100, O0400D) on all assessments from June 1, 2025. The May 2025 plan was an interim method using the Nursing and/or NTA (non-therapy ancillary) components, then a final model reviewed with stakeholders in spring 2026 and implemented in fall 2026. A SPA and regulations are still needed. As of Oct 2026 no PDPM case-mix SPA appears on the 2026 long-term care SPA list.
Verified October 11, 2026
Low-acuity residents
None found. New York has no reduced or flat rate for low case-mix residents. Case mix is a home-wide average (now frozen at July 2023), so a low-acuity resident is paid the home's single Medicaid rate. Related rules: RUG-III weights were raised, not cut, for Impaired Cognition A/B and Reduced Physical Functions B. The $8 dementia add-on targets dementia residents in Reduced Physical Functions A/B/C or Behavioral A/B with an ADL score of 10 or less. Checked: 10 NYCRR 86-2.40(m) and (z); PHL 2808(2-c); the Jan 2025 benchmark rate file.
Verified October 11, 2026
Capital
Each home's actual cost: depreciation (voluntary and public homes, 86-2.19), interest (86-2.20), proprietary capital and leases (86-2.21), movable equipment, and real estate taxes or payments in lieu of taxes. Taken from the certified cost report two years before the rate year; homes can file capital attestations during a preview period. Cuts: -5% since 4/1/2020 (PHL 2808(2-c)(a)(iv)(B)). An extra -10% applied 4/1/2024-3/31/2026 (SPA 24-42; pediatric exempt). The SFY2027 budget ended it (SPA 26-35 pending), and DOH says it will come out of rates from 4/1/2026. Residual-equity reimbursement for proprietary homes was eliminated 4/1/2020. After the state-court cases (Aaron Manor v. Zucker) ended, it was removed from 2026 rates, and DOH is preparing to recoup back to 4/1/2020. Homes still in federal litigation keep receiving it. Median Jan 2025 capital $19.57/day.
Verified October 11, 2026
Budget adjustment factor
No single factor, but several standing statutory cuts: (1) Capital -5% since 4/1/2020, plus -10% from 4/1/2024 to 3/31/2026 (ended in SFY2027). (2) Bed-hold savings guarantee: if bed-hold cuts save less than $40M/yr, a statewide per diem cut makes up the gap (86-2.40(ac)(4)(iv)). It shows as a negative 'Bed Hold Per Diem Adjustment' (median -$0.58). (3) PHL 2808(2-c)(f): a per diem adjustment to save $18M every state fiscal year since 4/1/2017 (non-pediatric homes). (4) Operating prices still rest on 2007 costs with no general inflation trend for adult homes, so they erode in real terms except through ATB increases. (5) Case mix frozen at July 2023 (SPA 24-43). Sources: https://www.nysenate.gov/legislation/laws/PBH/2808 ; https://regs.health.ny.gov/content/section-86-240-statewide-p…
Verified October 11, 2026
Add-ons and money outside the rate
Paid outside the posted rate
- Level
large
- Estimate
About 20% of base Medicaid payments. Derived: SFY2027 recurring ATB lump sums (up to $854.1M), public-home UPL ($500M) and the 2% supplemental ($140M) total about $1.49B. The base is about $7.46B of statewide Medicaid nursing home revenue (1/1/2024 rates x 2024 Medicaid days, from the 2024 NHQP file). The NHQP ($50M) nets to zero. For a private home the share is about 13% (ATB lump sums and the 2% supplemental only); county homes get more.
- Components
ATB lump sums: $854.1M/yr from 4/1/2026 ($438.3M in SFY2026; $280.5M for 7/2024-3/2025). Public nursing home UPL: $500M/yr. 2% supplemental: $140M/yr. NHQP: $50M, budget neutral. VAP/safety-net awards: size not found.
