Medicaid Nursing Home Rates by State

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Pennsylvania

Medicaid nursing facility payment · Peer-group price · researched October 2026

Pennsylvania’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

Peer-group price

Case-mix level

Facility average

Classification

Transitioning to PDPM

Rate updates

Quarterly

Managed care (LTC)

Yes

Quality program

CHC NF Quality Incentive

Paid outside the rate

Large

Bed hold

Hospital and leave

Published rates

Rates and build‑ups

Assisted living

Limited

Personal needs allowance

$60 / month

Overview

• Pennsylvania pays private (nonpublic) homes a peer-group price, set each year from each home's 3 most recent audited cost reports.
• Per diem = resident care + other resident related + administrative + capital.
• Resident care price = 117% of the peer group's case-mix-neutral median cost, times the home's Medicaid case-mix index (CMI, average acuity score) each quarter.
• Other resident related = 112% of median and administrative = 104% of median.
• A home's resident care and other resident related rates are also capped at 103% of its own cost plus 30% of the gap up to the price.
• Capital is a fixed $26,000 per bed times a bond yield, plus audited movable property and real estate tax.
• The total is then multiplied by a statewide budget adjustment factor (BAF), which shrinks every rate so the average fits the money the legislature appropriated.
• For Oct 1, 2026 the BAF is 0.77617: the formula rates are cut about 22%.
• Oct 1, 2026 proposed rates for 576 nonpublic homes: median $253.42/day, range $196.94-$518.62.
• The 14 county-owned homes are paid differently: a frozen per diem times a county BAF.

What matters in Pennsylvania

• Formula rates are cut about 22% by the budget adjustment factor (0.77617 for Oct 2026) to match the appropriation.
• Managed care minimum rates pay private homes about $53 a day above fee-for-service, about 19% more.
• The 14 county-owned homes get managed care minimums about double their FFS rate: median $596.04 versus $285.76.
• Case mix is one PDPM (federal acuity measure) nursing-only average per home, blended in during 2026 and full from 1/1/2027.
• The provider tax is $33.41 per non-Medicare day, but $9.32 for homes with 94%+ Medicaid occupancy and others.
• Hospital bed hold pays one-third of the rate for up to 15 days, and only if occupancy is 85% or higher.

Frequently asked

Does a Pennsylvania home's rate rise when its residents' acuity increases?

Yes, through one PDPM nursing-only case-mix average per home each quarter. A budget adjustment factor of 0.77617 for October 2026 scales all formula rates to match the appropriation.

Does Pennsylvania managed care pay more than the fee-for-service rate?

Yes. Minimum rates pay private homes about $53 a day more, roughly 19%. The 14 county homes have a median minimum of $596.04 versus $285.76 fee-for-service.

How long do Pennsylvania nursing homes wait for final rates?

Rates are published as proposed and paid provisionally. Final rates follow CMS certification of the budget factor amendment; FY2025-26 final rates were published May 9, 2026.

How much is paid outside the posted rate in Pennsylvania?

Large: about 20% of base for private homes and about 100% for county homes, mainly the managed care minimum rate.

What does Pennsylvania Medicaid pay on Medicare coinsurance days?

Lesser-of: Medicaid pays its rate minus Medicare's payment, usually $0, and the home cannot bill the resident.

Does Pennsylvania require a minimum share of spending on care?

No spending floor, but care rates are capped at 103% of own cost plus 30% of the gap to the price.

How is the Pennsylvania nursing home provider tax charged?

$33.41 per non-Medicare day, or $9.32 for county, small, high-Medicaid and certain CCRC homes; not returned as an add-on.

How the rate is set

How the method got here

Verified October 11, 2026

Cost basis

Uses cost reports

Yes

Cost report

Pennsylvania MA-11 nursing facility cost report, audited by the Department (Myers and Stauffer handles the resident day reports). Medicare cost data are also reported on the MA-11 for the Medicare upper-limit test (55 Pa. Code 1187.71, 1187.109).

Base year and rebasing

Rebased every year. Each July 1 price year uses each home's 3 most recent audited MA-11 reports issued by March 31, indexed forward (55 Pa. Code 1187.91). FY2025-26 prices used reports with fiscal year-ends from mid-2018 through 2022-23, mostly CY2020-CY2022, indexed to 12/31/2025 (56 Pa.B. 2765). Cost reports under 12 months are excluded. New homes get the peer group price until they have an audited report.

