Medicaid Nursing Home Rates by State

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Texas

Medicaid nursing facility payment · Statewide price · researched October 2026

Texas’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

Statewide price

Case-mix level

Resident-level

Classification

PDPM

Rate updates

Once a year

Managed care (LTC)

Yes

Quality program

QIPP

Paid outside the rate

Large

Bed hold

Leave only

Published rates

Statewide schedule

Assisted living

Covered

Personal needs allowance

$75 / month

Overview

• Texas pays one uniform statewide rate schedule, not facility-specific rates.
• Since 9/1/2025 it is the 'PDPM LTC' schedule (a Texas long-term-care version of Medicare's Patient Driven Payment Model), with 36 groups: 6 nursing x 3 non-therapy-ancillary (NTA) x BIMS severe-cognitive-impairment yes/no, plus 2 default groups.
• Each group's per diem = nursing + NTA + BIMS add-on + four flat amounts every home gets: dietary $21.58, administration $27.43, operations $7.70, fixed capital $7.13.
• Rates run from $164.24 (lowest group P3X and the defaults) to $417.49 (E1Y); the nursing component alone spans $95.68-$326.71.
• Components come from day-weighted statewide median costs from cost reports x 1.07, inflated, then limited to appropriations.
• A $1.67/day liability-insurance add-on and the very large QIPP directed payment sit on top.

What matters in Texas

• Pay is set per resident by assessment group, $164.24-$417.49 a day; there is no single rate per home.
• QIPP, a $1.75B-a-year quality directed payment, adds about $126 a day for government-licensed homes and $47 for private homes.
• 927 of 1,030 QIPP homes hold a government license, which unlocks 60% of the pool closed to private homes.
• An 80% patient care expense ratio is enforced by recoupment, but waived for homes with 4+ stars in 3 of 4 categories.
• No provider tax: QIPP's state share comes from local government IGT (intergovernmental transfers), not a bed tax.
• Hospital bed hold is not paid; therapeutic home visits are paid at the full rate for up to 3 days each.

Frequently asked

How does a privately operated Texas nursing home qualify for the government-only share of QIPP?

It must hold a government license. Components 1 and 4, 60% of the $1.75B annual pool, are open only to non-state government-owned homes, and 927 of 1,030 QIPP homes hold such a license.

Does a Texas home's Care Compare star rating exempt it from spending recoupment?

Yes. Homes with 4 or more stars in 3 of 4 CMS categories are exempt from the 80% patient care expense ratio. Homes at or below 75% occupancy need only 70%.

Does Texas price a Medicare PDPM HIPPS code directly at the Medicaid rate?

No. Texas PDPM uses only nursing and NTA components plus a BIMS flag, with nursing collapsed to 6 groups, so a HIPPS code cannot be priced without a crosswalk.

How much is paid outside the posted rate in Texas?

Large, about 20-60% of base: about $126 a day for government-licensed homes and $47 for private homes.

What does Texas Medicaid pay on Medicare coinsurance days?

Partial: Medicaid pays a portion of the coinsurance, likely limited by the Medicaid rate; the exact formula was not found.

How is the Texas nursing home provider tax charged?

None; Texas has no nursing facility provider tax, and QIPP is funded by intergovernmental transfers.

How the rate is set

How the method got here

Verified October 11, 2026

Cost basis

Uses cost reports

Yes

Cost report

Texas state-specific Nursing Facility Cost Report from the HHSC Provider Finance Dept. (STAIRS, moving to STEPS in 2026). From SFY2026 it is annual on the state fiscal year (Sept-Aug) and reports costs and Medicaid revenue by the seven PDPM LTC components, plus paid days by PDPM group and payer. No SFY2025 report is collected; the first SFY2026 report is due Feb 1-Apr 30, 2027 (IL 2026-03).