Verified October 11, 2026
Payments by owner type
- Applies
yes
- Detail
$500M/yr in UPL supplemental payments goes only to non-state, publicly operated (county) nursing homes, e.g. in Erie, Nassau and Westchester. It is split by Medicaid days from two years earlier and paid each September and March. Town- and city-operated public homes are excluded, and private or voluntary homes get none. The number of eligible homes was not confirmed.
- Funding
The non-federal share is believed to come from counties through intergovernmental transfers (IGT), but the SPA's funding answer did not confirm it. No lease or management route for private operators was found.
Verified October 11, 2026
Quality program
- Program
Nursing Home Quality Pool (NHQP), scored by the Nursing Home Quality Initiative (NHQI): PHL 2808(2-c)(d), 10 NYCRR 86-2.42, SPA 26-08. A separate 2% Medicaid revenue penalty hits homes that score low year after year (PHL 2808(2-c)(g)).
- Funding
Budget neutral, carved from rates. Every home pays in (its rate x Medicaid days / statewide Medicaid revenue x $50M), and the pool is redistributed to quintiles 1-3. 70/40 recoupments are also to be deposited in the pool (PHL 2828).
- Size
$50 million/yr, about 0.7% of the $7.46B statewide Medicaid revenue base used for the 2024 pool.
- Paid as
Lump-sum net transaction (award minus contribution), not a rate add-on. The 2% penalty is a negative per diem.
- Measures
Measure Source Weight How points are earned 13 quality measures: pneumococcal and flu vaccination, falls with major injury, new/worsened incontinence, pressure ulcers, depressive symptoms, weight loss, ADL decline, UTI, employee flu vaccination, contract/agency staff %, case-mix-adjusted staffing hours per resident day, total nursing turnover (by region) MDS QM / PBJ / NYS HERDS / CMS Care Compare 65 points (5 each) Quintile measures: Q1 5 pts, Q2 3, Q3 1, Q4-5 0, plus improvement points. Threshold measures (5 or 0 points): agency staff <10%, falls <=5%, UTI <=5%. CMS health inspection star rating (re-cut by region) + timely flu-data submission survey / state 15 points Regional five-star cut points (Metro, Western, Capital, Central) Potentially avoidable hospitalizations, long stay state (risk adjusted) 10 points quintile - Scoring period
Each NHQI year scores the prior calendar year (NHQI 2025 uses 2024 MDS data). Payment lags about 2 years: the 2024 NHQP (2023 performance) was paid 10/21/2026 using 1/1/2024 rates and 2024 days.
- Payment formula
Homes are ranked into quintiles on total score. Award = Medicaid revenue x 3 (Q1), x 2.25 (Q2), x 1.5 (Q3), 0 for Q4-5, scaled pro rata to the $50M; net = award minus contribution. 2% penalty: Medicaid revenue is cut 2% if the home was in the bottom two quintiles in both of the last two NHQI years and in the bottom quintile in the latest. It can be waived for financial distress. 60 homes carried the penalty in the Jan 2025 benchmark rates.
- Eligibility
Non-specialty Medicaid nursing homes. Excluded: Special Focus Facilities, CCRCs (continuing care retirement communities), transitional care units, and specialty facilities and units. A home with a J/K/L (immediate jeopardy) deficiency between July 1 of the measurement year and June 30 of the reporting year is not ranked and gets no award, but still pays in.
- Cadence
Scored and settled once a year as a lump sum.
- Scores published
Yes. NHQI methodology and quintile rankings by year: https://www.health.ny.gov/health_care/medicaid/redesign/nursi… ; per-facility NHQP contribution and award: https://www.health.ny.gov/facilities/long_term_care/reimburse…
- Notes
2024 NHQP (569 homes): Q1 112, Q2 120, Q3 98, Q4 120, Q5 119. The pool is small next to rates; for low performers the 2% penalty and the J/K/L exclusion matter more.
Verified October 11, 2026
Provider tax
- Charged
% of net patient revenue
- Standard amount
6% of gross cash receipts from patient care and other operating income, excluding Medicare (Title XVIII) receipts; held at 6% for 4/1/2025-3/31/2029.