Components

Component	Method	Notes
resident care (nursing, therapy, medical supplies, OTC drugs, oxygen, social services, activities)	Peer group price = 117% of the peer group median of 3-year-average case-mix-neutral resident care cost per day. Neutralized with the total facility CMI from the February 1 picture date closest to each report's midpoint. The price is limited by 1187.107, then multiplied each quarter by the home's Medicaid CMI.	1187.107 limit: the lower of the peer price or 103% of the home's own neutralized cost + 30% of (price - 103% of cost). This keeps low-cost homes below the price. Example: Oct 2026 PDPM prices (CMI 1.0) range from $153.12 (PG1) to $246.46 (PG13a special rehab); PG2 is $164.81 and PG6 $183.75.
other resident related (dietary, laundry, housekeeping, plant operation)	Peer group price = 112% of the peer group median 3-year-average cost per actual resident day, limited by the same 103% + 30% rule. Not case-mix adjusted.	PDPM-era prices range from $56.75 (PG11) to $141.16 (PG13a).
administrative	Peer group price = 104% of the peer group median 3-year-average cost per day, with days adjusted to at least 90% occupancy. Every home in the peer group gets the price (no own-cost limit).	Prices range from $26.10 (PG1) to $63.78 (PG13).
capital	Not price-based: allowable beds x $26,000 x financial yield rate (Moody's Aaa corporate 60-month average), plus audited major movable property, plus audited real estate tax. Divided by resident days adjusted to 90% occupancy. See capital field.	Oct 2026 capital per diems are typically $4-$18.
budget adjustment factor	The sum of the components is multiplied by the quarterly BAF (0.77617 for Oct 2026). See budget_adjustment_factor.	Rate files show NFRATE (at 100%), NFRATEMULT (the BAF) and PROPOSEDRATE (paid).

Inflation

CMS Nursing Home Without Capital Market Basket Index (1st-quarter issue). Each cost report is indexed forward to the midpoint (6th month) of the price year (1187.91(1)(iv)). FY2025-26 factors ran from 1.0580 to 1.3860 depending on report year-end. In practice the BAF removes most of the inflation the formula adds.

Verified October 11, 2026

Case mix

System

Transitioning to PDPM

Applied at

Facility average

How it works

Each home gets one resident care rate per quarter: the peer price x the home's average Medicaid CMI on the picture date. Every Medicaid resident in the home is billed the same per diem (55 Pa. Code 1187.93, 1187.96(a)(5)).

Classification

PDPM nursing component only, with Pennsylvania's own fixed weights (Appendix D): 25 groups from ES3 3.95 down to PA1 0.64. The PT, OT, SLP and NTA components are not used, because about 91% of residents are dual eligibles whose therapy Medicare pays. Before April 2026: RUG-III 44-group (index version 5.12) from the PA-specific OBRA MDS / Optional State Assessment.

Applies to

Resident care component only. Other resident related, administrative and capital are not case-mix adjusted. County homes (Ch. 1189) are not case-mix adjusted at all.

Acuity measured from

Two CMIs. (1) Facility MA CMI = the average CMI of residents listed as Medicaid on the CMI report for the quarterly picture date. It sets the payment. Picture dates are the first day of the second month of each quarter: Feb 1 -> July rate, May 1 -> Oct, Aug 1 -> Jan, Nov 1 -> Apr. (2) Total facility CMI (all residents, any payer) from the Feb 1 picture date is used only to neutralize costs at price setting. If a home has no MA residents, it gets the statewide average MA CMI. New homes get the statewide average MA CMI.

Updated

Quarterly (each Jan 1, Apr 1, Jul 1, Oct 1 rate quarter, from the picture date about 5 months earlier). Prices are annual (July 1).

Move to PDPM

Final rule 55 Pa.B. 5119 (Aug 2, 2025; amends 1187.2/.33/.92/.93/.96/.97, adds Appendix D). Blended resident care rate: Apr-Jun 2026 = 75% RUG-III + 25% PDPM. Jul-Sep 2026 = 50/50. Oct-Dec 2026 = 25% RUG-III + 75% PDPM. 100% PDPM from Jan 1, 2027. The 'RUG-III rate' in the blend is frozen at the average of the Oct 2025 and Jan 2026 quarter rates. The blend uses each resident's most recent comprehensive assessment; from 2027 it uses the most recent classifiable assessment of any type. DHS published separate PDPM medians and prices and PDPM total-CMI values for 2017-2024 (rate page). The rule is budget neutral only through the BAF. Without a BAF, PDPM would have raised rates an average 32.94%. With the BAF, about 47% of homes gain and about 310 lose; the biggest gain is +48.94% and the biggest loss -13.82%. Driver: CMS stopped supporting the RUG-III Optional State Assessment on Oct 1, 2025.

