North Dakota
North Dakota’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
- Resident-level
- Classification
- PDPM
- Rate updates
- Once a year
- Managed care (LTC)
- No
- Quality program
- NF Incentive Program
- Paid outside the rate
- Small
- Bed hold
- Hospital and leave
- Published rates
- Rates only
- Assisted living
- Covered
- Personal needs allowance
- $118 / month
Overview
- North Dakota pays each home its own cost-based rate, held under a price: direct care and other direct care have statewide prices, and indirect care has one price for homes with 55 or fewer beds and another for larger homes.
- Homes below the price keep part of the gap through a 'margin cap'.
- Property is the greater of a fair rental value rate or actual property cost.
- Since 1/1/2026 the direct care part is scaled by each resident's ND PDPM case-mix weight (0.64-3.71).
- Rate equalization means private-pay residents cannot be charged more than the Medicaid rate.
- The 1/1/2026 list shows base rates of $296.18-$648.22 (median $393.55) across 76 homes and units.
What matters in North Dakota
- Rate equalization since 1990: homes cannot charge private-pay residents more than the Medicaid rate for the same care level.
- Base rates on 1/1/2026 run from $296.18 to $648.22 a day; the median of 76 homes and units is $393.55.
- 1,800 ND PDPM classes since 1/1/2026; each resident's own weight (0.64-3.71) scales the direct care part of the rate.
- Own cost up to a price: 2024 prices were $291.06 direct care, $38.99 other direct care, $105.70-$108.00 indirect care.
- No nursing home provider tax was found, and nursing home care is fee-for-service; no managed care plan pays it.
- Indirect care, property and pass-through costs are spread over at least 90% occupancy, so emptier homes get less per day.
Frequently asked
Can North Dakota nursing homes charge private-pay residents more than the Medicaid rate?
No. NDCC 50-24.4-19 bars charging private-pay residents more than the Medicaid rate for similar services, apart from private rooms and optional extras charged to everyone. Violations carry triple damages. Homes also cannot charge a managed care plan less than the Medicaid rate.
Does North Dakota still use RUG-IV case mix for nursing home rates?
No. From 1/1/2026 North Dakota uses its own version of PDPM: a three-letter class (speech, nursing, non-therapy ancillary) with 1,800 combinations and weights of 0.64-3.71. It replaced 48 RUG-IV groups.
How does North Dakota limit the indirect care part of a nursing home rate?
Indirect care is capped at a price set by bed size ($108.00 for 55 or fewer beds, $105.70 for larger homes in 2024) and divided by at least 90% of licensed bed days.
How much is paid outside the posted rate in North Dakota?
Small: only the yearly incentive payment and legislated one-time adjustments are paid outside the posted rate; no public-home or managed care payments.
What does North Dakota Medicaid pay on Medicare coinsurance days?
Lesser of the Medicaid calculated payment or the coinsurance, by the general crossover rule; usually $0 on Part A coinsurance days.
Does North Dakota require a minimum share of spending on care?
No general floor; legislated add-ons and hardship adjustments must be spent for their stated purpose or are recovered.
How is the North Dakota nursing home provider tax charged?
None; North Dakota taxes only ICF/IID providers, not nursing homes.
