Virginia
Virginia’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
- Resident-level
- Classification
- PDPM
- Rate updates
- Once a year
- Managed care (LTC)
- Yes
- Quality program
- Value-Based Purchasing (NF VBP)
- Paid outside the rate
- Moderate
- Bed hold
- Leave only
- Published rates
- Rates only
- Assisted living
- Not covered
- Personal needs allowance
- $40 / month
Overview
- Virginia pays a price per peer group, not each home's own cost (fully price-based since FY2018; no cost settlement for dates of service on or after 7/1/2014).
- Per diem = (direct care rate x the resident's PDPM case-mix weight) + indirect rate + capital (fair rental value) + NATCEP (nurse aide training) + criminal records check cost.
- The direct price is 109.3% of a peer group's case-mix-neutral cost at the day-weighted median facility (moved to the 59th-percentile day from 7/1/2025).
- The indirect price is 103.3% of the day-weighted median.
- Homes whose cost is below 95% of the price get a lower 'adjusted price'.
- The Oct 1, 2025 - Jun 30, 2026 rate file covers 270 facilities (265 freestanding + 5 hospital-based).
- Median posted total = $255.08/day, range $181.23-$577.54.
- That total uses a case-mix weight of 1.0; the actual payment scales the direct line by each resident's PDPM weight.
What matters in Virginia
- Pay is set per resident: the posted rate assumes case-mix weight 1.0 and is multiplied by each resident's PDPM weight (median about 1.77).
- Quality pay totals $185M for SFY2027, worth up to about $44.53 per Medicaid day for homes rated Best on all four measures.
- No inflation increase for FY2027-FY2028, and the withheld inflation is permanently excluded from future rebasings.
- A one-year $70M add-on (about +3.30%) runs through 6/30/2027 in both fee-for-service and managed care.
- No provider tax on nursing homes; Virginia's provider assessment falls on hospitals.
- Hospital bed hold is not paid, and Medicare coinsurance usually pays $0 because crossover claims are priced at weight 1.0.
Frequently asked
Does Virginia's posted rate file show a nursing home's total Medicaid revenue?
No. The posted rate assumes a case-mix weight of 1.0, and each claim is multiplied by the resident's PDPM weight, with a median of about 1.77.
Does Virginia restore the inflation withheld for FY2027 and FY2028 at rebasing?
No. The withheld inflation is permanently excluded from future rebasings, and rebasing is deferred to 7/1/2030.
How does Virginia's value-based purchasing program pay nursing homes?
It pays $185M in SFY2027 lump sums for turnover, staffing, falls and pressure ulcers, worth up to about $44.53 per Medicaid day for homes rated Best on all four measures.
How much is paid outside the posted rate in Virginia?
Moderate, about 9% of base from quality lump sums, plus UPL payments to government-owned homes of unknown size.
What does Virginia Medicaid pay on Medicare coinsurance days?
Lesser-of at a weight-1.0 Medicaid rate, so the home usually receives $0 of the coinsurance.
Does Virginia require a minimum share of spending on care?
No spending rule, but homes with cost below 95% of the price get a lower adjusted price.
How is the Virginia nursing home provider tax charged?
None; Virginia has no nursing home bed tax or quality assessment.
How the rate is set
How the method got here
| Effective | From | To | Change | Headline | Source |
|---|---|---|---|---|---|
| 2014-07-01 | Facility cost-based operating rates with year-end cost settlement | Prospective peer-group prices built from a CY2011 cost base, with RUG-III 34-group case mix on each claim and no cost settlement | Virginia stopped cost settlement for dates of service on or after 7/1/2014 and began paying peer-group prices with per-claim RUG-III case mix (FY2015-2017); the file says rates were not fully price-based until FY2018. | Cost settlement ended; peer-group prices with RUG-III case mix | https://law.lis.virginia.gov/admincode/title12/agency30/chapt… |
| 2017-07-01 | Transition to price-based rates on the CY2011 base, with RUG-III 34-group claims | Fully price-based rates (first rebase) with RUG-IV 48-group case mix | Virginia became fully price-based in FY2018 with its first rebase and moved claims to RUG-IV 48-group case mix (the file gives the fiscal year only; 7/1/2017 is the start of FY2018). | Fully price-based rates with RUG-IV case mix | https://law.lis.virginia.gov/admincode/title12/agency30/chapt… |
| 2022-07-01 | No quality-based payment for nursing facilities | Nursing Facility Value-Based Purchasing (NF VBP) program, paid mainly as an MCO directed payment from new state appropriations | Virginia started paying nursing homes for quality through the NF VBP program, created by the 2021 Appropriation Act. | Nursing facility value-based purchasing program begins | https://dmas.virginia.gov/data-reporting/value-based-purchasi… |
| 2025-10-01 | RUG-IV 48-group case mix on each claim | PDPM-based case mix covering all five components (PT, OT, SLP, Nursing, NTA) on each claim, with direct rates restated to stay budget neutral | Virginia switched claims from RUG-IV to PDPM case-mix weights in one step, restating direct care rates so total spending stayed the same. | Case mix moves from RUG-IV to PDPM | https://www.dmas.virginia.gov/media/x2bbekn3/spa-25-019_nursi… |
Verified October 11, 2026
Cost basis
- Uses cost reports
Yes
- Cost report
Medicare-format cost reports (CMS-2540) filed with Virginia Medicaid and audited/settled by DMAS's contractor Myers and Stauffer, plus a separate calendar-year FRV (capital) report. Cost data set the day-weighted medians, the 95%-of-price adjustment and the NATCEP/CRC components (DMAS NF FAQ, rev. 5/19/2026).