Verified October 11, 2026

Low-acuity residents

None found. There is no reduced or flat rate for low-acuity residents. Pennsylvania pays one facility-average rate, so a low-acuity resident only lowers the home's average MA CMI. The lowest PDPM nursing groups are weighted PA1 0.64, PA2 0.69 and CA1 0.91 (Appendix D). Related rules (not carve-outs): (1) A Medicaid resident with no valid assessment in the window is counted at the LOWEST PDPM CMI (0.64) in the facility MA CMI, and at the HIGHEST (3.95) in the total facility CMI used to neutralize costs. Both choices lower the home's rate. (2) If a home files no valid CMI report, it gets the same treatment for the whole home (1187.33(b)). Checked: 55 Pa. Code Ch. 1187 (1187.33, 1187.92-1187.96, Appendix D), the PDPM final rule 55 Pa.B. 5119, and the Oct 2026 rate file.

Verified October 11, 2026

Capital

Fixed property is a deemed value, not fair rental value or actual cost: allowable beds as of April 1 x $26,000 per bed x the financial yield rate (Moody's composite Aaa corporate bond yield, 60-month average ending March). Added to that: audited major movable property cost and audited real estate tax (or payment in lieu) from the latest audited MA-11. The total is divided by resident days adjusted to a minimum 90% occupancy. The capital payment for new or added beds requires prior DHS approval and a Certificate of Need/1122 history, or a capital cost reimbursement waiver (1187.113, 1187.113b). The Jul 2026 file shows a 4.53 yield rate (YLDRATE). Source: 55 Pa. Code 1187.96(d), 1187.2.

Verified October 11, 2026

Budget adjustment factor

Pennsylvania's BAF ('revenue adjustment neutrality factor') is the main thing setting nursing home rates. Each quarter the formula rates at 100% are multiplied by BAF = annual target rate / statewide day-weighted average quarterly rate at 100%, capped at 1.0. The annual target rate = last year's target x (1 + the % increase the General Appropriation Act funds). So the statewide average paid rate equals the appropriation, whatever the cost formula produces. In use since 7/1/2005 (35 Pa.B. 6232), reauthorized in 2007, 2008, 2011, 2013, 2016, 2019 and 2022 (Act 54 of 2022, through 6/30/2026), and in 2026 for FY2026-27 (Oct 2026 rate file: 'The General Assembly has enacted legislation to continue the use of a BAF in FY 2026-2027, subject to CMS approval'; SPA pending). Authority: Human Services Code 443.1(7), Fiscal Code 72 P.S. 1601-T/1602-T. DHS says the BAF held rate growth FY2004-05 to FY2025-26 to +55.03% (+$4.35/day/yr) instead of +70.24% (+$5.56/day/yr). NONPUBLIC QUARTERLY BAF / TARGET RATE (DHS BAF workbooks): FY2020-21: 0.80753, 0.80825, 0.79551, 0.79901 (target $199.96, flat since at least FY2019-20). FY2021-22: 0.80409, 0.79879, 0.80412, 0.79808 ($199.96). FY2022-23: Jul 0.78302, Oct 0.77939, then a +17.5% budget increase raised the target to $234.95 from Jan 1, 2023: Jan 0.92282, Apr 0.90477. FY2023-24: 0.89957, 0.88922, then +1.88% to $239.37 from Jan 2024: 0.90182, 0.89719. FY2024-25: 0.78683, 0.78233 (rates at 100% jumped about 14%, from $266.80 to $304.22, on rebasing), then +7.04% to $256.22 from Jan 2025: 0.83848, 0.83746. FY2025-26 (0% budget change, target held at $256.22): 0.80875, 0.80272, 0.80365, Apr 2026 0.80534. FY2026-27 (proposed, assumes FY2025 funding level): Jul 2026 0.79416, Oct 2026 0.77617. The PDPM blend is pushing average rates at 100% up (about $318 in Apr 2026 to about $330 in Oct 2026) while the target stays flat, so the BAF falls. COUNTY BAF (applied to the prior year per diem): 1.0 for 7/1/2020-7/1/2022, 1.175 (posted as the 7/1/23 step), 1.0188 (7/1/24), 1.0704 (1/1/25), 1.0 (7/1/25; proposed 1.0 for 7/1/26).

Verified October 11, 2026

Add-ons and money outside the rate

Paid outside the posted rate

Level

large

Estimate

About 20% of base for nonpublic homes (the CHC minimum payment rate adds about +$53/day on a $253.42 median FFS rate, Oct 2026) and about 100% for county homes (MPR median $596.04 vs FFS $285.76). The CMS quality preprint puts other directed payments (the MPR) at 29.0% of commercial on a 45.4% base. MDOI, targeted supplements and the $15M quality payment add a little more.

