Rhode Island
Rhode Island’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)
- Yes
- Quality program
- None
- Paid outside the rate
- None
- Bed hold
- Not paid
- Published rates
- Rates and build‑ups
- Assisted living
- Covered
- Personal needs allowance
- $75 / month
Overview
- Rhode Island uses a price-based, acuity-adjusted per diem (since 2013).
- Every home gets the same statewide prices for direct care, other direct care and indirect care.
- Only the direct care price is multiplied by each resident's PDPM nursing weight.
- Facility-specific fair rental value (capital) and property tax amounts are added, plus a 5.82% gross-up that covers the 5.5% provider tax.
- The statewide prices were rebased from cost reports on 10/1/2024 (direct care base $143.16 at weight 1.0) and are otherwise trended each October 1.
What matters in Rhode Island
- PDPM since 10/1/2025: each resident's PDPM nursing weight multiplies a statewide direct-care price on every claim.
- Rebasing on 10/1/2024 raised the average rate about 14.5% ($259 to $297 at weight 1.0), costing $73.2M a year.
- +5.3% on 10/1/2025 (2.3% inflation plus a 3% staffing adjustment that must be spent 100% on direct-care pay).
- From 1/1/2026, homes below 3.58 staff hours per resident day face a fine of 3% of Medicaid revenue.
- 5.5% gross-revenue provider tax is returned through a 5.82% add-on to every home's per diem.
- Most long-stay residents are fee-for-service; the voluntary Neighborhood FIDE-SNP must pay at least the FFS rate.
Frequently asked
Does Rhode Island Medicaid apply PDPM case mix per resident or as a facility average?
Per resident. Since 10/1/2025, MMIS uses the PDPM nursing component from each resident's latest MDS. That weight multiplies the statewide direct-care price on each claim, and the home's other components are added on top.
When did Rhode Island last rebase its nursing facility Medicaid prices?
October 1, 2024. That was the first rebase of direct, indirect and other direct care since 2012. The direct-care base rose to $143.16 and the average rate at weight 1.0 rose about 14.5%, to $297.05.
What penalty does Rhode Island impose on nursing homes that miss minimum staffing?
From 1/1/2026, a home below 3.58 direct-care hours per resident day in a quarter is fined 3% of its Medicaid reimbursement. The fine is waived for good survey history, bottom-25% nursing case mix, or compliance on 75% of days.
How much is paid outside the posted rate in Rhode Island?
None found: no supplemental, IGT or directed payments to nursing homes were identified.
What does Rhode Island Medicaid pay on Medicare coinsurance days?
Coinsurance up to the rate: Medicaid pays the lesser of the Medicare coinsurance or the home's Medicaid per diem.
Does Rhode Island require a minimum share of spending on care?
Yes: 80% of each inflation increase and 100% of the 10/1/2025 3% staffing adjustment must go to direct-care pay, or be clawed back with a 25% penalty.
How is the Rhode Island nursing home provider tax charged?
5.5% of gross patient revenue for every licensed home, with no tiers; returned through a 5.82% add-on to the per diem.
How the rate is set
How the method got here
| Effective | From | To | Change | Headline | Source |
|---|---|---|---|---|---|
| 2004-09-01 | Actual depreciation/interest/lease cost reimbursement | Fair rental value system for capital | Capital costs were replaced with a fair rental value payment. | Fair rental value replaces capital cost | https://www.macpac.gov/publication/nursing-facility-payment-p… |
| 2013-05-04 | Facility-specific cost-based rates with cost-center ceilings (110%/105% of median) | Statewide price-based per diem with RUG-IV per-resident acuity on direct care, plus FRV, property tax and provider-tax add-on | RI moved from cost-based to price-based rates with per-resident RUG-IV acuity (full RUG billing from 6/1/2013), with a transition phased out by 10/1/2021. | Price-based acuity-adjusted rates replace cost-based rates | https://webserver.rilegislature.gov/Statutes/TITLE40/40-8/40-… |
| 2024-10-01 | 2012 prices trended by market basket/legislated % | Prices rebased to recent cost reports, with periodic revision required | Direct, indirect and other direct care prices were rebased for the first time since 2012. | First price rebase since 2012 | https://eohhs.ri.gov/sites/g/files/xkgbur226/files/2024-05/Nu… |
| 2025-10-01 | RUG-IV 48-group per-resident weights | PDPM nursing-component per-resident weights | SPA 25-0014 switched the acuity factor on direct care from RUG-IV to PDPM nursing. | RUG-IV replaced by PDPM nursing component | https://eohhs.ri.gov/sites/g/files/xkgbur226/files/2025-12/to… |
Verified October 11, 2026
Cost basis
- Uses cost reports
Yes
- Cost report
State BM-64 Medicaid cost report (calendar year, due May 31).