How the rate is set
How the method got here
| Effective | From | To | Change | Headline | Source |
|---|---|---|---|---|---|
| 1990-01-01 | Facility cost-based per diems without acuity adjustment | Case-mix classification of each resident with rate equalization for private-pay residents | North Dakota began case-mix rates and required the same rate for private-pay and Medicaid residents. | Case mix and rate equalization begin | https://www.hhs.nd.gov/sites/default/files/documents/rate-nd-… |
| 2022-01-01 | Own cost up to limit rates (direct care $178.18, other direct $28.15, indirect $77.29 in 2017; base year 2014) plus a 3% operating margin and an indirect care efficiency incentive (2019 baseline) | Own cost up to price limits from the June 30, 2021 base year, with indirect care priced by bed-size peer group, a margin cap of at least 3.46%, and property at the greater of fair rental value or actual cost | North Dakota moved from cost limits to price limits with a margin cap (homes could still choose the cost rate for 2022-2023). | Cost limits replaced by price-based limits | https://www.ndlegis.gov/cencode/t50c24-4.pdf |
| 2026-01-01 | RUG-IV 48 groups with index maximizing | ND PDPM: SLP, nursing and NTA letters, 1,800 classes, weights 0.64-3.71 | Per-resident case mix switched from RUG-IV to a state-adjusted PDPM. | Case mix moves from RUG-IV to ND PDPM | https://www.ndlegis.gov/information/acdata/pdf/75-02-06.pdf |
Verified October 11, 2026
Cost basis
- Uses cost reports
Yes
- Cost report
North Dakota state cost report for the report year ending June 30, filed by October 1 (Rate Setting Manual section 2; NDAC 75-02-06-02).
- Base year and rebasing
The rate year is the calendar year. Each home's actual rate is recalculated every year from its most recent June 30 cost report. The prices (caps) come from a base year: the June 30, 2021 report year set the first prices for 2022; a new base year from the June 30, 2023 report year set the 2024 prices (NDCC 50-24.4-10(6); NDAC 75-02-06-16.3(3)). Between rebases the prices rise by the adjustment factor (2023 and 2025 rate years).
- Components
Component Method Notes Direct care Own allowable cost (nursing, therapy, nursing supplies) x adjustment factor / standardized resident days (days x case-mix weight), plus margin cap, limited to the statewide price ($291.06 for 2024). The result is the rate at weight 1.0, multiplied by each classification's weight. NDAC 75-02-06-16.3(1)(a); Rate Setting Manual sec. 25 (July 2024). Other direct care Own cost (food, laundry, social services, activities) x adjustment factor / resident days, plus margin cap, limited to the statewide price ($38.99 for 2024). Not case-mix adjusted. Indirect care Own cost (administration, plant, housekeeping, dietary, medical records, chaplain, pharmacy consultant) x adjustment factor / the greater of actual days or 90% of licensed bed days, plus margin cap, limited to a peer-group price: $108.00 for homes with 55 or fewer beds, $105.70 for larger homes (2024). Peer groups defined in NDAC 75-02-06-01(57). Property Greater of a fair rental value (FRV) rate or actual allowable property cost per day (90% occupancy floor on days). FRV: 950 sq ft per bed, Minneapolis location factor, land at 10% of building value, $15,000/bed equipment, 8% rental rate, 2% yearly depreciation. An FRV increase is phased in over 4 years and held until a renovation of at least $2,000 per bed is placed in service. NDAC 75-02-06-16.3(1)(e), (2), (3)(l). Pass-through Actual allowable pass-through costs (e.g., property taxes, start-up, education, bad debt, software/cloud technology) / resident days with the 90% occupancy floor; no cap or inflation. NDCC 50-24.4-10(5) makes software and cloud services a direct pass-through. - Inflation
Adjustment factor = CMS SNF market basket four-quarter moving average percent change (before the productivity adjustment) for quarter 2 of the rate year, from the data file available August 31 of the prior year, plus any legislatively approved NF inflation increase (Rate Setting Manual definition 3; NDCC 50-24.4-10(3),(8)). It inflates historical costs and the prices, but not property or pass-throughs. The 2023 factor was reduced by one-half percent (NDAC 75-02-06-16(5)).
Verified October 11, 2026
Case mix
- System
PDPM
- Applied at
Resident-level
- How it works
Each resident is classified from their own MDS and billed at their classification's rate: the home's direct care rate at weight 1.0 times the class weight, plus the home's other components (NDAC 75-02-06-16.3(1)(a),(f); 75-02-06-17).