Components

CHC minimum payment rate directed payment (uniform $22.41 + variable median $30.66/day nonpublic; uniform $250.82 + $16.92-$102.05/day county, 2026); MDOI $49.307M total FY2026-27; targeted supplementation payments ~$19.4M FY2025-26; disproportionate share incentive $0.20-$2.50/day; CHC quality incentive $15M CY2025; HAI surcharge refunds.

Source

https://www.pa.gov/agencies/dhs/resources/for-providers/ltc-p…

Verified October 11, 2026

Payments by owner type

Applies

yes

Detail

The 14 county-owned homes get a CHC minimum payment rate about double their FFS rate (uniform $250.82/day + county-specific $16.92-$102.05; median $596.04 vs $285.76 FFS), against about +$53/day for nonpublic homes. County homes are also on a separate frozen-per-diem x county BAF method, can have county-certified costs claimed as MA expenditures, and MDOI is for nonpublic homes only. Some targeted supplements are restricted to county or nonprofit homes by county class.

Funding

The county uniform per diem looks county/IGT-funded (unconfirmed); DHS may claim county-certified costs as MA expenditures (443.1(6)).

Source

https://www.pa.gov/agencies/dhs/resources/for-providers/ltc-p…

Verified October 11, 2026

Quality program

Program

Nursing Facility Quality Incentive (pay for performance), paid through Community HealthChoices MCOs as a CMS state-directed payment. CY2025 preprint PA_VBP_NF2_Amend_20250101-20251231, approved by CMS 8/20/2026. County homes also have a separate Ch. 1189 pay-for-performance incentive (1189.105(b)), not researched in detail.

Funding

MCO directed payment paid as a separate payment term outside monthly capitation: $15.0M total ($8.26M federal + $6.74M non-federal). The non-federal source checkbox was not captured from the PDF.

Size

$15M per calendar year (CY2025), about 0.2% of what CHC plans pay nursing homes (the preprint's payment analysis: base 45.4% of commercial + 29.0% from other SDPs [the MPR] + 0.2% from this = 74.6%).

Paid as

Lump sum after the performance year, sent through each MCO in proportion to the home's resident days with that MCO.

Measures

Measure	Source	Weight	How points are earned
Short-stay residents re-hospitalized after NF admission (521)	Medicare Part A claims (CMS Care Compare)	0-2 benchmark points + 0-2 improvement points	1 point at the PA median, 2 at the best quartile (25th percentile, lower is better). Improvement vs baseline: 0.5 pt for >=0.5, 1 pt for >=1, 2 pts for >=2 points of improvement.
High-risk long-stay residents with pressure ulcers (453, now 479)	MDS QM	same point scale	Median / 25th percentile; measure frozen Apr 2024-Jan 2025.
Long-stay residents with one or more falls with major injury (410)	MDS QM	same point scale	Median / 25th percentile.
Long-stay residents given seasonal influenza vaccine (454)	MDS QM	same point scale	Median / 75th percentile (higher is better).
Long-stay residents given pneumococcal vaccine (415)	MDS QM	same point scale	Median / 75th percentile.
Long-stay residents who received an antipsychotic medication (419)	MDS QM	benchmark points only for CY2025	Median / 25th percentile; no improvement points because CMS respecified the measure in Jan 2026.

Scoring period

Calendar-year performance (CY2025). Improvement is measured from the CY2022 base year. Measures use the whole NF population (all payers). Paid after CMS data release and CMS preprint approval: the CY2025 amendment was approved Aug 2026, so payment lags the performance year by 9+ months.

Payment formula

Points summed across measures, then x the home's CHC MA occupancy % (CHC Medicaid days / total days, from the resident day report). Value per point = $15M / total adjusted points, so the whole pool is paid out. Payment = adjusted points x value per point.

Eligibility

Nonpublic and county NFs serving CHC members. A home must have attended at least one live DHS Learning Network webinar, or it is disqualified. No points on a measure when CMS suppresses it for a small denominator.

Cadence

Annual, scored and paid once per calendar year.

Scores published

Not found. No per-facility score or payment file was located on the DHS rates page.

Notes

Small next to the CHC minimum payment rate (MPR) directed payment, which adds about $50/day for nonpublic homes. The PA quality strategy links it to the Governor's Healthcare Reform Recommendations (2021).