- Base year and rebasing
12VAC30-90-44: rebase every 3 years using the latest cost-settled calendar-year reports complete as of September 1. Initial base was CY2011, first rebase FY2018. The FY2022 rebase was deferred one year to use CY2021 reports. The last rebase took effect for FY2025 rates (7/1/2024); the 2025 Act refers to 'the rebasing model implemented for fiscal year 2025 rates'. The next rebase, due 7/1/2027, is deferred: the 2026 Appropriation Act Item 291.TTTTT says the normal cycle resumes for rates effective 7/1/2030, and DMAS must report each Dec 1 on methodology fixes. In non-rebase years, rates are the prior rates inflated, except that no inflation is given for FY2027-FY2028 (see budget_adjustment_factor).
- Components
Component Method Notes direct patient care operating Peer group price. Each home's base-year Medicaid direct cost per day is case-mix neutralized and inflated to the rate year. The price is 109.3% (since 7/1/2021) of the peer group's day-weighted median neutralized cost; from 7/1/2025 the median day is replaced by the 59th-percentile day (2025 Act Item 288.VVVVV). Claims pay the facility direct rate x the resident's PDPM case-mix index x days. 4 direct peer groups: Northern Virginia MSA (Urban3), Other MSA (Urban4), Northern Rural (Rural1), Southern Rural (Rural2), plus a 'Special' group (see other_add_ons). Max posted direct rates (Oct 2025 PDPM file): Urban3 $154.50, Urban4 $149.64, Rural1 $132.30, Rural2 $114.74. On the Jul-Sep 2025 RUG file: Urban3 $175.99, Urban4 $168.11, Rural1 $157.96, Rural2 $128.39. indirect patient care operating Peer group price, not case-mix adjusted: 103.3% (since 7/1/2021) of the peer group day-weighted median inflated cost per day. Indirect cost per day uses the greater of actual Medicaid days or 88% occupancy of licensed beds. 5 indirect peer groups: Northern Virginia MSA, Other MSA, Northern Rural, Southern Rural, and 'Rest of State <=60 beds' (Small). Max posted indirect rates FY2026: Small $131.58, Urban3 $126.80, Rural2 $110.54, Urban4 $110.25, Rural1 $109.92. 95% adjusted price A home whose cost projected to the rate year is below 95% of the price gets price minus (95% of price - its cost). Reset at each rebasing; new homes get no adjustment until the next rebase. This is why many homes post direct/indirect rates below the peer maximum. capital (FRV) Fair rental value for freestanding homes; see capital field. Hospital-based homes get their last settled capital per diem. FY2026 median capital $19.29/day. NATCEP Facility-specific nurse aide training/competency cost per day (PFY2022 cost inflated to SFY2026). Almost all homes $0.00. criminal records check (CRC) Facility-specific actual Central Criminal Records Exchange charges per day, PFY2022, not inflated. Pennies per day. - Inflation
Virginia Nursing Home moving-average inflation index (IHS Markit/S&P Global, formerly DRI), 4th-quarter moving average, used to inflate base-year costs to the rate-year midpoint and corrected for prior revisions. Not applied for FY2027 and FY2028 (2026 Act Item 291.PPPPP).
Verified October 11, 2026
Case mix
- System
PDPM
- Applied at
Resident-level
- How it works
Each claim pays the home's direct care rate x that resident's own PDPM case-mix weight from their latest assessment, so every resident has a different rate.
- Classification
PDPM-based since 10/1/2025. DMAS publishes one combined case-mix index for each of about 28,800 4-character PDPM codes, covering all five components: PT, OT, SLP, Nursing and NTA. Each component uses Medicare's CMI, weighted by its share of Medicare per diems. Default code ZZZZ = 0.8653. Before that: RUG-IV 48-group (FY2018-Sep 2025), normalized to RUG-III 34-group, which was used for cost neutralization; RUG-III 34 for claims FY2015-2017.