- Classification
ND PDPM, a state-adjusted PDPM: three letters for the SLP (20% of the weight), nursing (60%) and NTA (20%) components; PT/OT components are not used. 1,800 classes plus default ZZZ; weights 0.64 to 3.71 (unweighted median 1.73) per the ND PDPM Case Mix Values file. Default (no valid assessment) weight 0.64.
- Applies to
Direct care component only, per NDAC 75-02-06-16.3; the HHS family FAQ describes the case-mix value as multiplied by the facility's daily base rate (see open_questions).
- Acuity measured from
Standardized resident days (each day x the resident's weight) set the home's direct care cost per weighted day. Leave days count at 0.64; unclassified respite days at 1.0.
- Updated
Per resident: an assessment within 14 days of admission or return from hospital, then quarterly; the classification can change only at those points (NDAC 75-02-06-17(3); FAQ January 2026).
- Move to PDPM
Moved from RUG-IV 48 groups (index maximizing) to ND PDPM effective 1/1/2026 (NDAC 75-02-06-17 amended 1/1/2026; Nursing Facility Payment System FAQ, January 2026; 1/1/2026 rate list labelled 'base rate for ND PDPM').
Verified October 11, 2026
Low-acuity residents
None found. There is no flat or reduced rate for low-acuity residents; the lowest ND PDPM classes carry weights of 0.64-0.71 on the direct care part. Residents without a valid assessment are billed at the default class (weight 0.64). Hospital and therapeutic leave days are paid at no more than the 'PA1' (lowest reduced physical functioning) rate (NDAC 75-02-06-14).
Verified October 11, 2026
Capital
Greater of fair rental value or actual property cost (depreciation, interest, leases), divided by days with a 90% occupancy floor. FRV uses 950 sq ft/bed, Minneapolis building cost, 8% rental rate; increases phase in over 4 years and need a $2,000/bed renovation. Homes with actual cost above FRV must elect actual cost each year by November 28 (NDAC 75-02-06-16.3(2)).
Verified October 11, 2026
Budget adjustment factor
No standing across-the-board factor. The 2023 adjustment factor was reduced by one-half percent (NDAC 75-02-06-16(5)). The department may lower limits if aggregate payments exceed what Medicare principles would pay (NDAC 75-02-06-16.3(3)(b)).
Verified October 11, 2026
Add-ons and money outside the rate
Paid outside the posted rate
- Level
small
- Estimate
Under 5% of base, by elimination: the only payment outside the per diem is the yearly NFIP quality payment (pool not stated) plus occasional legislated one-time adjustments. No UPL/IGT, public-home or managed care payments were found.
- Components
NFIP annual payment: size not found.
Verified October 11, 2026
Payments by owner type
- Applies
no
- Detail
No payments limited to government-owned homes were found in NDAC 75-02-06, NDCC 50-24.4 or the HHS pages. The state-owned ND Veterans Home is paid from the same list ($419.48).
- Funding
Not applicable.
Verified October 11, 2026
Quality program
- Active
Yes
- Program
Nursing Facility Incentive Program (NFIP), a value-based purchasing program
- Funding
Legislature-allocated funds; limited to the allocation and the aggregate upper payment limit.
- Size
Not stated on the program page.
- Paid as
Annual lump sum per home, paid during the July quarter through MMIS.
- Measures
Measure Source Weight How points are earned Long-stay urinary tract infections MDS QM (CMS Five-Star) points per CMS QM point ranges CMS Technical Users' Guide QM point thresholds Long-stay antipsychotic use MDS QM (CMS Five-Star) points per CMS QM point ranges CMS Technical Users' Guide QM point thresholds Long-stay pressure ulcers MDS QM (CMS Five-Star) points per CMS QM point ranges CMS Technical Users' Guide QM point thresholds Long-stay hospitalizations claims QM (CMS Five-Star) points per CMS QM point ranges CMS Technical Users' Guide QM point thresholds Active AHCA/NCAL National Quality Award recipient state additional points active award (Baldrige framework) 30% or more residents with severe mental illness state additional consideration bipolar, psychotic disorder, schizophrenia, PTSD, hallucinations - Scoring period
CMS federal fiscal year fourth-quarter average performance in the Provider Data Catalog; paid the following July quarter on that FFY's Medicaid days.