Verified October 11, 2026

Provider tax

Charged

per non-Medicare day

Standard amount

$33.41 per non-Medicare resident day (FY2025-26 final, CMS waiver approved 3/11/2026; same rate proposed for FY2026-27)

Tiers

Who	Test	Amount
>= 94% MA (Medicaid) occupancy (CY2021)	medicaid_utilization	$9.32 per non-Medicare day
>= 57,000 MA (Medicaid) days (CY2021)	medicaid_utilization	$9.32 per non-Medicare day
county homes	public	$9.32 per non-Medicare day
<= 44 beds	size	$9.32 per non-Medicare day
certain CCRCs	ccrc	$9.32 per non-Medicare day
state and veterans homes, free-care homes, new homes in their first quarter	other	exempt

Lower for high-Medicaid homes

yes

Returned in the rate

Not returned as a separate add-on; the revenue plus federal match funds the general case-mix rates, MDOI and supplements, and the assessment is an allowable cost on the MA-11.

Source

https://www.pacodeandbulletin.gov/Display/pabull?file=/secure…

Verified October 11, 2026

Provider tax notes

Nursing Facility Assessment Program (Human Services Code Art. VIII-A, 62 P.S. 801-A-815-A), charged on non-Medicare resident days of the prior quarter. FY2025-26 final (CMS waiver approved 3/11/2026) and FY2026-27 proposed: $33.41 per non-Medicare day for most homes. A $9.32 lower rate applies to county homes, homes with <=44 beds, certain CCRCs, homes with >=94% MA occupancy (CY2021), and homes with >=57,000 MA days (CY2021). Exempt: state and veterans homes, free-care homes, and new homes in their first quarter. Aggregate: $468.256M FY2024-25, $462.282M FY2025-26, $460.966M proposed FY2026-27. Must raise at least $50M of new revenue. Not returned as a separate add-on. The revenue plus federal match funds the general case-mix rates, MDOI and supplements, and the assessment is an allowable cost on the MA-11.

Verified October 11, 2026

Supplemental payments

(1) CHC minimum payment rate state-directed payment (since 1/1/2023): MCOs must pay at least FFS + a uniform per diem + a facility-specific per diem. Nonpublic: +$22.41 uniform + about $30.66 median variable, about +$53/day (2026). County: +$250.82 uniform + about $60 variable, about +$310/day (2026). This is the largest supplemental stream (see managed_care_rate_floor). (2) Medical Assistance Day One Incentive (MDOI), for nonpublic homes with >=85% overall occupancy and >=65% MA occupancy: up to 2 payments/yr pro rata to PA MA days. $21M state funds ($47.792M total) FY2025-26; $21M state ($49.307M total) FY2026-27 (56 Pa.B., Sept 19, 2026). (3) Targeted 'supplementation' payments, paid per MA day of the prior year to homes meeting narrow county-class / bed / acuity tests, FY2025-26: county NF in a 2nd class A home rule county with >725 beds, $4.552M ($2.0M state); nonpublic in a 1st class county (Philadelphia) with >395 beds, $2.276M; nonpublic in a 2nd class A county with >126 beds, $3.414M; nonprofit in a 2nd class A city of a 3rd class county, $3.414M; nonpublic in an 8th class county with >119 beds, $5.690M. (4) Disproportionate share incentive (1187.111): per MA paid day for homes with >=90% occupancy and >=80% MA occupancy, $0.20-$2.50/day (year-1 values, inflated). (5) One-time 2023 Enhanced Supplemental (COVID) payment: $40M ($18.352M state), FY2023-24. (6) County homes: DHS may claim county-certified costs as MA expenditures (443.1(6)). The large county MPR uniform per diem looks county/IGT-funded (unconfirmed). (7) Health care-associated infection (HAI) payments: the MA share of the annual HAI surcharge, refunded per MA-11 (Pa.B. notices).

Verified October 11, 2026

Other add-ons

(1) Supplemental ventilator/tracheostomy payment (1187.117), quarterly, for homes with >=10 MA residents on vent/trach care and >=10% of MA residents: per diem = (vent-trach share x $69) x vent-trach share, times MA days. (2) Statutory added vent/trach payment since FY2020-21 (443.1(7)(vii)): $130 x (vent-trach MA residents / total MA residents) per eligible MA day, for homes with >=10 such residents and >=17%. Paid in FFS and CHC. (3) Extra FY2025-26 vent/trach add-ons split equally among homes that had >90% vent/trach MA residents in FY2014-15 ($1.138M), and among Philadelphia homes opened after 2017 with >=90% ($0.569M). (4) Exceptional DME grants (1187.151-158) for listed high-cost equipment for individual residents. No COVID per diem add-on remains in the rate.