- Applies to
Direct patient care only. Indirect, capital, NATCEP and CRC are not case-mix adjusted.
- Acuity measured from
Two uses. (1) Payment is resident-level: each claim pays the facility direct rate x that resident's PDPM CMI from their most recent OBRA assessment (HIPPS code + occurrence code 50 ARD on the claim). Late assessments bill the default code. Medicare crossover claims use a weight of 1.0. (2) Cost neutralization at rebasing divides each home's direct cost by its average Medicaid CMI. Picture dates are 3/31, 6/30, 9/30 and 12/31; the average covers residents with Medicaid as payer on the last day of the quarter, normalized to the statewide average. For the 10/1/2025 conversion only, PDPM case mix used MDS records from 7/1/2023-6/30/2024.
- Updated
Per claim and per assessment for payment, changing with each OBRA/significant-change assessment. Facility average CMI is computed quarterly and used only at rebasing.
- Move to PDPM
Effective 10/1/2025 per 2025 Appropriation Act Item 288.IIIII and SPA 25-019 (submitted to CMS 12/11/2025). It was done budget neutrally: DMAS restated each home's case-mix-neutral direct rate (indirect, capital, NATCEP and CRC unchanged; rate file change log 'Updated Direct Rates to transition to PDPM', logged 8/25/2025). Posted direct rates fell, e.g. median $158.25 -> $125.91, because PDPM weights run higher than the old normalized RUG weights. Posted direct rates before and after 10/1/2025 are not comparable. Specialized care, state NFs and DBHDS ICFs were not affected. Hospice room-and-board in a NF = 100% of the facility PDPM rate.
Verified October 11, 2026
Low-acuity residents
None found. Virginia has no reduced or flat rate carved out for low case-mix residents. Every Medicaid resident is paid the facility direct rate x their own PDPM case-mix index (CMI), so low-acuity residents simply get a proportionally lower direct line on a continuous scale. In DMAS's 10/1/2025 PDPM weight file (28,801 codes), the lowest CMI is 0.825 (PAYF) and the median is 1.772. Indirect, capital, NATCEP and CRC are paid in full regardless of acuity. Two related rules (not low-acuity carve-outs): (1) Late or missing OBRA assessments bill the default code ZZZZ at CMI 0.8653. (2) Assessments that can't be classified get the lowest CMI (Appendix IV, 12VAC30-90-306). Residents who don't meet NF level-of-care criteria are not Medicaid-covered at all (pre-admission screening), not paid at a reduced rate. Checked: SPA 25-019 (4.19-D Supp. 1 pp. 26.1-26.5.1 and Appendix IV), 12VAC30-90-44, the DMAS NF PDPM FAQ (5/19/2026), the PDPM weight file, and the 2025/2026 Appropriation Act NF paragraphs.
Verified October 11, 2026
Capital
Fair rental value (12VAC30-90-35..39) for freestanding homes. Value = imputed square feet (461/bed if <=90 beds, 438 if larger) x R.S. Means 75th-percentile NF construction cost/sq ft (base $110 in Jan 2000, indexed) x 1.429 for land and soft costs. Movable equipment is $3,475/bed (SFY2001, indexed). Depreciation is 2.86%/yr on facility average age, capped at 60% of replacement value. Rental rate = 10+ year Treasury yield (3-year average) + 2 points, with an 8% floor and 11% ceiling; the floor has applied since SFY2015. Property tax and insurance are added. The total is divided by the greater of actual days or 88% occupancy. Based on the prior calendar-year FRV report, aged to the SFY. Mid-year adjustments apply for new beds or major renovation (>=$3,000/bed), but not effective after April 30. Hospital-based NFs get the last settled capital per diem.
Verified October 11, 2026
Budget adjustment factor
(1) 2026 Appropriation Act Item 291.PPPPP: no inflation adjustment for nursing facilities (or hospitals) in FY2027 and FY2028. The withheld inflation is also excluded from future inflation adjustments and rebasings, so it is a permanent base cut relative to the formula. (2) The PDPM conversion on 10/1/2025 was required to be budget neutral. (3) Rebasing deferred from 7/1/2027 to 7/1/2030 (Item 291.TTTTT); the methodology review 'is not intended to increase nursing facility reimbursement in the aggregate.' (4) Historical: inflation was 0.0% for FY2016.
Verified October 11, 2026
Add-ons and money outside the rate
Paid outside the posted rate
- Level
moderate
- Estimate
About 9% of base, derived: the NF VBP directed payment ($184.9M SFY2027, paid as lump sums) against a base of roughly $2.1B implied by the CCMC rate report booking the $70M add-on as +3.30%. UPL payments to local-government, Type One hospital and DVS state-owned homes come on top; their size was not found.