Base year and rebasing

1 TAC 355.318: each component is the median allowable cost per day from 'the most recently examined cost report database', weighted by total NF units of service, inflated to the rate period and x 1.07. These are 'recommended' rates. Adopted rates 'are limited to available levels of appropriated state and federal funds', so the Legislature's biennial riders set the actual level. 9/1/2025 rates were adopted under Rider 25 (2026-27 GAA, S.B. 1), which increased dietary and facility/operations. No fixed rebasing cycle is stated, and the cost-report base year for the 9/1/2025 rates was not confirmed.

Components

Component	Method	Notes
nursing	Statewide median nursing cost/day x 1.07, inflated, x the current Medicare PDPM nursing CMI for each of 6 Texas nursing groups (E, H, L, C, B, P).	9/1/2025: E $326.71/$292.50/$264.94 (by NTA group), H $165.72, L $140.28, C $132.85, B $114.29, P $95.68. Covers RN/LVN/med aide/CNA/restorative aide, DON/ADON, social workers, and respiratory therapists in vent homes. Paid feeding assistants and administrators are excluded.
non-therapy ancillary (NTA)	Statewide median NTA cost/day x 1.07, inflated, x the Medicare PDPM NTA CMI for each of 3 Texas NTA groups.	$14.78 / $7.73 / $4.72. Covers central supply, lab/radiology, DME, oxygen, pharmaceuticals, therapy consultants and supplies.
BIMS (cognitive)	Flat add-on for residents flagged with severe cognitive impairment ('Y' groups); the rule sets it at 5% of the nursing component of the highest-CMI nursing classifier.	$12.16/day on 9/1/2025. 5% of $326.71 would be $16.34, so the posted amount reflects a different base or an appropriation limit (see open_questions).
dietary	Statewide median x 1.07, inflated; same for every group.	$21.58/day (9/1/2025), raised by Rider 25.
administration	Statewide median x 1.07, inflated; same for every group. Facility/administration costs of homes below target occupancy (the lower of 85% or the statewide average) are adjusted up to that occupancy.	$27.43/day. Management fees are capped at the 90th percentile. Excluded from the patient-care spending ratio.
operations	Statewide median x 1.07, inflated; same for every group.	$7.70/day (laundry, housekeeping, maintenance, activities, utilities, insurance). Counts as patient care in the expense ratio.
fixed capital asset	Flat statewide amount, same for every group.	$7.13/day. Under the pre-2025 rule: 80th percentile of appraised property value per bed, indexed to PCE.

Inflation

Inflated from the cost-report period to the rate period with HHSC forecast indices (1 TAC 355.108; PCE chain-type price index for general costs), before the 1.07 multiplier. Final rates are capped by appropriations.

Verified October 11, 2026

Case mix

System

PDPM

Applied at

Resident-level

How it works

Each Medicaid resident gets their own PDPM LTC group from their latest OBRA MDS; the claim carries that group's bill code and is paid that group's statewide rate. There is no facility-average CMI (9/1/2025 NF rate sheet; 1 TAC 355.318).

Classification

PDPM LTC (Texas version) since 9/1/2025. It uses only three Medicare PDPM pieces. (1) Nursing, collapsed to 6 groups: E, H, L, C, B, P. These appear to map to extensive services, special care high, special care low, clinically complex, behavioral/cognitive and reduced physical function. (2) NTA, 3 groups. (3) A BIMS severe-cognitive flag: X = no, Y = yes. The PT/OT/SLP components are not used. Nursing and NTA CMIs are the latest Medicare SNF PPS PDPM CMIs. Default groups Z01 and PCE are paid at the lowest group (P3X, $164.24). Before 9/1/2025: RUG-III 34-group (v5.20) plus defaults, in use since 2008-09, when it replaced TILE (Texas Index for Level of Effort) under a hold-harmless transition.

Applies to

The nursing and NTA components; the BIMS add-on applies by flag. Dietary, administration, operations and capital are flat.

Acuity measured from

Not applicable: payment is resident-level only. An MDS must be received on time (within 31 days of completion) or payment stops. A 'missed' MDS is paid at the default rate for the period it covers (26 TAC 554.2413). The admission MDS sets the rate from the admission date.