Verified October 11, 2026

Units paid separately

(1) Special rehabilitation facilities (>70% of residents with neurological/neuromuscular diagnoses and severe functional limits): their own peer group 13, never collapsed. 13a = SRFs classified after 7/1/2000 priced on all SRFs. They have the highest prices (PDPM RC $246.46, ORR $141.16). (2) Hospital-based NFs (those with a hospital-based rate on 6/30/1995): peer group 14 (RC $236.30). (3) County nursing facilities (Ch. 1189): not case-mix; per diem = prior-year per diem x county BAF, unchanged in method since 2007. County costs were removed from nonpublic price setting over FY2009-10 to FY2011-12. (4) State-owned homes and state veterans homes are outside Ch. 1187/1189. (5) Ventilator/tracheostomy residents get supplements, not a separate rate (see other_add_ons). (6) LIFE (PACE) is a separate capitated program.

Verified October 11, 2026

Payment rules

Managed care for long-term care

Status

yes

Detail

Community HealthChoices (most residents 21+ and duals)

Verified October 11, 2026

Who pays

mixed, mostly managed: Community HealthChoices (CHC), Pennsylvania's managed long-term services and supports program (1915(b)/(c)), covers most Medicaid nursing home residents age 21+ and dual eligibles. It was phased in by zone: Southwest Jan 2018, Southeast Jan 2019, the rest of the state Jan 2020. DHS still sets the fee-for-service (FFS) case-mix rate, which is component 1 of the CHC minimum rate. Fiscal notes for the nursing facility assessment book the program under 'MA - Community HealthChoices'. FFS pays residents outside CHC (e.g. under 21, LIFE/PACE excluded populations).

Verified October 11, 2026

Managed care rate floor

Yes, and above FFS. Since Jan 1, 2023, a CMS-approved state-directed payment (42 CFR 438.6(c), approved 12/30/2022) sets a 'minimum payment rate' (MPR) that each CHC-MCO must contract at, at least. MPR = (1) the State Plan FFS per diem + (2) a uniform per diem by provider class + (3) a facility-specific variable per diem. Oct 1, 2026 nonpublic homes: uniform $22.41; variable median $30.66 (range $5.64-$65.47); total MPR median $301.79 vs FFS median $253.42, about 19% above FFS. County homes: uniform $250.82 plus a county-specific $16.92-$102.05, total median $596.04, about double the county FFS rate of $285.76. The uniform and variable parts are reset each calendar year under the CY preprint. Nonpublic uniform: $24.13 (2023), $21.30 (2024), $21.19 (2025), $22.41 (2026). County uniform: $294.78 / $233.77 / $244.77 / $250.82. MPR files are posted quarterly on the DHS rates page. Source: https://www.pa.gov/agencies/dhs/resources/for-providers/ltc-p…

Verified October 11, 2026

Included in the daily rate

Included (1187.51(c), (e)): room, dietary, nursing, social services, medical/surgical supplies, oxygen and its administration, OTC drugs, routine DME (canes, walkers, wheelchairs, traction), tube-feeding supplements, laundry, nonemergency transportation, beauty/barber, and physical, occupational and speech therapy (a resident care cost). Separate: prescription drugs, billed by the pharmacy (1187.105); exceptional DME by grant (1187.151+); physician and hospital services. Medicare Part B-type services are reported separately (1187.72). In practice Medicare pays most therapy for dual eligibles.

Verified October 11, 2026

Bed hold

Hospital stays

Paid at 1/3 of the home's current per diem, up to 15 consecutive days per hospitalization. The home must hold the same bed for stays of 15 days or less, and cannot bill those days to the resident or as therapeutic leave.

Leave days

Paid at 100% of the current per diem, up to 30 days per calendar year, if in the plan of care and ordered by the attending physician.

Occupancy rule

Hospital reserved bed days are paid only if the home's overall occupancy is >=85% for the rate quarter (since 2010-11). Occupancy = assessments on the CMI report / certified beds; the highest of the last 3 picture dates counts. No valid CMI report means no hospital bed-hold pay. No occupancy test for therapeutic leave.

Notes

In the BAF day-weighting, 1/3 of hospital reserve days count as base days.

Source

https://www.pacodeandbulletin.gov/Display/pacode?file=/secure…

Verified October 11, 2026

Personal needs allowance

Per month

60

Effective

2025-01-01

Notes

LTC Handbook 468.32 and Appendix A: $60 effective 1/1/2025 (was $45 from 7/1/2007 to 12/31/2024). ICF/ID residents not on SSI with sheltered-workshop earnings get a graduated PNA (55 Pa. Code 181.452, up to $110 + 50% of earnings over $150). Not COLA-indexed.