- Base year and rebasing
Prices were set in 2012/2013 and trended until the 10/1/2024 rebase. That rebase used the most recent finalized cost reports (Milliman, May 2024). RIGL 40-8-19(a)(2)(iii) and 4.19-D sec. D: 'beginning October 2024' rates are revised as necessary from the latest finalized cost report year. FRV was last rebased 10/1/2012 and is trended yearly. Property tax is updated yearly from cost reports.
- Components
Component Method Notes Direct nursing care Statewide price x resident PDPM nursing weight $143.16 at weight 1.0 from 10/1/2024 (rate file). The 4.19-D text still lists $133.46. Other direct care Statewide price Activities, medical supplies, food. $30.70 weighted average after the 10/1/2024 rebase (4.19-D text still shows $23.74). Indirect care Statewide price Administration, housekeeping, maintenance, utilities. $84.09 after the 10/1/2024 rebase (4.19-D text still shows $53.53). Fair rental value Facility-specific FRV frozen at the 7/1/2012 calculation, trended by the CMS SNF capital cost index $19.12 average. FRV adjustment requests are allowed for renovations or bed additions (EOHHS FRV Guidelines). Property taxes Facility-specific pass-through: allowable tax / total patient days from the latest cost report $3.64 average Provider assessment 5.82% of the sum of the other components Grosses up the rate for the 5.5% tax. - Inflation
CMS SNF PPS market basket (actual regulatory update, without productivity adjustment) for direct, other direct and indirect care each October 1. Statute overrides apply in some years: none in 2015/2017, +3% 10/1/2022, +2.3% plus a 3% staffing adjustment 10/1/2025. FRV uses the IHS Markit SNF capital cost moving average.
Verified October 11, 2026
Case mix
- System
PDPM
- Applied at
Resident-level
- How it works
Claim = (Direct Care Rate x Patient Acuity Factor [PDPM weight] + Provider Base Rate) / Provider Assessment Rate x days - patient liability. The PDPM code on each resident's latest MDS is used for each date of service (EOHHS PDPM Information Guide v1.2, FAQ 6).
- Classification
PDPM nursing component only (the third character of the HIPPS code). The provider-calculated code from the MDS (Z0100A) is used, not a state grouper.
- Applies to
Direct nursing care component only
- Acuity measured from
Not a facility average for payment. A facility 'Nursing Case-Mix Index' is used only for the staffing-fine waiver (bottom 25% of homes).
- Updated
Every MDS assessment (OBRA and interim); the code is effective from the ARD.
- Move to PDPM
SPA 25-0014 (approved 11/25/2025, effective 10/1/2025) replaced RUG-IV 48-group weights with PDPM nursing weights. Claims with dates of service before 10/1/2025 still pay on RUG. EOHHS required OBRA assessments with PDPM HIPPS codes between 9/1/2024 and 11/1/2024 to collect data, and posted a PDPM Transition Report (2025-06). No blend was used.
Verified October 11, 2026
Low-acuity residents
None found after checking 4.19-D and the PDPM guide. A missing or blank PDPM code defaults to 'ZZZZZ', which suspends or denies the claim (edit 252, EOB 916) rather than paying a reduced rate. Separately, stays of 30 days or less without LTC approval (post-hospital) are paid at the PDPM rate on professional claims.
Verified October 11, 2026
Capital
Fair rental value: facility-specific value frozen from the 7/1/2012 calculation and trended yearly by the CMS SNF capital cost index, plus property tax as a pass-through. New homes get an FRV calculated under the same method.
Verified October 11, 2026
Budget adjustment factor
No standing budget-neutrality factor. The legislature overrides the market-basket update in some years: no update 10/1/2013-2015, 2017-2019 and 10/1/2022 (flat raises used instead); +98% cap on 4/1/2015 rates for SFY2016; +3% 10/1/2022; base-rate staffing adjustments of +0.5% (10/1/2021), +1% (10/1/2022) and +1.5% (10/1/2023); +2.3% plus a 3% staffing adjustment 10/1/2025 (RIGL 40-8-19).