Updated

Per resident, with each OBRA admission, quarterly or significant-change MDS. The statewide schedule changes with the biennial appropriation, usually on Sept 1.

Move to PDPM

Rider 25 (2024-25 GAA, H.B. 1, 88th Leg.) directed a Texas PDPM; the NF Payment Methodology Advisory Committee had recommended it in April 2022. Rules were adopted effective 9/12/2024 (1 TAC 355.318), and the new method took effect 9/1/2025, with the RUG-III rules (355.306/355.307) repealed. Residents moved to PDPM at their next MDS with an ARD on or after 9/1/2025, with no off-cycle assessments. Until then claims kept pricing at the RUG-III rate, without any enhancement add-on (IL 2025-12). Rider 25 funding was meant to stabilize revenue through the conversion. HHSC planned to file a state plan amendment before 9/1/2025.

Verified October 11, 2026

Low-acuity residents

None as a carve-out. Texas has no reduced or flat rate for low-acuity residents: every resident is paid their PDPM LTC group rate on one statewide schedule. The lowest groups (nursing group P, reduced physical function) are just lower on the scale: $164.24-$186.46/day, against $417.49 at the top (9/1/2025). The default groups Z01 (missed/late MDS) and PCE pay the same as P3X ($164.24). Residents must meet medical necessity (26 TAC 554.2401-2407) to be paid at all. Under RUG-III the lowest groups (PA1, BC1, PCE) paid $89.16/day (9/1/2023). Checked: the 9/1/2025 rate sheet, 1 TAC 355.318, IL 2025-12 and 26 TAC 554.2413.

Verified October 11, 2026

Capital

Included in the price as a flat statewide fixed-capital-asset component of $7.13/day for every group (9/1/2025). It is not fair rental value and not facility-specific. The pre-PDPM rule used the 80th percentile of appraised property value per bed, inflated by half the forecast PCE change and capped at the prior fee inflated by PCE.

Verified October 11, 2026

Budget adjustment factor

No explicit across-the-board factor. The limit is appropriations: the formula gives 'recommended' rates, and adopted rates 'are limited to available levels of appropriated state and federal funds' (1 TAC 355.318). The Legislature's riders therefore set the final level each biennium (e.g. Rider 25, 2026-27 GAA). The 9/1/2025 PDPM rates were funded to 'stabilize revenue levels' through the conversion.

Verified October 11, 2026

Add-ons and money outside the rate

Paid outside the posted rate

Level

large

Estimate

About 20-60% of base: QIPP is $1.75B/yr, paid as quarterly MCO lump sums outside the per diem. SFY2027 preprint: about $126.01/day for NSGO homes on a $212.74 Medicaid base (~59%) and $47.35/day for private homes on a $212.93 base (~22%).

Components

QIPP directed payment $1.75B/yr all funds SFY2025-27 ($1,026.4M federal, $723.6M IGT), four components (44/20/20/16). MPAP (NSGO minimum payments, 2014-2016) status unconfirmed. No FFS UPL found.

Source

https://rad-apps.hhsc.texas.gov/downloads/7-3-2026-sfy-2027-q…

Verified October 11, 2026

Payments by owner type

Applies

yes

Detail

QIPP components 1 and 4 are open only to non-state government-owned (NSGO) homes, so NSGO homes average about $126/day of QIPP vs about $47/day for private homes; 927 of 1,030 participants are government-licensed.

Funding

IGT from non-state government entities (hospital districts and authorities, counties, cities) that hold the NF licenses; private operators run many of these homes under the government license, subject to same/contiguous-county and active-partnership rules.

Source

https://rad-apps.hhsc.texas.gov/downloads/7-3-2026-sfy-2027-q…

Verified October 11, 2026

Quality program

Program

Quality Incentive Payment Program (QIPP) for Nursing Facilities. It began in SFY2018; Year 9 = SFY2026 and Year 10 = SFY2027 (9/1/2026-8/31/2027). Rules: 1 TAC 353.1301-353.1303.