- Payment formula
Total points 70-600. Tier 1 = 400+, Tier 2 = 300-399, Tier 3 = 200-299, Tier 4 < 200. Pool / weighted Medicaid days (Tier 1 x 100%, Tier 2 x 85%, Tier 3 x 60%, Tier 4 excluded) = base per day; each home gets its Medicaid days x base x its tier %.
- Eligibility
Medicaid-certified ND NFs with paid Medicaid days, open at least 10 months of the FFY. Tier 4 gets nothing.
- Cadence
Annual.
- Scores published
Not found; CMS QM data are public in the Provider Data Catalog.
- Notes
Start year and annual pool not found on the program page.
Verified October 11, 2026
Provider tax
- Charged
none
- Standard amount
None. KFF SFY2025 (state Medicaid agency survey): North Dakota - hospital tax No, nursing facility tax No, ICF/IID tax Yes, MCO No, ambulance No. NDCC 50-24.4 (nursing home rate setting) has no assessment; it only lets homes count federal ACA taxes as allowable cost.
- Lower for high-Medicaid homes
no
- Returned in the rate
Not applicable.
Verified October 11, 2026
Provider tax notes
None. KFF's SFY2025 survey of state Medicaid agencies lists North Dakota with no nursing facility (and no hospital) provider tax; its only provider tax is on ICF/IID. No nursing facility bed tax or quality assessment appears in NDCC 50-24.4, NDCC 50-24.1, NDAC 75-02-06 or the Rate Setting Manual.
Verified October 11, 2026
Supplemental payments
(1) NFIP annual quality payment (legislative pool, size not found). (2) One-time adjustments or supplemental payments approved by the legislature, which must be used for the prescribed purpose (NDAC 75-02-06-16.2). No UPL/IGT public-home payments or MCO directed payments found.
Verified October 11, 2026
Other add-ons
Margin cap for homes below price; indirect-care efficiency incentive (70% of gap, max $2.60) and 4.4% operating margin under the older cost-rate section (NDAC 75-02-06-16, used for the 2021 report year). Hardship adjustment for unforeseeable cost increases up to the price, and one-time adjustment for homes below 1.2 nursing hours per standardized resident day (NDAC 75-02-06-16.3(5)).
Verified October 11, 2026
Units paid separately
Geropsychiatric units (St. Luke's Dickinson $474.34; Benedictine Ellendale $356.09; SMP St. Raphael Valley City $459.94) and Dakota Alpha, Mandan ($648.22) are paid one rate for all residents (1/1/2026 list) and are excluded from setting prices (NDCC 50-24.4-13). Specialized rates for individuals with extraordinary medical needs (ventilator, TPN, extensive pulmonary care, intensive restorative therapy) equal the individual's total cost per day less the direct care cost for their class (NDAC 75-02-06-21).
Verified October 11, 2026
Payment rules
Managed care for long-term care
- Status
no
- Detail
Nursing facility care is billed to ND Medicaid fee-for-service (Nursing Facilities billing and policy manual, April 2026). The BCBS ND Medicaid Expansion plan covers expansion adults aged 19-64 only; no MLTSS program exists. NDCC 50-24.4-19(9) still bars homes from charging any Medicaid MCO less than the department's rate for the same classification.
Verified October 11, 2026
Who pays
fee_for_service. ND Medicaid pays nursing facility claims directly through MMIS. The only Medicaid managed care is the Medicaid Expansion plan (Blue Cross Blue Shield of North Dakota) for adults aged 19-64 up to 138% FPL (Member Eligibility policy).