- Components
NF VBP directed payment $184.9M SFY2027 (two lump sums a year); UPL supplemental payments for local government-owned NFs (IGT-funded), Type One (state teaching) hospital-owned NFs, and DVS veterans homes: size unknown. The FY2027 $70M add-on is in the per diem and is not counted.
Verified October 11, 2026
Payments by owner type
- Applies
yes
- Detail
UPL supplemental payments go only to government-related owners: local government-owned NFs (or a managed-care minimum fee schedule in lieu), NFs owned by Type One state teaching hospitals, and Department of Veterans Services state-owned NFs; nonstate government-owned NFs can also draw federal match on certified unreimbursed Medicaid costs, capped at UPL. Private homes get none of these. Number of homes and size of the gap were not found.
- Funding
IGT from the local government owner under intergovernmental agreements; transfers from Type One hospitals for their homes. No lease or management arrangement described.
Verified October 11, 2026
Quality program
- Program
Nursing Facility Value-Based Purchasing (NF VBP) Program. Created by the 2021 Appropriation Act and began 7/1/2022; SFY2027 is program year 5.
- Funding
New state appropriation (not carved from base rates; there is no NF provider tax). $20M GF + $20.8M NGF/yr was added from 7/1/2024 on top of the earlier base, including money moved from the removed COVID per diem add-on. Paid mainly as an MCO separate-payment-term directed payment (42 CFR 438.6(c), preprint VA_VBP_NF_Renewal_20260701-20270630), with DMAS paying the few FFS-only homes. Must move into capitation rates by SFY2029.
- Size
$185M for SFY2027 (MCO directed payment $184.9M). Split by measure: turnover $37.0M, nurse staffing HPRD $37.0M, falls $55.5M, pressure ulcers $55.5M. Projected Best-tier per diems: $8.55 / $11.60 / $11.88 / $12.50, about $44.53 per Medicaid day if Best on all four. In SFY2025, 264 homes (about 93% of Medicaid NFs) were eligible.
- Paid as
Lump sum (two per year), calculated as per diem x Medicaid days. Not a rate add-on.
- Measures
Measure Source Weight How points are earned Total nurse staffing turnover (RN+LPN+aide) CMS Provider Information file (PBJ-based) 20% ($37.0M) Best 0-40.30%, Better 40.31-48.60%, Fair 48.61-58.80%; quartiles from FFY2025 data. Improvement: >=5% better and moved up a tier. Total nurse staffing hours per resident day, case-mix adjusted PBJ via CMS Provider Information file; quarters weighted by Medicaid days 20% ($37.0M) Best 3.84+, Better 3.44-3.83, Fair 3.08-3.43. The Fair floor equals the 3.08 state minimum for VBP participants (2023 Acts Ch. 483 Item 1.B.32); tiers were raised 5.12% for SFY2027. Improvement: >=0.5% and moved up a tier; no improvement pay within Best. Long-stay residents with one or more falls with major injury MDS QM (CMS Care Compare) 30% ($55.5M) Best 0-2.03%, Better 2.04-3.29%, Fair 3.30-4.65%; quartiles from FFY2025 data. Improvement: >=5%. Long-stay residents with pressure ulcers (Stage II-IV/unstageable) MDS QM (CMS Care Compare) 30% ($55.5M) Best 0-3.44%, Better 3.45-5.22%, Fair 5.23-7.63%. Improvement: >=5%. - Scoring period
SFY2027 payments (Jul 2026-Jun 2027) use performance in FFY2026 (Oct 2025-Sep 2026), measured with Medicaid days from the same period; Q4 days are estimated as the average of Q1-Q3. Data become available Jan 2027 (MDS measures) and Apr 2027 (staffing), so payment lags the end of the performance period by 7-10 months. RD55 (Dec 2025) floated moving to a prior-SFY performance period; that is not adopted.
- Payment formula
Each measure is scored on its own against fixed tiers (originally 25th/50th/75th percentiles). Best earns 100% of the measure per diem, Better 75%, Fair 50%, Below 0%. Under the 'maintenance' rule from 42 CFR 438.6(c), a home that dropped one tier from last year earns less (Best->Better 50%, Better->Fair 25%, Best->Fair 0%), and one that dropped two tiers earns $0. Attainment $ = per diem x Medicaid days. Unearned funds per measure form an improvement pool, split by Medicaid days among homes meeting the improvement target. Per diems flex so the full pool is spent and never exceeded.