Funding

MCO directed payment under 42 CFR 438.6(c) (preprint TX_VBP_NF_Amend3_20240901-20270831), paid through STAR+PLUS capitation and authorized under the 1115 waiver, not the state plan. The non-federal share is entirely IGT from non-state government entities (hospital districts and authorities, counties, cities) that hold NF licenses. It is not carved from base rates. Texas says it would cover any IGT shortfall with general revenue, and refunds surplus IGT pro rata.

Size

$1.75 billion per year (all funds) for each of SFY2025-SFY2027: $1,026.4M federal and $723.6M non-federal IGT. Per Medicaid day (SFY2027 preprint Table 2): about $126.01/day for non-state government-owned (NSGO) homes, on a $212.74 Medicaid base, and $47.35/day for private homes, on a $212.93 base. For NSGO homes that lifts total pay from 38.3% to 61.0% of the average commercial rate.

Paid as

Quarterly lump sums from each MCO, paid when measure targets are met. Each home's maximum is allocated in advance by component, metric and quarter, in proportion to its historical Medicaid days. The money sits in capitation as a QIPP PMPM, and the MCO pays the earned share x member months. It is not a per diem add-on to claims.

Measures

Measure	Source	Weight	How points are earned
C1 Hospital Partner (NSGO only, 44% of pool): long-stay falls with major injury (N013.02)	MDS QM (CMS Provider Data Catalog)	1 of 5 C1 metrics; meeting 1 metric earns 90% of C1, 2+ earns 100%	Program benchmark 3.27% (CY2025), or relative improvement over the facility baseline of 5%/10%/15%/20% in Q1/Q2/Q3/Q4. C1 and C4 benchmarks use the Texas average where it beats the national average.
C1: long-stay UTI (N024.02)	MDS QM	1 of 5 C1 metrics	Benchmark 0.83%, or 5-20% relative improvement by quarter
C1: long-stay excessive weight loss (N029.03)	MDS QM	1 of 5 C1 metrics	Benchmark 3.21%, or 5-20% improvement
C1: long-stay antipsychotic use (N047.01)	MDS QM	1 of 5 C1 metrics	Benchmark 9.43%, or 5-20% improvement
C1: long-stay ability to walk independently worsened (N035.06)	MDS QM	1 of 5 C1 metrics	Benchmark 14.89%, or 5-20% improvement
C2 Workforce (all homes, 20% of pool): reported CNA hours per resident day	PBJ via CMS Provider Information	1/3 of C2 in SFY2027 (equal shares; SFY2026 paid 60/85/100% for 1/2/3 metrics met, SFY2025 paid 70/100%)	National average 2.33 HPRD, or relative improvement of 1%/2%/3%/4% in Q1-Q4
C2: reported licensed nursing staff HPRD	PBJ	1/3 of C2	National average 1.545 HPRD, or 1-4% improvement
C2: reported total nursing staff HPRD	PBJ	1/3 of C2	National average 3.88 HPRD, or 1-4% improvement
C3 Texas Priority (all homes, 20% of pool): long-stay depressive symptoms (N030.03)	MDS QM	1/3 of C3	National average 12.08%, or 5-20% improvement
C3: long-stay antianxiety/hypnotic use (N036.03)	MDS QM	1/3 of C3	National average 19.54%, or 5-20% improvement
C3: long-stay new/worsened bowel or bladder incontinence (N046.02)	MDS QM	1/3 of C3	National average 19.42%, or 5-20% improvement
C4 Resident Focus (NSGO only, 16% of pool): long-stay pressure ulcers (N045.02)	MDS QM	1/2 of C4	Benchmark 4.04%, or 5-20% improvement
C4: long-stay catheter left in bladder (N026.03)	MDS QM	1/2 of C4	Benchmark 0.39%, or 5-20% improvement

Scoring period

Scored each quarter of the SFY against facility baselines and program benchmarks; for SFY2027 both come from CY2025 Provider Data Catalog data. The 3-year plan (SFY2025-2027) was approved as one package, and the SFY2027 amendment only refreshed baselines and the enrolled-home list. The MDS measures are all-payer, not limited to STAR+PLUS members (Texas to CMS, Aug 2026). The lag from quarter end to payment was not confirmed.