Verified October 11, 2026
Add-ons and money outside the rate
Paid outside the posted rate
- Level
none
- Estimate
No payments outside the per diem were found. The provider-tax return is inside the rate, and the FIDE-SNP pays at least FFS (above-FFS contracts are unknown).
- Components
None identified.
Verified October 11, 2026
Payments by owner type
- Applies
no
- Detail
One price-based method applies to all participating homes. The only ownership distinction found is that the new-facility rule refers to 'newly constructed for-profit facilities.' The tax applies to governmental units too.
- Funding
N/A
Verified October 11, 2026
Quality program
- Active
No
- Notes
RIGL 40-8-19.2 (2015) authorizes a Nursing Facility Incentive Program (NFIP) with payments no earlier than 7/1/2016. No active NFIP appears in the current 4.19-D (TN 25-0014). The 2026 staffing statute waives fines for high-quality homes, but that is not a payment.
Verified October 11, 2026
Provider tax
- Charged
% of net patient revenue
- Standard amount
5.5% of gross patient revenue, effective 1/1/2008 (RIGL 44-51-3(b)). It applies to every licensed nursing facility, including governmental units.
- Lower for high-Medicaid homes
no
- Returned in the rate
Provider assessment component = 5.82% of the sum of the other rate components, so the rate x 5.5% equals the tax on Medicaid revenue (4.19-D p.8). Average $16.34/day after the 10/1/2024 rebase.
Verified October 11, 2026
Provider tax notes
Nursing Facility Provider Assessment: 5.5% of gross patient revenue, monthly (RIGL 44-51-3, since 1/1/2008). It is returned through a 5.82% per diem add-on.
Verified October 11, 2026
Supplemental payments
None found: no UPL, IGT or MCO directed payments for nursing facilities appear in 4.19-D or EOHHS nursing home pages.
Verified October 11, 2026
Other add-ons
$175 per day behavioral health add-on for complex residents in a certified Nursing Facility Specialized Psychiatric Unit (NFSPU). It requires a hospital stay of 6+ months, NF level of care and PASRR Level II approval, and is not inflated (4.19-D sec. C). The 2019-era $200/day ventilator differential is not in the current 4.19-D (see open questions).
Verified October 11, 2026
Units paid separately
Special Prospective Rate Appeal for homes under a DOH monitor, temporary manager or plan of correction: a per diem add-on based on the approved spending plan for 6 months, extendable to 24 months, with unspent funds recouped. Hardship rate increase requests are limited to 1 per year. Hospice room and board is paid at 95% of the NF rate. Out-of-state NFs are not enrolled.
Verified October 11, 2026
Payment rules
Managed care for long-term care
- Status
yes
- Detail
Voluntary, and for duals only. MMP members were auto-enrolled into Neighborhood's FIDE-SNP on 1/1/2026 with an opt-out to FFS. The plan has a 'Dual - Nursing Home' rate cell and pays nursing home and SNF care in-plan. In the SFY2025 Milliman estimate, the MMP accounted for $78.0M of $505.3M in NF and hospice spending (about 15%), with FFS at $421.8M. Milliman notes that 'most members residing in a nursing facility are enrolled in the fee-for-service delivery system.' Other managed care programs cover only skilled nursing facility claims.
Verified October 11, 2026
Who pays
mixed: mostly fee-for-service. Dual eligibles can choose Neighborhood Health Plan of RI's FIDE-SNP (Medicare-Medicaid Plan 'INTEGRITY' until 12/31/2025; FIDE-SNP from 1/1/2026), which pays nursing homes. PACE covers a small number of people. Other Medicaid managed care (RIte Care, Rhody Health Partners, Expansion) covers only skilled/short stays.
Verified October 11, 2026
Managed care rate floor
Yes for the FIDE-SNP: Schedule of in-plan benefits, Nursing Facility: 'Pay no less than the Medicaid FFS Minimum Fee Schedule' (NHPRI FIDE-SNP contract 2026-02, eff. 1/1/2026). Statute 40-8-19 applies its rate increases to 'both fee-for-service and managed care.'