- Lower for high-Medicaid homes
no
- Returned in the rate
Yes, as a separate CRA per diem: the assessment (capped at 6%) divided by total patient days minus Medicare days. Billed under its own fee-for-service rate code and reconciled to the actual tax owed (most recent: 2023 CRA rates, reconciled 8/4/2025). Managed care plans must pay it as part of the benchmark rate. It is excluded from 'revenue' in the 70/40 test.
Verified October 11, 2026
Provider tax notes
Cash Receipts Assessment (CRA), PHL 2807-d(2)(b)(vi): 6% of each home's gross cash receipts from all patient care and other operating income, excluding Medicare receipts; extended through 3/31/2029. The Medicaid share comes back as a separate CRA per diem (its own rate code), reconciled to the actual tax owed. Median $17.15/day in Jan 2025.
Verified October 11, 2026
Supplemental payments
(1) Public (non-state, county-operated) nursing home UPL payments: $500M/yr (CY2025, CY2026 'and each year thereafter'), paid in September and March. Split by each public home's share of Medicaid days two years earlier (SPA 26-18, 4.19-D p. 47(x)(2)(b)). Town- and city-operated homes are excluded; Erie, Nassau and Westchester county facilities are included. (2) Recurring ATB lump sums to all homes (SPA 25-35, approved 7/23/2026; SPA 26-39 pending): $280.5M (7/2024-3/2025), $438.3M (SFY2026), and from 4/1/2026 $379.1M + $475M = up to $854.1M/yr. Paid mostly as dollars per Medicaid day of the latest calendar year (SFY2026: $14.49/day on CY2024 days), with $60M (SFY2026) and $238.4M (SFY2027+) shared by Medicaid revenue. (3) 2% ATB supplemental payment: $140M/yr to all nursing homes (SPA 20-0072), a lump sum on estimated Medicaid days, later reconciled to cost-report days. (4) NHQP: $50M budget-neutral redistribution. (5) Vital Access Provider / Safety Net rate adjustments for named homes (e.g. SPA 26-12 Wartburg Home, 25-60 Elderwood).
Verified October 11, 2026
Other add-ons
(1) Dementia/behavioral $8, BMI>35 $17 and TBI extended care $36 per qualifying resident, folded into the facility rate by the share of residents who qualify (86-2.40(z)). (2) HIV add-on for homes with more than 25 HIV residents but no AIDS unit. (3) Yearly minimum-wage adjustment (2026 wage: $17.00 in NYC, Long Island and Westchester; $16.00 elsewhere). (4) ATB per diems: the 1.5% 'transformation' investment, 1% (4/1/2022) and 7.5% (4/1/2023; 6.5% paid first, the last 1% released July 2024 after CMS approval). The median 7.5% ATB is $17.25/day. (5) Recurring ATB lump sums of up to $854.1M/yr from SFY2027 (see supplemental_payments). (6) CRA per diem. (7) A statutory rate of 117% of FFS for one home (PHL 2808(2-c)(g)), plus VAP/safety-net adjustments.
Verified October 11, 2026
Units paid separately
Discrete specialty facilities and units (86-2.40(a),(ad)) are paid outside the price method: AIDS, long-term ventilator, pediatric, TBI (3-12 month rehab), neurobehavioral/behavioral intervention, and neurodegenerative (Huntington's/ALS, from 4/1/2016). They are paid their 1/1/2009 rates trended forward. New units start on a budget and are reset to their first year of costs at 90% occupancy. None are case-mix adjusted. Jan 2026 medians: vent $654 (56 units), AIDS $495, TBI $578, behavioral $399, pediatric $1,805. The Young Adult Demonstration (2022-) has its own benchmark rates; an Aging Adults Medical Fragility Demonstration is pending (SPA 25-49). Hospice residents: the hospice bills 95% of the benchmark rate and pays the home. Respite (scheduled short-term care, 86-2.36) has its own rate code.