Payment formula

Pool split: C1 44% (NSGO only), C2 20% (all), C3 20% (all), C4 16% (NSGO only). Private homes can therefore earn from only 40% of the pool. Each home's share of a component equals its share of historical Medicaid days. C1: meeting 1 metric earns 90%, 2+ earns 100%. C2 (SFY2027): equal thirds. C3/C4: equal share per metric. If a home lacks data for a metric, that money is spread over the component's other metrics. Unearned money is redistributed to homes that met an HHSC-designated measure, in proportion to their total QIPP earnings.

Eligibility

Two classes. (1) NSGO: a Texas non-state governmental entity holds the license and is party to the Medicaid agreement. From 9/1/2024 the home must be in the same or a contiguous county as that entity, with a documented 'active partnership': monthly admin meetings, quarterly joint trainings and annual on-site quality inspections. (2) Private: at least 65% Medicaid NF days (FFS + managed care, hospice excluded). Homes must enroll every year (with an application fee). From 9/1/2025 a home that changes class mid-year is removed. A home needs at least one Medicaid resident in each reporting period. The SFY2027 preprint lists 1,030 homes: 927 in C1/C4 (NSGO) and 103 private, counted from Table 1.A rows.

Cadence

Annual enrollment and IGT call (June/July); scored and paid quarterly by STAR+PLUS MCOs.

Scores published

Yes. Quarterly per-facility scorecards (xlsx), e.g. Year 9 Q3: https://rad-apps.hhsc.texas.gov/downloads/qipp-qrtr3-year9-sc… . Baselines/targets, estimated component values and suggested-IGT workbooks are on https://pfd.hhs.texas.gov/long-term-services-supports/quality…

Notes

The scale is unusual: $1.75B/yr adds about 59% on top of the Medicaid base for NSGO homes. The NSGO class is what unlocks C1 and C4. Typically a hospital district or authority holds the license of a privately operated home under a management agreement; this is inferred from the 927 NSGO count and was not detailed in the sources read. In Aug 2026 CMS asked how IGT entities without taxing authority fund their share. Texas cited hospital-authority patient revenue (e.g. Uvalde County HA $35.2M IGT, Fannin County HA $38.5M). Directed payments must exclude people with unsatisfactory immigration status for rating periods starting on or after 9/30/2026 (SMD 25-003).

Verified October 11, 2026

Provider tax

Charged

none

Standard amount

None found. No NF quality assessment or bed tax; QIPP is funded by IGT, not a provider tax.

Lower for high-Medicaid homes

no

Returned in the rate

n/a

Source

https://pfd.hhs.texas.gov/sites/default/files/documents/long-…

Verified October 11, 2026

Provider tax notes

None found. No nursing facility quality assessment or bed tax appears in the NF rate rules, rate sheets or information letters reviewed. QIPP is funded by IGT, not a provider tax; Texas told CMS that 'LGEs do not IGT health care-related tax revenue' for QIPP.

Verified October 11, 2026

Supplemental payments

(1) QIPP directed payment, $1.75B/yr, IGT-funded (see quality_incentive); it dwarfs everything else. (2) Nursing Facility Minimum Payment Amount Program (MPAP, 1 TAC 353.608): IGT-funded minimum payments for NSGO NFs in STAR+PLUS, with enrollment periods in 2014-2016. Current status was not confirmed; QIPP appears to have replaced it. (3) No FFS NF UPL supplemental program was found in this pass.

Verified October 11, 2026

Other add-ons

(1) Liability insurance add-on (H.B. 154): $1.67/day for homes that attest to both professional and general liability coverage ($1.53 professional only, $0.14 general only). It needs an annual July attestation and continued for SFY2026 (IL 2025-12); this cost is excluded from base rates. (2) HIV/AIDS enhancement: nursing +18%, plus NTA raised to the highest NTA group. That adds $17.22-$59.70/day, billed under separate codes PD051-PD088. (3) BIMS severe cognitive impairment add-on, $12.16/day (built into the group rate). (4) Direct Care Staff Rate Enhancement: ended 8/31/2025 (see changes). (5) Nurse aide training and testing is reimbursed at actual cost by quarterly voucher, outside the per diem.