- Eligibility
NFs (provider types 010/015) in Medicaid managed care, plus non-MCO homes that got the COVID enhanced per diem and are not cost-settled. Excluded: Special Focus Facilities and SFF candidates on CMS's Oct 2026 list. Under the 2026 Act, homes under complaint surveys for major quality/safety issues can be made ineligible, and facilities failing quality standards get nothing. A new home can qualify after one full Medicaid quarter, with no improvement pay in its first year. No pay for a measure when CMS suppresses the result.
- Cadence
Scored annually on the federal fiscal year and paid twice a year: April/May (falls, pressure ulcers) and June/July (turnover, staffing). Each home is paid by a single attributed MCO, or by DMAS if FFS-only. The payment goes to the operator at payment time, after any CHOW.
- Scores published
Yes. DMAS's NF VBP Tableau dashboard has Facility Score Card, Performance Payments (per-facility $ by measure, CSV/Excel download) and Distribution tabs. It is linked from https://dmas.virginia.gov/data-reporting/value-based-purchasi… (direct dashboard URL not captured).
- Notes
The HPRD Fair floor of 3.08 comes from the 2023 Acts Ch. 483 minimum for VBP participants. HB 605 (2026) would have made 3.08 a general mandate; it was converted to a JCHC study. SFY2027 added turnover and falls measures; earlier years included other measures (e.g. UTI, hospitalization) not verified here. Media (WTVR, Sept 2025) reported low-rated homes receiving VBP money.
Verified October 11, 2026
Provider tax
- Charged
none
- Standard amount
None found. No NF bed tax or quality assessment; Virginia's provider assessment is on hospitals and funds Medicaid expansion.
- Lower for high-Medicaid homes
no
- Returned in the rate
n/a
Verified October 11, 2026
Provider tax notes
None found. No NF bed tax or quality assessment appears in the Appropriation Act Medicaid item or the NF rate pages. Virginia's provider assessment is on hospitals and funds Medicaid expansion.
Verified October 11, 2026
Supplemental payments
(1) UPL supplemental payments for local government-owned nursing homes, IGT-funded under intergovernmental agreements. The Act authorizes a 438.6(c) minimum fee schedule in managed care in lieu of this; otherwise such residents are carved out to FFS. (2) UPL supplemental payments for nursing homes owned by Type One (state teaching) hospitals, with an MCO minimum fee schedule funded by hospital transfers. (3) UPL supplemental payments for Department of Veterans Services state-owned NFs (Item 291.PP). (4) Authority to draw federal match on certified unreimbursed Medicaid costs of nonstate government-owned NFs, capped at UPL (291.VVVV). (5) NF VBP directed payment, $184.9M (see quality_incentive). Source: 2026 Act Item 291.JJ/PP/VVVV.
Verified October 11, 2026
Other add-ons
(1) FY2027 add-on (7/1/2026-6/30/2027): $70M total ($35M GF + $35M NGF) added to the per diems in effect 6/30/2026 for NFs and specialized care, in both FFS and managed care (2026 Act Item 291.LLL.1.b). The CCMC rate report books it as a +3.30% NF unit-cost increase. The per-day amount was not found. (2) 'Special' peer group: homes where >=80% of residents have quadriplegia, TBI, MS, paraplegia or cerebral palsy, with >=90% Medicaid and CMI >=1.15 in FY2014. They get direct and indirect operating rates 25.4% above the computed price (15% from 2016 + 10.4% from 2020); 1 facility in FY2026, with a $577.54-$678.95 total. (3) Specialized care (ventilator, complex/rehab, pediatric) is a separate Medicaid service with its own cost-based prospective rates (12VAC30-90-264), posted separately. (4) The COVID-era $20 then $15/day add-on (2020-21) fell to $6.13 in FY2024 and was removed from 7/1/2024; its funding moved into the NF VBP directed payment (CCMC FY2027 rate report). (5) Hospice room-and-board = 100% of the facility PDPM rate.
Verified October 11, 2026
Units paid separately
(1) Specialized Care (12VAC30-90-264): adult complex/ventilator and pediatric units under DMAS contract. Paid a separate facility-specific prospective per diem, cost-based and inflated with the Virginia nursing home index, not the price method. It is outside the PDPM transition, and rates are posted separately each SFY. Specialized care units must provide therapy, respiratory therapy, psych services, DME, supplies and non-emergency transport within the rate. (2) Ventilator residents in NFs without a specialized care contract: the regular NF rate, plus DMAS pre-authorizes and pays DME vendors directly for ventilator rental, suction, oxygen, trach supplies and similar items (FFS). (3) Traumatic brain injury add-on (12VAC30-90-330): fixed per-day add-on for qualifying TBI residents (age 14+, documented aggressive/disruptive behavior). The amount is not stated in the regulation. (4) 'Special' peer group for homes with >=80% quadriplegia/TBI/MS/paraplegia/CP residents: operating rates +25.4% (1 home). (5) State veterans homes (DVS) and state/DBHDS facilities are outside the price-based system (cost-based or UPL supplemental). Hospital-based NFs keep cost-based capital.