Verified October 11, 2026
Payment rules
Managed care for long-term care
- Status
yes
- Detail
Plans that pay for long-stay care: mainstream Medicaid Managed Care (from 2015 in NYC, 2016 in the rest of the state), MAP and PACE. MLTC Partial Capitation, the largest MLTC product, covers 'up to 3 months of nursing home care' (DOH MLTC page, rev. Sept 2026). PHL 4403-f(7)(b)(v)(13) excludes 'a person who is permanently placed in a nursing home for a consecutive period of three months or more' from MLTC (the 2020 MRT II carve-out), so those residents move to fee-for-service. MAP eligibility explicitly allows people 'permanently placed in a nursing home'. Under-21s are not required or eligible to enroll for nursing home care (benchmark DAL 8/19/2025). Sources: https://www.health.ny.gov/health_care/managed_care/mltc/ ; https://www.nysenate.gov/legislation/laws/PBH/4403-F ; https://www.health.ny.gov/health_care/managed_care/mltc/map.htm
Verified October 11, 2026
Who pays
mixed. Fee-for-service plus three managed care routes: mainstream Medicaid Managed Care (MMC; took the nursing home benefit in 2015-16); MLTC Partial Capitation (MLTCP; up to 3 months of nursing home care); and the integrated Medicaid Advantage Plus (MAP) and PACE plans, which can keep permanently placed members. Permanently placed MLTCP members go to fee-for-service. Under-21 residents and Assisted Living Program enrollees are not enrolled. The share of nursing home days paid FFS vs. managed was not found.
Verified October 11, 2026
Managed care rate floor
Yes, by statute. PHL 2808(2-c)(e): plan payments for Medicaid nursing home residents 'shall be the rates of payment that would be paid ... under the medical assistance program', including the CRA add-on. Exceptions: a rate the home negotiates and agrees to, and short rehab stays followed by discharge. DOH calls this the 'benchmark rate' (DAL 8/19/2025). In-network homes get the benchmark or a mutually agreed rate. Out-of-network homes get the benchmark indefinitely. Plans must always pass through the capital component and pay retroactive rate changes (case-mix audits, appeals, capital revisions, CRA reconciliations). Sources: https://www.nysenate.gov/legislation/laws/PBH/2808 ; https://www.health.ny.gov/facilities/long_term_care/reimburse…
Verified October 11, 2026
Included in the daily rate
Included (benchmark DAL Att. A-2): room, board, nursing, physician medical direction, giving medications, ADL help, PT/OT/speech/audiology, routine and emergency dental, medical supplies and stocked equipment (wheelchairs, walkers), non-prescription drugs, activities and social services. In the rate only if the home provides them itself (otherwise the outside provider bills): x-ray, EKG and EEG, lab, psychology and psychiatry, respiratory therapy, podiatry, optometry. Not included: prescription drugs (pharmacy benefit / Part D), bed hold (separate code), hospice, respite, outpatient therapy, adult day health care, emergency transport and ambulance. Separate rates are posted for residents with Medicare Part B (lowered by a Part B offset) and Part D.
Verified October 11, 2026
Bed hold
- Hospital stays
Generally not paid for adults 21+. Paid only for residents on hospice in the home: 50% of the rate, up to 14 days per 12 months (86-2.40(ac)(4)(v)). State veterans homes: 50%, 14 days per 12 months (PHL 2808(25-a)). These limits do not apply to under-21s.
- Leave days
Paid at 95% of the Medicaid rate, up to 10 days per 12 months for adults (PHL 2808(25); 86-2.40(ac)(4)(vi)); billed under a separate bed-hold rate code.
- Occupancy rule
None found in the current statute or regulation.
- Notes
A statewide negative 'bed hold per diem adjustment' (median -$0.58) enforces a $40M/yr bed-hold savings target. Managed care plans pay bed hold under a separate revenue code.
Verified October 11, 2026
Personal needs allowance
- Per month
50
- Effective
long-standing
- Notes
18 NYCRR 360-4.9: $50 for residential health care facility residents; $35 in psychiatric facilities/developmental centers/related ICFs; veterans with reduced VA pension (38 USC 5503(f)) up to $90. Not COLA-indexed.