Verified October 11, 2026

Units paid separately

(1) IDD NF Special Reimbursement Class: a separate rate schedule for residents with intellectual/developmental disabilities (9-1-2025-idd-nf-rates.pdf; IL 2025-15). Amounts were not extracted. (2) Pediatric care facilities have their own methodology (1 TAC 355.316). (3) Under RUG-III, ventilator and pediatric tracheostomy supplements were paid on top: on 9/1/2023, +$128.62/day for continuous vent, +$51.45 non-continuous, +$77.17 pediatric trach. They are not on the 9/1/2025 PDPM schedule, and respiratory therapist cost now sits in the nursing component, so they were probably folded into group E. Unconfirmed. (4) Hospice residents: the hospice is paid at least 95% of the NF rate. (5) Medicaid swing beds in rural hospitals (26 TAC 554.2326).

Verified October 11, 2026

Payment rules

Managed care for long-term care

Status

yes

Detail

STAR+PLUS

Verified October 11, 2026

Who pays

managed_ltss: STAR+PLUS (1115 Texas Healthcare Transformation and Quality Improvement Program). Nearly all adult Medicaid NF residents are in STAR+PLUS MCOs. HHSC still publishes an FFS schedule and bill codes (PD001-PD088), and MCOs use 'similar coding'. Cost reports split days among fee-for-service, STAR+PLUS, hospice and the Dual Demonstration (IL 2026-03).

Verified October 11, 2026

Managed care rate floor

Effectively yes, but not confirmed from primary text in this pass. MCO NF claims are priced on the same PDPM LTC schedule ('Similar coding will be applied to NF billing on managed care side', 9/1/2025 rate sheet), and HHSC adjusted SFY2026 capitation for the PDPM move (MCAC 6/11/2025). The statutory floor in Gov't Code 533.00251 (recodified to Ch. 540 in 2025) is recalled: MCOs pay no less than the FFS NF rate and pay clean claims within 10 days. Its text could not be retrieved. Sources: https://pfd.hhs.texas.gov/sites/default/files/documents/long-… ; https://www.hhs.texas.gov/sites/default/files/documents/june-…

Verified October 11, 2026

Included in the daily rate

Included (26 TAC 554.2601): nursing; social services; all diets, including tube feeding; over-the-counter (nonlegend) drugs except insulin; legend drugs not covered by Vendor Drug or Part D; laundry; medical accessories and shared equipment (wheelchairs, beds, walkers, enteral pumps, oxygen concentrators, tanks and tubing); medical supplies; basic hygiene items. Paid separately: prescription drugs (Vendor Drug Program or Part D); therapy, billed outside the NF rate; custom power wheelchairs and augmentative communication devices (554.2613-2614); transport beyond normal transportation (554.2320). Applied income (patient liability) is deducted from the Medicaid payment (554.2318).

Verified October 11, 2026

Bed hold

Hospital stays

Not paid. Texas makes no vendor payment while a resident is a hospital inpatient (26 TAC 554.2602(a)(2)); the home files a discharge. Outpatient or observation stays past midnight are paid.

Leave days

Paid at the full per diem for physician-authorized home visits of up to 3 days per visit (midnight-to-midnight days). A visit over 3 days requires a discharge effective day 1, and one night must be spent in the facility between visits. No annual cap is stated (26 TAC 554.2603).

Occupancy rule

None.

Notes

For hospital stays the home may make a private bed-reservation agreement with the resident or family (554.2602(b), 554.503), paid by them, not Medicaid.