Verified October 11, 2026
Payment rules
Managed care for long-term care
- Status
yes
- Detail
Cardinal Care Managed Care; fee-for-service pays a minority of days
Verified October 11, 2026
Who pays
mixed, mostly managed: Cardinal Care Managed Care (CCMC; CCC Plus long-term care was folded into it) covers most NF residents in the MLTSS rate cells. Fee-for-service pays a minority of days (DMAS put the FFS share of the FY2027 $70M add-on at about $9.8M of $70M) plus excluded groups such as state government-owned nursing homes.
Verified October 11, 2026
Managed care rate floor
Yes, in effect. The FY2027 CCMC rate certification says the CCMC contract has a minimum fee schedule for 'LTSS Services': MCOs must pay no less than the DMAS fee schedule (a 42 CFR 438.6(c) directed payment based on state plan rates). Budget add-ons (the FY2027 $70M) are specifically 'made through existing managed care capitation rates as a mandated specified rate increase' that applies across FFS and managed care (2026 Appropriation Act Item 291.LLL.1). The rate report does not name nursing facilities in the LTSS floor line. Sources: https://www.dmas.virginia.gov/media/liil1wed/fy2027-ccmc-rate… ; https://budget.lis.virginia.gov/item/2026/2/HB30/Chapter/1/291/
Verified October 11, 2026
Included in the daily rate
Included: room, board, nursing, routine medical supplies (e.g. testing strips, dressings, standard wheelchairs, pressure mattresses, IV treatments, splints, some drugs), and lab/X-ray customarily provided by the NF. Paid separately: (a) Prescription and OTC drugs are billed by the pharmacy to DMAS/MCOs; homes without an in-house pharmacy may not put drug costs in the cost report. (b) Outpatient PT/OT/SLP by enrolled rehab providers is paid directly by DMAS to the therapy provider unless the NF employs its therapists. (c) Ventilator/oxygen/trach DME through vendors for non-specialized-care homes. (d) Physician and hospital services. Specialized care per diems are broader and include therapy, respiratory therapy, DME and non-emergency transport. Source: NF Provider Manual Ch. IV (rev. 6/30/2017).
Verified October 11, 2026
Bed hold
- Hospital stays
Not paid. 12VAC30-20-170 pays bed reservation only 'for any reason other than inpatient hospital admissions'.
- Leave days
Paid at the regular per diem for leave in the plan of care (home visits, rehab-center evaluation up to 7 days). Limited to 18 days per 12 months per resident, counted from the first overnight leave. The percentage of per diem is not stated separately; billed as covered days.
- Occupancy rule
None for leave days. The 88% occupancy floor applies only to the indirect and FRV per-day denominators.
- Notes
MDS assessments due during leave must still be completed on time or default PDPM days apply (DMAS FAQ).
Verified October 11, 2026
Personal needs allowance
- Per month
40
- Effective
In force per Virginia Medical Assistance Eligibility Manual M1470.210 (page revised May 2015; chapter M14 posted 4/1/2024)
- Notes
M1470.210 Facility Personal Needs Allowance: 'Basic Personal Allowance: Deduct $40 per individual,' plus a guardianship fee of up to 5% of gross income and a special earnings allowance for therapeutic work programs. 12VAC30-40-370 adds payments received under the Virginia Eugenical Sterilization Act. Not COLA-indexed.
- Confidence
confirmed
Verified October 11, 2026
Medicare coinsurance days
- Method
lesser_of
- Rule
12VAC30-80-170 (State Plan payment of Medicare Part A/B deductible and coinsurance): Part A deductible and coinsurance for QMBs, other dual eligibles and QMB-Plus are all coded 'SP': 'Payments are limited to state plan rates and payment methodologies.' 12VAC30-10-320 A points to 80-170 for crossover payment. With the DMAS PDPM FAQ (crossover NF claims priced at PDPM weight 1.0), Medicaid pays coinsurance only up to the 1.0-weight Medicaid rate minus Medicare's payment. 12VAC30-80-80 (noninstitutional, Medicare allowed less Medicare paid) does not apply to NFs. No coinsurance or crossover text in 12VAC30-90.
- Effect
Because the crossover rate is a 1.0-weight Medicaid rate, well below Medicare's PDPM per diem, the home usually receives $0 of the day-21+ coinsurance.
