Medicaid Nursing Home Rates by State

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Washington

Medicaid nursing facility payment · Hybrid · researched October 2026

Washington’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

Facility average

Classification

PDPM

Rate updates

Twice a year

Managed care (LTC)

Short stays only

Quality program

Quality Enhancement (QE)

Paid outside the rate

Small

Bed hold

Leave only

Published rates

Rates only

Assisted living

Covered

Personal needs allowance

$108.74 / month

Overview

• Washington pays each home a facility-specific rate built from four statewide-priced parts (RCW 74.46.561, in place since 7/1/2016): direct care (statewide case-mix-neutral median cost per case-mix unit x the home's Medicaid average PDPM nursing case-mix index x a county wage index, capped at 118% of the home's own base-year direct care cost), indirect care (one flat statewide price, $71.41/day for every home in FY2027), capital (fair rental value) and a quality enhancement add-on ($0-$7.96).
• It is a hybrid because direct care is settled at the lower of cost or rate each year: a home must return unspent direct care money above 1% of the component.
• Everything is then forced under a legislated statewide weighted-average rate (the 'budget dial', $382.37 cap for FY2027).
• The 9/1/2026 rate file covers 183 Medicaid homes (18,065 beds, 2.89M Medicaid days in 2025).
• Median total paid rate = $389.86/day, range $298.37-$1,570.19 (the top is Bailey-Boushay House, an HIV/AIDS specialty home).
• The Medicaid-day weighted average is $404.24 including the $20.67 average provider-tax add-on, or $382.30 before the bed-license-fee and tax add-ons.

What matters in Washington

• A legislated 'budget dial' caps the statewide average rate at $382.37 for FY2027, cut from $394.32 mid-biennium.
• Unspent direct care money above 1% is returned each year; homes with substandard quality return all of it.
• No home's rate may fall below its 6/30/2026 rate through FY2028; 78 homes are now paid above formula.
• Case mix is one PDPM nursing-only (federal acuity measure) average per home, reset each January and July.
• Posted totals include a provider tax payback averaging $20.67 a day ($29 at most homes); compare rates without it.
• Managed care pays only skilled or rehab stays at negotiated rates; long-stay days are fee-for-service, and hospital bed hold is unpaid.

Frequently asked

Does a Washington nursing home keep unspent direct care money?

Only up to 1%. Unspent direct care money above 1% is returned each year, and homes with substandard quality return all of it.

What explains Washington nursing homes paid above their formula rate in FY2027?

No home's rate may fall below its 6/30/2026 rate through FY2028, and 78 homes are now paid above formula.

Does a Washington home's posted total rate include the provider tax?

Yes. Posted totals include a provider tax payback averaging $20.67 a day ($29 at most homes), so rates should be compared without it.

How much is paid outside the posted rate in Washington?

Small, under 1% of base, from UPL payments to public hospital district homes.

What does Washington Medicaid pay on Medicare coinsurance days?

Lesser-of: because Medicare's rate exceeds the Medicaid rate, the home usually receives $0 of the coinsurance.

Does Washington require a minimum share of spending on care?

Yes; unspent direct care money above 1% is recovered yearly, plus wage add-on and 3.4 staffing-hour rules.

How the rate is set

How the method got here

Verified October 11, 2026

Cost basis

Uses cost reports

Yes

Cost report

Washington state-specific annual Medicaid nursing facility cost report, filed with DSHS Office of Rates Management (WAC 388-96-099/-102, due March 31) and examined/settled by DSHS. Public-hospital-district homes also file Medicare 2552-10/2540-10 reports for their supplemental (UPL) payments.

Base year and rebasing

Direct and indirect care are rebased in even-numbered years using cost report data from two years before (RCW 74.46.561(8)), with legislative overrides. FY2024 used CY2021 costs +4.7% inflation. FY2025 (7/1/2024) used CY2022 costs +5%. FY2026 (7/1/2025) kept the CY2022 medians and froze direct and indirect at FY2025 levels by add-on (2025 ESSB 5167). FY2027 (7/1/2026, last rebase) moved to CY2024 costs, with a direct care median built on the four 2024 quarters of PDPM nursing case mix (2026 ESSB 5998). Capital (fair rental value) is rebased every July 1 from the prior calendar year's cost report (FY2027 uses 2025 data). After a rebase, DSHS may raise rates if the statewide average rose less than the CMS SNF market basket (RCW 74.46.561(8)(a)); the budget dial overrides this.