Source

https://www.law.cornell.edu/regulations/texas/26-Tex-Admin-Co…

Verified October 11, 2026

Personal needs allowance

Per month

75

Effective

2024-01-01

Notes

MEPD Handbook H-1500: $75 from 1/1/2024 (was $60 1/1/2006-12/31/2023). VA pension ($90) handled separately per E-4300/E-4311.2; compilation says veterans may keep both. Not COLA-indexed.

Confidence

confirmed

Source

https://fhb.hhs.texas.gov/handbooks/medicaid-elderly-people-d…

Verified October 11, 2026

Medicare coinsurance days

Method

partial

Rule

Partial payment. 26 TAC 554.2610: when HHSC receives valid Medicare claims it pays 'a portion' of the Medicare Part A SNF deductible and coinsurance, and adjusts the Medicaid coinsurance payment when Medicare changes its daily interim payment. The exact formula (presumably capped at the NF unit rate minus Medicare payment) was not found. In STAR+PLUS, MCOs process 'Nursing Facility Medicare Coinsurance' claims (UMCM 2.3), which presumably covers MA coinsurance too. Pricing is not stated.

Effect

The home receives only part of the coinsurance, likely limited by the Medicaid NF rate. The exact amount could not be confirmed.

Confidence

likely

Source

https://www.law.cornell.edu/regulations/texas/26-Tex-Admin-Co… ; https://www.hhs.texas.gov/sites/default/files/documents/laws-…

Medicare Advantage

not addressed: UMCM 2.3 'Medicare Coinsurance' covers a dual's 'Medicare-covered stay' with no Part A vs. Part C distinction. It applies to STAR+PLUS MCOs and MMPs. No explicit MA cost-sharing amount was found.

Medicare Advantage source

https://www.hhs.texas.gov/sites/default/files/documents/laws-…

Verified October 11, 2026

Required care spending

Applies

yes

Rule

From SFY2026 (S.B. 457), an annual 80% Patient Care Expense Ratio: spending on nursing, NTA, BIMS, dietary and operations vs Medicaid patient-care revenue must reach 80%, enforced by recoupment. Homes with 4+ stars in 3 of 4 CMS categories (overall, health inspection, staffing, long-stay QM) are exempt; homes at or below 75% occupancy need only 70%; waived for declared disasters. Replaced the Direct Care Spending Requirement tied to the ended staff rate enhancement.

Source

https://pfd.hhs.texas.gov/sites/default/files/documents/il202…

Verified October 11, 2026

Occupancy rules

Applies

yes

Rule

(1) The patient care expense ratio drops from 80% to 70% for homes at or below 75% occupancy. (2) In rate setting, facility/administration costs of homes below target occupancy (lower of 85% or the statewide average) are adjusted up to that occupancy; because rates are one statewide schedule, this affects the statewide median, not a single home's rate.

Source

https://pfd.hhs.texas.gov/sites/default/files/documents/il202…

Verified October 11, 2026

MDS accuracy penalties

Timeliness penalties are explicit. If an MDS is not received on time, claims payment stops until all due MDSs are in. A 'missed' MDS is paid at the default rate (now Z01, $164.24) for the whole period it covers (26 TAC 554.2413). HHSC OIG certifies assessors; PDPM certification training replaced RUG training. No specific recoupment threshold for case-mix accuracy was found.

Verified October 11, 2026

Published rates and changes

How often rates change

A home's rate changes

annual

When

Sep 1, usually once per two-year budget; each resident's group (and so pay) changes with every assessment

Verified October 11, 2026

When rates change

September 1 (state fiscal year), usually set once per biennium with the appropriations act. Recent sets: 6/10/2023-8/31/2023, 9/1/2023, and 9/1/2025 (PDPM LTC). Each resident's rate also changes with each MDS.

Verified October 11, 2026

Posted rates

Home-level rates published

No

Where

https://pfd.hhs.texas.gov/long-term-services-supports/nursing…

Format

pdf

Cadence

At each rate change (usually Sept 1 of a biennium)

History

NF rate schedules posted back to 2001 (2001-2015, 2023, 2025)

Home identifier

None. One statewide schedule by PDPM LTC group and bill code (PD001-PD088). Facility-level QIPP files use the Texas NF contract number plus name (e.g. '676437 - ACCEL AT COLLEGE STATION').