- Confidence
confirmed
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 price reduction rather than a stand-alone spending rule: a home whose cost projected to the rate year is below 95% of the peer-group price (direct and indirect) is paid the price minus the shortfall (95% of price minus its cost). Reset at each rebasing; new homes get no adjustment until the next rebase. Separately, VBP participants must meet a 3.08 total nurse staffing HPRD floor (hours, not dollars).
Verified October 11, 2026
Occupancy rules
- Applies
yes
- Rule
Indirect care cost per day and capital (FRV) per day use the greater of actual days or 88% occupancy of licensed beds, so homes under 88% get less per day for those parts. No occupancy test for leave days.
Verified October 11, 2026
Published rates and changes
How often rates change
- A home's rate changes
annual
- When
Jul 1; each resident's PDPM weight (and so pay) changes with every assessment
Verified October 11, 2026
When rates change
July 1 state fiscal year; rates are posted on the DMAS NF page in place of rate letters. Mid-year changes: the 10/1/2025 PDPM restatement, FRV changes for new beds or renovations (not effective after April 30), CHOW/NPI changes logged in the rate file change log, and new facilities.
Verified October 11, 2026
Posted rates
- Home-level rates published
Yes
- Where
https://www.dmas.virginia.gov/for-providers/rates-and-rate-se… ('Reimbursement Rates' by SFY; specialized care rates listed separately)
- Format
pdf (tabular, text-extractable; one row per facility + change log with effective/log dates)
- Cadence
Annual (July 1), re-posted when updated (e.g. the SFY26 PDPM file was revised through 7/14/2026). As of Oct 2026 the page did not yet list an SFY2027 (July 1, 2026) NF rate file. FY2027 should be the FY2026 rates (no inflation) plus the $70M add-on.
- History
SFY2015 onward: Jul 1-Oct 31, 2014 and Nov 1, 2014-Jun 30, 2015 through Oct 1, 2025-Jun 30, 2026. Specialized care rates are posted back to SFY2015. Weights: RUG-IV 48 (eff. 7/1/2017) pdf and PDPM weights (eff. 10/1/2025) xlsx. Note: the 'Jul 1, 2020-Jun 30, 2021' link appears to point to the SFY22 file name (/media/3459/...sfy-22...).
- Home identifier
NPI (10-digit) plus facility name. Also lists CCC Plus region and direct/indirect peer group. No CCN or Medicaid provider number. The change log records NPI changes on CHOW (former NPI/name).
Verified October 11, 2026
Rate build-ups
- Published
No
- Where
None posted. DMAS stopped sending rate letters to price-based NFs; the posted rate file is 'official publication of the rates ... in lieu of individual facility rate letters'. The rate file itself shows the per-facility component build-up. Worked formula examples are in Appendix F of the Nursing Facility Provider Manual. Inputs are posted separately: PDPM weights (xlsx), RS Means construction cost limits and FRV values (pdf), administrator/medical director salary limits, and the FRV reporting form (xlsx).
- What they show
The rate file shows, per facility: assigned direct and indirect peer group, case-mix-neutral direct rate (A), indirect rate (B), capital/FRV rate (C), NATCEP (D), CRC (E), and total A+B+C+D+E at CMI 1.0, plus a dated change log. Not shown: base-year cost, the peer-group medians/prices, the 95% adjustment, FRV inputs, or facility CMI.