Components

Component	Method	Notes
direct care (DC)	Statewide price: 100% or more of the statewide case-mix-neutral median direct care cost per case-mix unit. It is multiplied by the home's Medicaid average CMI (PDPM nursing component), adjusted every 6 months, and by a county wage index (BLS wages for RN/LPN/CNA weighted by cost-report mix, WAC 388-96-917). There is no minimum occupancy. The rate is capped at 118% of the home's own base-year direct care cost unless the home is below the 3.4 HPRD minimum staffing standard (FY2023-25 caps were 165%/153%/142%). Settled at the lower of cost or rate (see spending_requirements).	Covers nursing, routine (non-rehab) therapy, food, laundry and dietary. About 70% of the total rate (4.19-D p.6). 9/1/2026 file: DC median $268.14, range $183.22-$1,488.57, Medicaid-day weighted average $283.96. FY2027 DC includes 50% of each home's wage equity funding. Transition floor: each home's FY2027 DC is at least 9% above its 6/30/2024 DC, with no upper cap this year.
indirect care (ID)	One flat statewide price: 90% or more of the statewide median indirect cost per day (administration, maintenance, housekeeping, utilities). Days are imputed at a minimum occupancy of 90% (75% in FY2023, 80% in FY2024-25). It is not case-mix adjusted and has no settlement.	$71.41/day for all 183 homes on the 9/1/2026 file, including 50% of wage equity funding.
capital (FR, fair rental value)	See capital field. Rebased annually; 90% minimum occupancy.	9/1/2026: median $18.79, range $5.79-$30.95, weighted average $17.83.
quality enhancement (QE)	Five tiers set from a point score on CMS MDS/PBJ measures. Tier V pays $7.96/day, IV $5.97, III $3.98, II $1.99, I $0. Reset each Jan 1 and Jul 1. See quality_incentive.	Weighted average $3.66/day.
statutory add-ons	Minimum wage add-on (MW) $0.76; inflation add-on (IA, ESSB 6168, FY2021 CPI adjustment made permanent through FY2028) $3.84; hold-harmless add-on (HH, FY2027 only); budget-dial reduction (BR, negative); bed license fee add-on (BL) $1.30; safety net assessment payback (SNA) $29/$1/$0.	See other_add_ons and budget_adjustment_factor.

Inflation

No automatic annual inflation. The legislature sets inflation at each rebase (4.7% for FY2024, 5% for FY2025, none named for FY2027). RCW 74.46.561(8)(a) uses the CMS SNF market basket as a floor test after rebasing. The FY2021 24-month CPI-U adjustment survives as the flat $3.84 'IA' add-on through FY2028.

Verified October 11, 2026

Case mix

System

PDPM

Applied at

Facility average

How it works

Each home gets one direct care rate built from its Medicaid residents' average PDPM nursing-component CMI, updated every 6 months. Every Medicaid resident in the home is paid the same rate regardless of their own assessment (RCW 74.46.501(6); July 2026 rate letter).

Classification

PDPM Nursing Component only (the nursing case-mix group from the HIPPS code). PT, OT, SLP and NTA components are not used. In use since 7/1/2024 rates; RUG-III (44-group, Washington's own weights) before that.

Applies to

Direct care only. Indirect, capital, quality enhancement and add-ons are not case-mix adjusted.

Acuity measured from

DSHS computes two quarterly averages per home (RCW 74.46.501): (a) a facility average CMI over all residents, excluding default cases, used only at rebasing to case-mix-neutralize direct care cost; and (b) a Medicaid average CMI over Medicaid and Medicaid-pending residents (identified by the MDS Medicaid number field, WAC 388-96-739), including default cases, used for the semiannual rate update. It is day-weighted by days in each classification within the calendar quarter. The cutoff for assessment data is one month and one day after quarter end. The July 1, 2026 rate used the '1 Semiannual 2026 Case Mix Report'; January 1, 2026 used the '2 Semiannual 2025 Final' report.