Verified October 11, 2026
Included in the daily rate
The basic rate excludes dental, prescription drugs, personal items (hearing aids, eyeglasses, prosthetics), hospitalization and physician services. Drugs are billable separately if the home has an on-site pharmacy (EOHHS LTC Coverage Guidelines).
Verified October 11, 2026
Bed hold
- Hospital stays
Not paid by Medicaid.
- Leave days
Not paid by Medicaid.
- Occupancy rule
N/A
- Notes
Under RIGL 23-17.5-25(d), a home that allows bed holds cannot charge more than its Medicaid daily rate (at the resident's PDPM code) for at least the first 5 days of each hospital or leave absence. The family pays privately.
Verified October 11, 2026
Personal needs allowance
- Per month
75
- Effective
2023-07-01
- Notes
Raised from $50 under the FY2024 enacted budget (Attachment 2.6-A p.4a SPA). Not indexed.
Verified October 11, 2026
Medicare coinsurance days
- Method
coinsurance_up_to_rate
- Rule
EOHHS LTC Coverage Guidelines (Reimbursement Guidelines, Medicare Coinsurance/Deductible): 'The facility will be reimbursed at the lesser of the coinsurance/deductible rate or the individual nursing facility rate.' The cap is the home's Medicaid per diem, without subtracting Medicare's payment. FIDE-SNP duals' Medicare-covered SNF stays are paid by the integrated plan. MA cost-sharing treatment for other plans was not found.
- Effect
The 2026 SNF coinsurance is far below RI's roughly $300+ per diem, so homes usually get the full day 21-100 coinsurance.
Verified October 11, 2026
Required care spending
- Applies
yes
- Rule
(1) Since 10/1/2021, 80% of each inflation-index increase to direct and indirect care must go to compensation for eligible direct-care workers. Covered staff are RN/LPN/CNA/CMT, therapists, housekeeping, laundry and dietary; exempt nurses and agency staff are excluded. Homes certify each July 31, and non-compliance means a clawback of unspent funds plus a 25% penalty. (2) 100% of the 3% base-rate staffing adjustment of 10/1/2025 must be spent on direct-care compensation or new positions. (3) A 3.58 HPRD minimum from 1/1/2026 (PBJ-based, quarterly), with a fine of 3% of Medicaid reimbursement. It is waived for good survey history, bottom-25% nursing CMI, or compliance on 75% of days. Four straight non-compliant, non-waived quarters trigger an EOHHS financial audit. (RIGL 40-8-19(a)(3)-(4); 23-17.5-32, -33; 4.19-D pp.10-11)
Verified October 11, 2026
Occupancy rules
- Applies
no
- Rule
No occupancy-based rate cut or minimum-occupancy divisor for existing homes in the price-based method. For newly constructed homes only, the property tax component uses an occupancy equal to 98% of the prior year's statewide average (4.19-D p.14).
Verified October 11, 2026
MDS accuracy penalties
None specific found. MMIS uses the provider-reported PDPM code, and claims without a valid code suspend or deny. Records are subject to financial review and audit.
Verified October 11, 2026
Published rates and changes
How often rates change
- A home's rate changes
annual
- When
October 1 each year (market basket or a legislated %, FRV and property tax updates; a cost-based rebase when performed, as on 10/1/2024). The per-resident rate changes with each MDS PDPM code.
Verified October 11, 2026
When rates change
October 1 (federal fiscal year); staffing law and fines effective January 1, 2026.
Verified October 11, 2026
Posted rates
- Home-level rates published
Yes
- Where
https://eohhs.ri.gov/providers-partners/provider-directories/… (PDPM Rates web tables effective 10/1/2025 and 10/1/2026; 10/1/2024 rates in PDF/Excel)
- Format
xlsx/pdf and web table
- Cadence
annual (October 1)
- History
10/1/2024 file posted; PDPM rate tables for 2025 and 2026; older RUG weights files
- Home identifier
NPI plus provider legal name and d/b/a
Verified October 11, 2026
Rate build-ups
- Published
Yes
- What they show
Milliman rebasing appendices: per-provider rebased rates by RUG category, six components at weight 1.0, and FFS/MMP fiscal impact. The rate file lists direct care base, provider base rate and provider assessment factor for each NPI.