- Format
pdf
Verified October 11, 2026
Recent changes
| Effective | Change | Headline | Direction | Size | Source |
|---|---|---|---|---|---|
| 2024-07-01 | Rebased price-based rates (the FY2025 rebasing model) and added $40.8M/yr to NF VBP; the leftover COVID-era per diem add-on ($6.13 in FY2024) was removed and its funding shifted to the VBP directed payment. | Rates rebased; $40.8M added to quality program | increase | +$40.8M/yr to NF VBP | https://www.dmas.virginia.gov/media/liil1wed/fy2027-ccmc-rate… |
| 2025-07-01 | Direct care peer group prices reset using the 59th-percentile Medicaid day instead of the day-weighted median (about $21.65M/yr), held until the next rebasing. | Direct care price reset to 59th-percentile day | increase | about $21.65M/yr | https://budget.lis.virginia.gov/item/2025/1/HB1600/Chapter/1/… |
| 2025-10-01 | Case mix switched from RUG-IV 48 to PDPM (all five components, resident-level billing), budget neutral; posted direct rates were restated lower to offset higher PDPM weights. | Budget-neutral switch from RUG-IV to PDPM | structural | https://www.dmas.virginia.gov/media/x2bbekn3/spa-25-019_nursi… | |
| 2026-07-01 | One-year $70M ($35M GF + $35M NGF) per diem add-on for NFs and specialized care through 6/30/2027 in FFS and managed care. | One-year $70M per diem add-on | increase | +$70M one-year add-on ($35M GF + $35M NGF) | https://budget.lis.virginia.gov/item/2026/2/HB30/Chapter/1/291/ |
| 2026-07-01 | No inflation adjustment for FY2027-FY2028, and the withheld inflation is excluded from future rebasings. | No inflation adjustment for FY2027-FY2028 | cut | https://budget.lis.virginia.gov/item/2026/2/HB30/Chapter/1/291/ | |
| 2026-07-01 | Scheduled 7/1/2027 rebasing deferred; normal cycle resumes for rates effective 7/1/2030, with a DMAS/VHCA methodology and quality review reported each Dec 1. | Rebasing deferred from 2027 to 2030 | structural | https://budget.lis.virginia.gov/item/2026/2/HB30/Chapter/1/291/ | |
| 2026-07-01 | NF VBP SFY2027 measure set revised (adds total nurse turnover and falls with major injury; staffing HPRD floor 3.08), with Special Focus Facilities excluded and a 'maintenance' rule cutting attainment pay for homes that drop tiers. | Quality program measures revised; Special Focus Facilities excluded | structural | https://www.dmas.virginia.gov/media/22kjkenp/rev-nf-vbp-2027-… |
Verified October 11, 2026
Assisted living
Medicaid assisted living
- Covered
no
- Program
None. DMAS's Alzheimer's Assisted Living (AAL) 1915(c) waiver sunset 2018-06-30, and the CCC Plus waiver does not cover ALF services. The Auxiliary Grant (state/local income supplement, not Medicaid) helps pay for ALF room and board.
- What is paid
Medicaid pays nothing for ALF services. The Auxiliary Grant pays toward room, board and basic care, up to a set monthly rate, for SSI/AABD-eligible residents of AG-approved ALFs.
- Rate
No Medicaid ALF rate. (The Auxiliary Grant rate is a separate state program and is not captured here.)
- Limits
n/a
Verified October 11, 2026
Sources
- DMAS Nursing Facilities rates & rate-setting page · agency page
- SFY26 NF Price-Based Rates, Oct 1 2025-Jun 30 2026 (PDPM), updated 7/14/2026 · rate file
- SFY26 NF Price-Based Rates, Jul 1-Sep 30 2025 (RUG) · rate file
- Nursing Facility Reimbursement FAQ (Updated for PDPM), 5/19/2026 · agency page
- PDPM codes and relative weights eff. 10/1/2025 · rate file
- SPA 25-019 Nursing Facility Reimbursement Methodology (4.19-D Supp. 1 + Appendix IV), submitted 12/11/2025 · state plan
- DMAS bulletin: Change from RUG to PDPM grouper eff. 10/1/2025 · agency page
- 12VAC30-90-44 Nursing facility price-based reimbursement methodology · regulation
- 12VAC30-90-36 Nursing facility capital payment methodology (FRV) · regulation
- 12VAC30-20-170 Bed reservation during absence · regulation
- 2025 Appropriation Act (HB1600 Ch. 725) Item 288 (paras DDD, IIIII, VVVVV, QQQ, OO) · statute
- 2026 Appropriation Act (HB30 Ch. 1, 2026 Sp. Sess.) Item 291 (paras ZZ, BBB, LLL, PPPPP, TTTTT, JJ, PP, VVVV) · statute
- Conference amendment 291#11c Nursing Home Reimbursement ($70M) · statute
- Town Hall public notice: intent to amend state plan (FY2027 NF add-on), posted 8/26/2026 · agency page
- Updated SFY 2027 NF VBP Methodology (rev. 7/7/2026) · agency page
- DMAS NF VBP program page · agency page
- RD55 (2026): NF VBP Payment Timing and Methodology Workgroup report, Dec 2025 · agency page
- FY2027 Cardinal Care Managed Care rate report (Mercer), 5/13/2026 · agency page
- CMS directed payment preprint VA_VBP_NF_Renewal_20260701-20270630 · agency page
- DMAS Approved SPAs list · agency page
- Nursing Facility Provider Manual Ch. IV Covered Services and Limitations (rev. 6/30/2017) · agency page
- 12VAC30-90-330 Traumatic brain injury add-on · regulation
- NF VBP FAQs (rev. 2/9/2026) · agency page
- DMAS MDS 3.0 Guidance Document (rev. Oct 2018) · agency page
- Medicare crossover rule · regulation
- VHCA-VCAL 2026 Bill & Budget Update (as of 6/30/2026) · secondary
- JCHC, Affordability of Assisted Living Facilities (2022, RD643) · secondary
- Personal needs allowance · secondary
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