Updated

Semiannual: direct care rate updated Jul 1 and Jan 1 from the latest semiannual Medicaid CMI. CMIs are computed quarterly.

Move to PDPM

2024 c 246 (RCW 74.46.485) directed DSHS to use an MDS-based method from 7/1/2024 after CMS stopped RUG support. DSHS moved straight to the PDPM Nursing Component for 7/1/2024 rates, with no separate funding. Transition guardrails: FY2025, each home's DC was at least +9% vs its 6/30/2024 DC and capped at +15-16% for budget neutrality. FY2026, a floor of +6% vs 6/30/2024 and the same 15-16% cap, with DC/ID then held at FY2025 levels by add-on. FY2027, a floor of +9% vs 6/30/2024 and no upper cap, with the DC median rebuilt on 2024 PDPM nursing data. RCW 74.46.485 requires a final PDPM report to the legislature by 12/1/2026, with proposed adjustments for needs PDPM misses (e.g. behavioral/cognitive) and a monitoring plan. WAC 388-96-738/-905 still use RUG terms (default groups BC1/HD2).

Verified October 11, 2026

Low-acuity residents

None found. Washington pays one facility-average direct care rate to every Medicaid resident in a home, so there is no reduced or flat rate for low-acuity residents. Low-acuity residents only pull down the home's average CMI at the next semiannual update. Related rules (not carve-outs): (1) A resident discharged or deceased before the first assessment, or with an untimely assessment, is counted in the Medicaid CMI at a default group. WAC 388-96-738 still names RUG groups BC1 (low default) and HD2; the PDPM-era default was not found. (2) Residents must meet NF level of care under the state's CARE assessment to be Medicaid-covered at all. Checked: RCW 74.46.485/.501/.561, WAC 388-96-738/-739, 4.19-D Part I (TN 25-0022), the July 2024/2025/2026 rate letters and the 9/1/2026 rate file.

Verified October 11, 2026

Capital

Fair rental value (RCW 74.46.561(5); 4.19-D Sections X-XI). Allowable sq ft per bed (from the cost report, max 450) x RSMeans rental value per sq ft (83% or more of the WA median, indexed by facility zip code) x licensed beds = gross building value. Add a 10% equipment allowance, depreciate 1.5%/yr on the facility's average age (age reduced for renovations over $2,000/bed in a year; age capped at 0-44 years), and add land at 10% of undepreciated building value. Multiply by a fixed 7.5% rental rate. Divide by the greater of prior-calendar-year actual census or 90% occupancy of licensed beds (banked beds excluded). Rebased every July 1. FY2027 values: median $18.79/day, range $5.79-$30.95.

Verified October 11, 2026

Budget adjustment factor

Yes, the 'budget dial' (RCW 74.46.421; 4.19-D Section II; WAC 388-96-723/-730). The statewide Medicaid-day-weighted average rate may not exceed the figure in the appropriations act: $376.54 for FY2026 and $382.37 for FY2027. The 2026 supplemental budget (ESSB 5998 sec. 204) cut the FY2027 cap from the $394.32 enacted in 2025 (ESSB 5167). If computed rates exceed the cap, DSHS cuts rates prospectively. For FY2027 this took the form of a facility-specific negative 'Budget Dial Reduction' (BR) add-on on homes whose computed rate rose above their 6/30/2026 rate. 105 of 183 homes got BR, averaging -$3.62/day statewide and at most about -1.76% of the pre-dial rate (Bailey-Boushay -$28.03). At the same time, a 'Hold Harmless' (HH) add-on brought 78 homes back up to their 6/30/2026 rate, averaging $4.46/day statewide and up to $30.99. RCW 74.46.561(12) intends no facility rate cut in FY2027-FY2028, with increases capped to stay cost-neutral. The SNA add-on and bed license fee add-on sit outside the dial. FY2026: by RCW 74.46.561(11), a facility-specific add-on held the FY2026 weighted average at the FY2025 level ($35.4M GF-S + $39.0M federal to replace one-time 2023-25 increases).

Verified October 11, 2026

Add-ons and money outside the rate

Paid outside the posted rate

Level

small

Estimate

Under 1% of base. Derived: public-hospital-district UPL payments of $7.0M federal for the 2025-27 biennium (plus the districts' own nonfederal share) against about $1.17B/yr of FFS base (9/1/2026 total rate x 2.89M Medicaid days). The quality incentive and SNA payback are inside the per diem. MCO skilled-stay payments are negotiated and not visible.