Verified October 11, 2026

Rate build-ups

Where

HHSC posts proposed rate packets for public rate hearings on the PFD site (e.g. the July 16, 2025 hearing per IL 2025-12), but the packet URL was not captured. There are no facility-specific calculation sheets because rates are not facility-specific.

What they show

The posted schedule shows, per group, nursing, NTA, dietary, administration, operations, fixed capital, BIMS and the total, plus the HIV/AIDS enhancement. Medians, inflation factors and CMIs are expected to be in the rate packet (not verified).

Format

pdf

Example file

https://pfd.hhs.texas.gov/sites/default/files/documents/long-…

Verified October 11, 2026

Recent changes

Verified October 11, 2026

Assisted living

Medicaid assisted living

Covered

yes

Program

STAR+PLUS Home and Community-Based Services (HCBS) Assisted Living, under the 1115 Texas Healthcare Transformation and Quality Improvement Program, delivered by STAR+PLUS MCOs.

What is paid

Services only: an attendant amount ($37.52/day) plus an admin/facility amount. Room and board is paid by the resident; the state's room-and-board amount or cap was not verified.

Rate

Effective 9/1/2025, 6 levels mapped from PDPM LTC nursing groups (Level 1 = E ... Level 6 = P/Z01/PCE). Single-occupancy apartment $67.18-$74.04/day; double-occupancy apartment $55.78-$66.97/day; non-apartment $44.82-$63.16/day.

Limits

STAR+PLUS HCBS individual cost limit = 202% of the NF (PDPM LTC) cost. An interest list for people not otherwise Medicaid-eligible is believed to exist but was not verified.

Source

https://pfd.hhs.texas.gov/sites/default/files/documents/long-…

Verified October 11, 2026

Sources

1. HHSC PFD Nursing Facility payment page · agency page
2. Texas NF Medicaid Rates eff. 9/1/2025 (PDPM LTC), incl. HIV/AIDS table and 9/1/2023 RUG-III table · rate file
3. 1 TAC 355.318 PDPM LTC reimbursement methodology · regulation
4. 1 TAC 355.307 (RUG-III methodology, before 9/1/2025) · regulation
5. 1 TAC 355.308 Direct Care Staff Rate Component (before 9/1/2025) · regulation
6. IL 2026-03 Rider 25 and SB 457: PDPM LTC and Annual Patient Care Expense Ratio (2/4/2026) · agency page
7. IL 2025-16 Medicaid Payment Rate Actions for NFs eff. 9/1/2025 · agency page
8. IL 2025-12 Discontinuation of Rate Enhancement Program and Rate Adjustments eff. 9/1/2025 · agency page
9. HHSC MCAC June 11, 2025: PDPM LTC project presentation · agency page
10. HHSC PFD QIPP page · agency page
11. SFY2027 QIPP proposed preprint amendment package (7/3/2026), incl. Addendum Table 1.A and Table 2 workbook · agency page
12. Texas response to CMS Round 1 questions, SFY2027 QIPP (Aug 2026) · agency page
13. 1 TAC 353.1302 QIPP for Nursing Facilities (Year 3+) · regulation
14. HHSC NF Minimum Payment Amount Program page · agency page
15. 26 TAC 554.2601 Vendor payment (items and services included) · regulation
16. 26 TAC 554.2602 Additional charges / no payment for hospital inpatient absence · regulation
17. 26 TAC 554.2603 Therapeutic home visits · regulation
18. 26 TAC 554.2413 Payment rate based on MDS submission · regulation
19. 26 TAC 554.2318 Daily rate with applied income · regulation
20. STAR+PLUS payment rates eff. 9/1/2025 (incl. HCBS Assisted Living) · rate file
21. Medicare crossover / coinsurance rule · regulation
22. Medicare crossover rule · regulation
23. Medicare crossover rule · regulation
24. Personal needs allowance · regulation

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