Confidence

confirmed

Source

http://services.dpw.state.pa.us/oimpolicymanuals/ltc/468_Elig…

Verified October 11, 2026

Medicare coinsurance days

Method

lesser_of

Rule

Lesser-of. 55 Pa. Code 1187.102(a): if the Medicare payment is less than the NF's MA per diem, the Department pays coinsurance only so that Medicare plus Department plus other coinsurance payments do not exceed the MA per diem, and never more than the coinsurance. Under 1187.102(c) the NF may not seek the unpaid coinsurance from any source other than Medicare. 55 Pa. Code 1181.60 holds the older parallel rule. Medicare Advantage: not found. CHC MCOs cover duals and likely apply the same per-diem cap.

Effect

The home gets the MA per diem minus Medicare's payment, which is usually $0, and cannot bill the resident or family for the rest.

Confidence

confirmed

Source

https://www.pacodeandbulletin.gov/Display/pacode?file=/secure… (s. 1187.102)

Medicare Advantage

not addressed: 55 Pa. Code 1187.102 (lesser-of for Medicare coinsurance) has no Medicare Advantage, Medicare HMO or managed-care text. The CHC agreement (CHC-MCOs are aligned with D-SNPs) was not retrieved.

Medicare Advantage source

https://www.pacodeandbulletin.gov/Display/pacode?file=/secure…

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: resident care and other resident related rates are capped at the lower of the peer price or 103% of the home's own cost plus 30% of the gap up to the price (55 Pa. Code 1187.107), so homes that spend less than the price are paid less. Administrative has no own-cost limit. No recoupment rule found.

Source

https://www.pacodeandbulletin.gov/Display/pacode?file=/secure…

Verified October 11, 2026

Occupancy rules

Applies

yes

Rule

(1) Administrative and capital per diems use resident days adjusted to at least 90% occupancy. (2) Hospital reserved bed days are paid only if overall occupancy is 85%+ for the rate quarter. (3) MDOI requires 85%+ overall occupancy and 65%+ MA occupancy. (4) The disproportionate share incentive requires 90%+ occupancy and 80%+ MA occupancy.

Source

https://www.pacodeandbulletin.gov/Display/pacode?file=/secure…

Verified October 11, 2026

MDS accuracy penalties

No dollar penalty or recoupment program found. The built-in penalties are in 1187.33(b): a resident with no valid assessment counts at the lowest PDPM CMI (0.64) in the MA CMI. An uncorrected error on a classifiable item is scored 'no/not present'. A missing or invalid CMI report puts the whole home at the lowest MA CMI and makes it ineligible for vent/trach supplements and hospital bed-hold pay that quarter. Whether DHS runs MDS validation reviews with rate cuts is unconfirmed.

Verified October 11, 2026

Published rates and changes

How often rates change

A home's rate changes

quarterly

When

Jan 1, Apr 1, Jul 1, Oct 1 (case mix and the budget adjustment factor); prices Jul 1

Verified October 11, 2026

When rates change

Prices: July 1 state fiscal year, set in the spring. Rates: quarterly (Jan 1, Apr 1, Jul 1, Oct 1), as the MA CMI and the quarterly BAF change each quarter. Rates are published as PROPOSED in the Pa. Bulletin and on the DHS site and paid provisionally. FINAL rates come much later after CMS certifies the BAF SPA. FY2025-26 final rates were published May 9, 2026, and rate letters are issued only then. CHC MPR files are posted for each quarter, with the uniform/variable parts reset each calendar year.

Verified October 11, 2026

Posted rates

Home-level rates published

Yes

Where

https://www.pa.gov/agencies/dhs/resources/for-providers/ltc-p…

Format

xlsx

Cadence

Quarterly proposed rate files (nonpublic) and annual county files. Final 'condensed' and 'detailed' files after CMS approval, plus quarterly CHC Minimum Payment Rate files. Latest: Q4 2026 proposed (Oct 1, 2026) and Q4 2026 MPR (file date 9/4/2026). Final rates on the page currently run through Q2 2025.

History

The page says final rates go back to January 1996. Files linked directly cover July 2019 onward (xls/xlsx), plus crosswalk PDFs for detailed rates back to 2011-12, county detailed rates listed back to 2006-07, and BAF workbooks back to 2014-15 on the BAF page. CHC MPR files run from 1/1/2023.

Home identifier

PA Medical Assistance provider number (13-digit PNUM, e.g. 1041038130001) + DHS NIS provider ID (PROVID) + name; also county, owner type, peer group, beds. No CCN or NPI.