Verified October 11, 2026
Managed care rate floor
Yes, by statute: a home may not charge a managed care organization a rate less than the department's rate for a Medicaid resident in the same classification (NDCC 50-24.4-19(9), https://www.ndlegis.gov/cencode/t50c24-4.pdf). No MCO currently pays long-stay NF care.
Verified October 11, 2026
Included in the daily rate
Rate covers nursing, therapy staff and supplies, routine nursing supplies, non-capitalized wheelchairs, hair care, food and supplements, laundry, social services, activities, administration and property (cost categories in NDAC 75-02-06-02.2 to 02.5). Private rooms and optional special services may be charged to all residents at the same price.
Verified October 11, 2026
Bed hold
- Hospital stays
Paid, up to 15 days per occurrence, at no more than the PA1 (lowest reduced physical functioning) rate.
- Leave days
Paid, up to 30 days per resident per rate year (April 2026 billing manual), at no more than the PA1 rate. NDAC 75-02-06-14 text still says 24 days.
- Occupancy rule
None.
- Notes
Leave days right after a Medicare Part A stay are not covered. Leave days count at weight 0.64 in standardized days.
Verified October 11, 2026
Personal needs allowance
- Per month
118
- Effective
2026 (Non-ACA Medicaid Policy Manual 510-05-85-40, revised 7/1/2026); CPI-adjusted each year from the $115 base in NDAC 75-02-02.1-40
- Notes
ND calls the PNA the 'nursing care income level'. Manual 510-05-85-40: 'The nursing care income level is $118 per month' for residents of nursing facilities, the state hospital, Prairie St. John's, PRTFs and hospital swing beds. NDAC 75-02-02.1-40 sets a $115 base and requires a yearly consumer price index adjustment, which explains the $118. The exact start date of $118 was not printed on the page.
- Confidence
confirmed
Verified October 11, 2026
Medicare coinsurance days
- Method
lesser_of
- Rule
The Crossover Claims policy (January 2026) limits payment to the lesser of the provider's charge or the ND Medicaid calculated reimbursement after Medicare (including Medicare Advantage, billed with the Part C EOB). QMB cost-sharing is covered. Homes may bill Medicare Part A and B coinsurance (NDAC 75-02-06-22). An NF-specific coinsurance-day formula was not found in the state plan, so this is inferred from the general rule.
- Effect
Medicare's SNF rate usually exceeds the home's Medicaid rate, so homes usually receive little or nothing on day 21-100 coinsurance.
Verified October 11, 2026
Required care spending
- Applies
no
- Rule
No general minimum share of revenue for care or staff. Narrow purpose rules: legislated one-time adjustments, hardship adjustments and the low-nursing-hours adjustment (for homes below 1.2 nursing hours per standardized day) must be spent as approved or are recovered (NDAC 75-02-06-16.2; 75-02-06-16.3(5)).
Verified October 11, 2026
Occupancy rules
- Applies
yes
- Rule
Indirect care, pass-through and fair rental value rates are the lesser of the rate on actual census or on 90% of licensed beds x 365 (less beds out of service for construction). The department may waive this for homes shrinking capacity because of home and community services, and for geropsych or nongeriatric units short of referrals (NDAC 75-02-06-16.3(3)(i)-(k)). New-home rates may use census imputed at 95% of beds.
Verified October 11, 2026
MDS accuracy penalties
Residents without a timely assessment are billed at the default class (0.64). Residents can appeal a classification (NDCC 50-24.4-01.1). Late or incomplete cost reports can cut the rate to 80% (NDCC 50-24.4-23, -24); uncorrected violations can cut it by up to 20% (NDCC 50-24.4-20). No separate MDS audit penalty schedule found.
Verified October 11, 2026
Published rates and changes
How often rates change
- A home's rate changes
annual
- When
January 1 each calendar rate year (desk audit rate, then a final rate after audit, applied back to January 1). Mid-year changes for audits, property changes or one-time adjustments. Per resident, the rate changes when the classification changes (14-day and quarterly assessments).