- Confidence
confirmed
Verified October 11, 2026
Medicare coinsurance days
- Method
full
- Rule
Original Medicare Part A: SSL 367-a(1)(d)(i) says Medicaid payment for dual eligibles and QMBs (Qualified Medicare Beneficiaries) 'shall not be less than the amount of any deductible and co-insurance liability' under Part A, so the full SNF coinsurance is paid. Medicare Advantage (Part C): SSL 367-a(1)(d)(iv) pays 85% of the cost-sharing amount until 4/1/2027. After that it reverts to lesser-of: the coinsurance, capped at the Medicaid amount minus the plan's payment. Whether DOH applies the Part C 85% rule to SNF days was not confirmed.
- Effect
For Original Medicare days 21-100 the home usually gets the full daily coinsurance from Medicaid; for Medicare Advantage stays, 85% of the cost-sharing.
- Confidence
likely
Verified October 11, 2026
Required care spending
- Applies
yes
- Rule
PHL 2828 (from 1/1/2022): each home must spend at least 70% of revenue on direct resident care, with 40% on resident-facing staffing (counted within the 70%). Only 85% of agency/contract RN, LPN and CNA costs count. Revenue excludes the Medicaid capital portion, CRA reimbursement and COVID grants. Profit is capped: operating revenue may not exceed total expenses by more than 5%. Excess revenue, or the spending shortfall, must be paid to the state by Nov 1 of the next year (collected by offset or lawsuit) and goes into the Nursing Home Quality Pool. Exempt: specialty facilities (pediatric, AIDS, behavioral, neurodegenerative) and CCRCs. The Commissioner can waive it case by case for exceptional circumstances, and a 2023 demonstration project gives qualifying homes an alternative. Final regulations and actual recoupments were not confirmed.
Verified October 11, 2026
Occupancy rules
- Applies
no
- Rule
No occupancy-based cut or minimum-occupancy divisor found for standard nursing home operating or capital rates; prices are per actual 2007 day. Two minor related rules: new specialty units have their rates reset on their first 12 months of costs at 90% occupancy or higher, and AIDS facility rates carry an 'AIDS occupancy factor' (2009 law).
Verified October 11, 2026
MDS accuracy penalties
Yes. Case-mix adjustments and resident classifications are subject to audit by the Office of the Medicaid Inspector General (OMIG) (86-2.40(m)(8)). OMIG case-mix audits restate the index and lower the rate retroactively. The benchmark DAL lists them among the retroactive changes plans must also pay. Operators must certify each period's MDS data as complete and accurate. Each day a certification is late counts as a separate violation, with a penalty of up to $2,000 (PHL 12), and DOH uses the prior index. Audit error thresholds were not found.
Verified October 11, 2026
Published rates and changes
How often rates change
- A home's rate changes
annual
- When
January 1 rate year: operating, capital (from the cost report two years earlier), minimum wage, CRA. April 1 revisions carry state budget actions (ATBs, capital cuts or restorations). Case-mix updates were semiannual (January/July) but have been frozen at July 2023 since 4/1/2024. Rates come out late and apply back to the start date: the Jan 1, 2026 initial rates were issued Sept 10, 2026 (paid in cycle 2561, 10/7/2026).
Verified October 11, 2026
When rates change
Calendar-year rates effective January 1, revised April 1 (state fiscal year) for budget actions and, historically, July 1 for case mix. Rates routinely post 6-9 months after they take effect and apply retroactively. Appeals are due within 120 days of the publication date.
Verified October 11, 2026
Posted rates
- Home-level rates published
Yes
- Format
htm/xlsx/pdf
- Cadence
Each rate period (initial Jan 1 rates plus revisions); benchmark rates yearly; a misc per diem backup with each release
- History
Rates back to 2006-2008 (prior rates index); a historical benchmark rates page; 2% penalty rate files for 2023-2024 periods
- Home identifier
9-digit operating certificate number (Opcert), with an 'NF' line and specialty lines (VENT, AIDS, PEDS, TBI, BEHAV, ND). The NHQP files use a 7-digit + 'N' facility code, and payments are combined by MMIS ID.