Verified October 11, 2026

Rate build-ups

Published

Yes

Where

https://www.pa.gov/agencies/dhs/resources/for-providers/ltc-p… (proposed/detailed rate files) and https://www.pa.gov/agencies/dhs/resources/for-providers/budge… (BAF workbooks)

What they show

The July (rebase-quarter) proposed file shows each home's 3 cost reports: resident care/ORR/admin costs as reported and inflated, case-mix-neutral RC per diem, report end date, days, occupancy, CMI per report, inflation factor. Plus the price inputs: beds, $26,000 fixed property, movable property, yield rate, real estate tax, peer group. Then the rate: MA CMI, RC price, RC limit, RC rate, ORR price/limit/rate, admin rate, capital per diem, NFRATE at 100%, BAF (NFRATEMULT) and proposed rate. Other quarters show the condensed build-up. The BAF workbook shows the target rate, the weighted average rate at 100% per quarter, the quarterly BAF, and per-facility days and rates with and without the BAF, plus county BAF history.

Format

xlsx (BAF workbooks .xls)

Example file

https://www.pa.gov/content/dam/copapwp-pagov/en/dhs/documents…

Verified October 11, 2026

Recent changes

Verified October 11, 2026

Assisted living

Medicaid assisted living

Covered

limited

Program

No Medicaid assisted living benefit. Personal care homes (PCH) and assisted living residences (ALR) are 'typically not covered by Medicaid'. Some residents receive Community HealthChoices (1915(c)) home and community-based services.

What is paid

Room, board and the facility's care fee are paid privately (rates set by the facility). Medicaid may pay only for individual CHC waiver services a resident qualifies for. State SSI supplement for PCH residents not verified here.

Rate

No Medicaid ALF/PCH rate.

Limits

n/a

Source

https://www.pa.gov/agencies/dhs/resources/aging-physical-disa…

Verified October 11, 2026

Sources

1. DHS Nursing Facility Rates page (proposed/final rate files, CHC Minimum Payment Rates) · agency page
2. DHS Budget Adjustment Factor page (BAF workbooks FY2014-15 to FY2025-26) · agency page
3. FY2025-26 quarterly BAF workbook (file date 3/26/2026) · rate file
4. FY2024-25 quarterly BAF workbook · rate file
5. FY2023-24 quarterly BAF workbook · rate file
6. FY2022-23, FY2021-22, FY2020-21 BAF workbooks · rate file
7. Q4 2026 (Oct 1, 2026) proposed nonpublic NF rates · rate file
8. Q3 2026 (Jul 1, 2026) proposed nonpublic NF rates (detailed rebase file) · rate file
9. PDPM Medians and Prices · rate file
10. CHC Minimum Payment Rates, Oct 1, 2026 (and earlier quarterly MPR files 2023-2026) · rate file
11. 55 Pa. Code Chapter 1187 Nursing Facility Services (full text) · regulation
12. 55 Pa. Code 1187.96 Price-setting and rate-setting computations · regulation
13. 55 Pa. Code 1187.104 Limitations on payment for reserved beds · regulation
14. Final rule: Transition to Patient Driven Payment Model, 55 Pa.B. 5119 (Aug 2, 2025) · regulation
15. Notice: Budget Adjustment Factor for FY2026-27, 56 Pa.B. 3807 (Jun 27, 2026) · agency page
16. Notice: Proposed rates for SFY 2026-27 (Jun 27, 2026) · agency page
17. Notice: Final rates for SFY 2025-26, 56 Pa.B. (May 9, 2026) · agency page
18. Notice: Peer groups, medians and prices SFY 2025-26, 56 Pa.B. 2765 · agency page
19. Notice: Nursing Facility Assessment Program FY2026-27 (proposed) and FY2025-26 (final) · agency page
20. Notices: FY2025-26 county/nonpublic supplementation and vent/trach add-on payments (56 Pa.B., Mar 28, 2026) · agency page
21. Notice: MA Day One Incentive payments FY2026-27 (Sept 19, 2026) · agency page
22. Notice: 2023 one-time enhanced supplemental payment (Oct 7, 2023) · agency page
23. Human Services Code 443.1 (62 P.S. 443.1) - NF payments, BAF, vent/trach $130 add-on, MDOI · statute
24. CMS SDP preprint PA_VBP_NF2_Amend_20250101-20251231 (NF Quality Incentive, approved 8/20/2026) · state plan
25. DHS Personal Care Homes page · agency page
26. Medicare crossover / coinsurance rule · regulation
27. Medicare crossover rule · regulation
28. Personal needs allowance · regulation

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