Verified October 11, 2026
When rates change
January 1 (calendar rate year).
Verified October 11, 2026
Posted rates
- Home-level rates published
Yes
- Format
pdf (base rate per home) plus an online lookup tool for the rate by classification (Medicaid Long Term Care Services page)
- Cadence
Annual (January 1)
- History
Only the current 1/1/2026 list found.
- Home identifier
Facility name, city and a 7-digit ND Medicaid provider number
Verified October 11, 2026
Rate build-ups
- Published
No
- Where
Not found; the posted list gives base rates only.
- What they show
Base rate per home (direct care at weight 1.0 plus other components).
- Format
pdf
Verified October 11, 2026
Recent changes
| Effective | Change | Headline | Direction | Size | Source |
|---|---|---|---|---|---|
| 2024-01-01 | Prices were rebased to the June 30, 2023 cost report year: direct care $291.06, other direct care $38.99, indirect care $105.70 (large) and $108.00 (55 beds or fewer). | Prices rebased to 2023 cost reports | increase | direct care price $291.06/day (2024) | https://www.hhs.nd.gov/sites/default/files/documents/rate-nf-… |
| 2025-01-01 | Prices for all cost categories were increased by the adjustment factor (SNF market basket plus any legislated increase). | Prices inflated by adjustment factor | increase | https://www.ndlegis.gov/information/acdata/pdf/75-02-06.pdf | |
| 2026-01-01 | Resident classification moved from RUG-IV to ND PDPM, with a 0.64 default weight and new posted base rates. | ND PDPM case mix replaces RUG-IV | structural | https://www.hhs.nd.gov/sites/default/files/documents/rate-nd-… |
Verified October 11, 2026
Assisted living
Medicaid assisted living
- Covered
yes
- Program
Basic care services: ND Medicaid covers personal care services in licensed basic care facilities (NDCC 23-09.3; NDAC 33-03-24.1), with room and board through the Basic Care Assistance Program (BCAP) or Medicaid; case manager required.
- What is paid
Bundled: room and board days and personal care service days are billed separately (revenue codes for room and board and 0167 personal care).
- Rate
Facility-specific, set annually from cost reports under NDAC 75-02-07.1; amounts not checked.
- Limits
Age 65+ or disabled; not severely impaired in toileting, transferring or eating; impaired in 3 of 4 IADLs or needing supervision; assets under $3,000. Leave: 30 days per medical leave, 28 therapeutic days a year.
Verified October 11, 2026
Sources
- NDAC chapter 75-02-06, Ratesetting for Nursing Home Care (amended through 1/1/2026) · regulation
- NDCC chapter 50-24.4, Nursing Home Rates (incl. 50-24.4-19 rate equalization) · statute
- ND HHS Rate Setting Manual for Nursing Facilities (July 2024) · agency page
- ND Nursing Facility Payment System FAQs (January 2026) · agency page
- ND PDPM Provider Quick View and Case Mix Values (xlsx) · rate file
- Nursing Facilities - Rates effective January 1, 2026 · rate file
- ND HHS Long Term Care Providers page · agency page
- Nursing Facility Incentive Program page · agency page
- ND Medicaid Billing and Policy Manual: Nursing Facilities (April 2026) · agency page
- ND Medicaid Billing and Policy Manual: Crossover Claims (January 2026) · agency page
- ND Medicaid Member Eligibility policy (Medicaid Expansion via BCBS ND) · agency page
- NDAC 75-02-02.1-40 income levels (NF maintenance needs allowance) · regulation
- ND Medicaid Billing and Policy Manual: Basic Care Services (April 2026) · agency page
- MACPAC 2019 compendium, North Dakota tab (baseline only) · secondary
- KFF State Health Facts: States Reporting Taxes by Provider Type, SFY 2025 · secondary
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