Verified October 11, 2026
Rate build-ups
- Published
Yes
- Where
https://www.health.ny.gov/facilities/long_term_care/reimburse… (Benchmark Rates section). Full rate computation sheets go to homes through the state's Health Commerce System (HCS) and are not public.
- What they show
The benchmark rate file has one row per facility, with separate tabs for Medicare-eligible, non-eligible and specialty. It shows bed count, non-comparable, direct (case-mix adjusted), indirect, TBI/BMI/dementia add-on, miscellaneous, 2% penalty, minimum wage, the 1.5%/1%/7.5% ATBs, bed-hold adjustment, total price, capital, CRA per diem and total payment, plus tabs for non-comparable ancillaries and transportation in direct. It does not show the case-mix index or the wage factor.
- Format
pdf (htm); misc per diem backup in xlsx/pdf
Verified October 11, 2026
Recent changes
| Effective | Change | Headline | Direction | Size | Source |
|---|---|---|---|---|---|
| 2023-04-01 | Uniform increase to the operating component (6.5% released Nov 2023; the last 1% released Aug 2024 after CMS approval). | 7.5% across-the-board operating increase | increase | +7.5% of operating component (median $17.25/day) | https://www.health.ny.gov/facilities/long_term_care/reimburse… |
| 2024-04-01 | Case-mix index frozen at its July 2023 level until PDPM is in place (SPA 24-43). | Case-mix index frozen at July 2023 | structural | https://www.health.ny.gov/regulations/state_plans/status/ltca… | |
| 2024-04-01 | An extra 10% cut to the capital component on top of the existing 5% (pediatric exempt), for 4/1/2024-3/31/2026. | Extra 10% capital cut added | cut | -10% of capital (on top of -5%) | https://www.health.ny.gov/facilities/long_term_care/reimburse… |
| 2024-07-01 | One-time lump sum to nursing homes, adult day health care programs and hospices at $13.53 per CY2022 Medicaid day. | One-time $280.5M lump sum to nursing homes | increase | $285M gross ($280.5M nursing home share) | https://www.health.ny.gov/facilities/long_term_care/reimburse… |
| 2025-04-01 | SFY2026 ATB funding paid as lump sums ($14.49 per CY2024 Medicaid day plus $60M by Medicaid revenue), made recurring at $379.1M/yr from 4/1/2026 (SPA 25-35, approved 7/23/2026). | Recurring ATB lump sums of $379.1M per year | increase | $438.3M SFY2026; $379.1M/yr thereafter | https://www.health.ny.gov/regulations/state_plans/status/ltca… |
| 2026-01-01 | Residual-equity reimbursement removed from capital for homes covered by the state-court order (Aaron Manor v. Zucker); recoupment back to 4/1/2020 being prepared. | Residual-equity capital removed for state-court homes | cut | https://www.health.ny.gov/facilities/long_term_care/reimburse… | |
| 2026-01-01 | Public (county) nursing home UPL payment continued at $500M/yr for CY2026 and each year after (SPA 26-18, pending). | Public home UPL continued at $500M per year | structural | $500M/yr | https://www.health.ny.gov/regulations/state_plans/status/ltca… |
| 2026-04-01 | SFY2027 budget: an additional recurring ATB of up to $475M/yr, for a total of up to $854.1M/yr in lump sums (SPA 26-39, pending). | Additional $475M recurring ATB, total $854.1M | increase | +$475M/yr (total recurring up to $854.1M/yr) | https://www.health.ny.gov/regulations/state_plans/status/ltca… |
| 2026-04-01 | The extra 10% capital cut ended by the SFY2027 budget (SPA 26-35, pending); the 5% cut remains. | Extra 10% capital cut ended; 5% cut remains | increase | restores 10% of the capital component | https://www.health.ny.gov/regulations/state_plans/status/ltca… |
Verified October 11, 2026
Assisted living
Medicaid assisted living
- Covered
limited
- Program
Assisted Living Program (ALP), SSL 461-l and PHL 3614(6): a state plan service (personal care/home health) in licensed adult homes or enriched housing for people who would otherwise need nursing home care. ALP enrollees are excluded from MLTC and paid fee-for-service.