- Format
xlsx/pdf
Verified October 11, 2026
Recent changes
| Effective | Change | Headline | Direction | Size | Source |
|---|---|---|---|---|---|
| 2023-07-01 | Personal needs allowance raised from $50 to $75 per month (FY2024 budget). | Personal needs allowance raised to $75 | structural | $50 -> $75/month; $1.3M/yr all funds | https://eohhs.ri.gov/sites/g/files/xkgbur226/files/2023-06/23… |
| 2023-10-01 | A 1.5% base-rate staffing adjustment was added on top of the inflation update, with 80% of the increase dedicated to direct-care pay. | 1.5% staffing adjustment added to base rates | increase | +1.5% | https://webserver.rilegislature.gov/Statutes/TITLE40/40-8/40-… |
| 2024-10-01 | Direct, indirect and other direct care prices were rebased to recent cost reports; the average rate at weight 1.0 rose from $259.39 to $297.05. | Rates rebased, average per diem up 14.5% | increase | +14.5% average; $73.2M SFY2025 all funds (vs $30.4M trend-only) | https://eohhs.ri.gov/sites/g/files/xkgbur226/files/2024-05/Nu… |
| 2025-10-01 | Case mix switched from RUG-IV to PDPM nursing, and rates rose 5.3% (2.3% inflation plus a 3% staffing adjustment to be spent 100% on direct-care pay). | PDPM adopted; rates up 5.3 percent | increase | +5.3%; $1.3M SFY2026 / $2.8M SFY2027 state funds (SPA notice) | https://eohhs.ri.gov/sites/g/files/xkgbur226/files/2025-07/RU… |
| 2026-01-01 | The 3.58 HPRD minimum staffing standard took effect with a quarterly fine of 3% of Medicaid reimbursement; earlier fines were forgiven (P.L. 2025 ch. 278). | Staffing minimum enforced with 3% Medicaid fine | structural | 3% of Medicaid reimbursement per non-compliant quarter | https://webserver.rilegislature.gov/Statutes/TITLE23/23-17.5/… |
| 2026-01-01 | Neighborhood's Medicare-Medicaid Plan was replaced by a FIDE-SNP; members were auto-enrolled and the plan must pay NFs at least the FFS rate. | Dual-eligible MMP converted to FIDE-SNP | structural | https://eohhs.ri.gov/sites/g/files/xkgbur226/files/2026-09/CY… |
Verified October 11, 2026
Assisted living
Medicaid assisted living
- Covered
yes
- Program
Rhode Island Comprehensive 1115 Demonstration LTSS: assisted living services in state-licensed Assisted Living Residences certified for LTSS. These are also in-plan for FIDE-SNP members. SSI Enhanced Assisted Living state supplement for low-income residents.
- What is paid
Services only: 24-hour personal care, homemaker/chore, medication management, activities and health-related transport. Room and board is paid by the resident, helped by the SSI enhanced state supplement.
- Limits
Requires LTSS eligibility (institutional/high level of care) and a certified ALR. No cap found.
Verified October 11, 2026
Sources
- RI Medicaid State Plan Attachment 4.19-D, Principles of Reimbursement for Nursing Facilities (TN 25-0014, eff. 10/1/2025, approved 11/25/2025) · state plan
- RIGL 40-8-19 Rates of payment to nursing facilities · statute
- RIGL 40-8-19.2 Nursing Facility Incentive Program · statute
- RIGL 44-51-3 Nursing facility provider assessment · statute
- RIGL 23-17.5-32 and 23-17.5-33 Minimum staffing levels and enforcement · statute
- EOHHS RUG to PDPM SPA public notice (7/14/2025) · agency page
- EOHHS PDPM Information Guide v1.2 · agency page
- Milliman, Rhode Island Medicaid Nursing Facility Rate Development - October 1, 2024 (May 14, 2024) · agency page
- EOHHS NF Rates effective 10/1/2024 (Excel) · rate file
- EOHHS Nursing Homes provider page · agency page
- EOHHS Bed Hold Policy · agency page
- EOHHS Long Term Care Coverage Guidelines · agency page
- EOHHS Nursing Home Stay 30 Days or Less (Dec 2025) · agency page
- EOHHS PNA increase SPA public notice (6/27/2023) · agency page
- NHPRI FIDE-SNP State Medicaid Agency Contract 2026-02 (eff. 1/1/2026) · agency page
- CY 2026 FIDE-SNP Capitation Rate Certification (Milliman) · agency page
- MACPAC 2019 compendium, Rhode Island tab (baseline only) · secondary
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