- What is paid
Services only, at a capitated per diem. The resident pays room and board, usually from SSI at the Congregate Care Level 3 rate.
- Rate
By statute, 50% of what a nursing home would cost: based on 7/1/1992 mean prices (1983 costs) for freestanding low-intensity nursing homes under 300 beds, adjusted for regional wages, inflation and case mix. Current dollar rates were not captured. ALPs also shared in the SFY2026 one-time $460M lump sum.
- Limits
Bed-limited under statutory expansions (a 6,000-bed plan and later additions). Since 4/1/2025 new ALP beds are approved case by case on public need. Not available everywhere; counties with one or no ALP are targeted for new beds.
Verified October 11, 2026
Sources
- NYS DOH Nursing Home Rates page (current rates, NHQP, lump sums, benchmark, CRA, PDPM) · agency page
- 10 NYCRR 86-2.40 Statewide prices for non-capital reimbursement · regulation
- PHL 2808 (rates; case-mix freeze; capital cuts; MCO payment; quality pool; 2% penalty; bed hold) · statute
- PHL 2807-d Cash receipts assessment · statute
- PHL 2828 Minimum direct resident care spending (70/40) · statute
- PHL 2895-b Nursing home staffing levels · statute
- PHL 4403-f Managed long term care · statute
- SSL 367-a (Medicare cost-sharing) · statute
- SSL 461-l Assisted Living Program · statute
- PHL 3614(6) ALP capitated rate · statute
- DAL 9/10/2026 - January 1, 2026 initial rates · agency page
- January 2026 Nursing Home Initial Rates (rate file) · rate file
- 2026 MISC per diem backup · rate file
- DAL 8/19/2025 - January 1, 2025 Benchmark rates (Att. A, A-1, A-2, B) · agency page
- January 1, 2025 Nursing Home Benchmark Rates (component build-up) · rate file
- DAL 10/1/2026 - 2024 Nursing Home Quality Pool · agency page
- 2024 NHQP per-facility file · rate file
- NHQI 2024 methodology · agency page
- SPA 26-08 Nursing Home Quality Incentive (approved 6/5/2026) · state plan
- DAL 6/27/2025 - 2% penalty on poor performing homes · agency page
- DAL 3/18/2026 - 2% supplemental payment ($140M) · agency page
- DAL 3/6/2026 - SFY2025-26 one-time lump sum (state share) · agency page
- DAL 11/12/2025 - SFY2024-25 lump sum federal share · agency page
- SPA 25-35 Nursing Home ATB funding increase (approved 7/23/2026) · state plan
- SPA 26-39 Nursing Home Investment ($475M, submitted 6/30/2026) · state plan
- SPA 26-18 2026 Nursing Home UPL (public homes, $500M) · state plan
- SPA 26-35 Nursing Home 10% capital cut reinstatement · state plan
- SPA 24-43 Nursing Home Case Mix Rate Freeze (approved 9/5/2024) · state plan
- DAL 12/19/2024 - 10% capital reduction · agency page
- DAL 7/16/2024 - 7.5% ATB · agency page
- DAL 8/4/2025 - Cash receipts assessment rates · agency page
- PDPM case mix project update slides, 5/13/2025 · agency page
- PDPM overview slides, 10/30/2024 · agency page
- DAL 7/1/2021 - MDS collection changes · agency page
- NYS DOH Managed Long Term Care page (rev. Sept 2026) · agency page
- Medicaid Advantage Plus (MAP) page · agency page
- Long Term Care SPA status list 2026 · agency page
- Personal needs allowance · regulation
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