Components

Public hospital district proportionate-share UPL supplemental payments ($7.0M federal per biennium; only for district-operated homes). Tribal NF rates are a separate per diem, not supplemental. No directed payments.

Source

https://lawfilesext.leg.wa.gov/biennium/2025-26/Pdf/Bills/Ses…

Verified October 11, 2026

Payments by owner type

Applies

yes

Detail

(1) Only nursing homes operated by public hospital districts can get proportionate-share UPL supplemental payments, up to Medicaid routine cost minus Medicaid routine payments ($7.0M federal in 2025-27, number of homes not found). (2) Tribal (IHS/638) homes get a negotiated IHS-indexed per diem ($1,048.63 listed for SFY2027, vs a $382 average) at 100% federal match. (3) State-run DDA nursing facilities are cost-based (4.19-D Part II). (4) State, tribal, county, public hospital district and hospital-based homes are exempt from the $29 SNA but also get no SNA add-on, so the net effect is about neutral on Medicaid days.

Funding

Public hospital districts provide the nonfederal match (certified public expenditures/IGT) and are cost-settled from Medicare cost reports. No lease or management arrangement for private operators was found.

Source

https://www.hca.wa.gov/assets/program/SP_Att_4_Payment_for_Se… (4.19-D Part I Section XVII, Supplement A) ; https://lawfilesext.leg.wa.gov/biennium/2025-26/Pdf/Bills/Ses…

Verified October 11, 2026

Quality program

Program

Nursing facility Quality Enhancement rate component / 'quality incentive' (RCW 74.46.561(6); 4.19-D Section XII), since 7/1/2016.

Funding

Inside the per diem and inside the budget-dial weighted average rate, so it is funded from the NF appropriation, not new money outside the rate. Statute requires the whole biennial QE appropriation to be allocated. Staffing-penalty receipts and direct care settlement recoveries go to a quality enhancement account (RCW 74.46.581) that can raise the QE; in 2025-27 that account may fund general NF costs.

Size

About $10.6M a year (9/1/2026 QE x 2025 Medicaid days), about $3.66 per Medicaid day on average. Statute: Tier V = 1% to 5% of the statewide average daily rate; currently $7.96, about 2% of the $382 average.

Paid as

Per-diem add-on (the QE line of the rate).

Measures

Measure	Source	Weight	How points are earned
Long-stay residents with pressure ulcers (CMS measure 479, replaced high-risk measure 453 from 7/1/2025)	MDS QM (CMS)	25 points max (equal weights)	CMS Five-Star QM point cut-offs: 80/60/40/20-point thresholds earn 25/20/15/0 points
Long-stay residents with one or more falls with major injury	MDS QM (CMS)	25 points max	Same Five-Star cut-off method
Long-stay residents with a urinary tract infection	MDS QM (CMS)	25 points max	Same
Short-stay residents who newly received an antipsychotic medication	MDS QM (CMS)	25 points max	Same (added 7/1/2017)
Direct care staff turnover	PBJ (cost report fallback)	25 points max	Thresholds set by DSHS from PBJ (added 7/1/2017)
Long-stay residents who self-report moderate to severe pain (statutory original measure)	MDS QM (CMS)	25 points max if still used	CMS retired this measure from Five-Star; whether DSHS still scores it is unconfirmed

Scoring period

Most recent four-quarter average of CMS quality data (rate letters; statute says at least three quarters). The 7/1/2026 rate used CY2025 (Q1-Q4 2025), and 1/1/2026 used Q3 2024-Q2 2025. That is a 6-12 month lag.

Payment formula

Points are summed and turned into a share of available points. 80% or more = Tier V, 70-79% = Tier IV, 60-69% = Tier III, 50-59% = Tier II, under 50% = Tier I. Tier IV/III/II get 75%/50%/25% of Tier V; Tier I gets $0. Homes with too little CMS data are tiered by their Five-Star rating (5-star = Tier V, 1-star = Tier I). 9/1/2026 distribution: Tier V 39 homes ($7.96), IV 23 ($5.97), III 41 ($3.98), II 33 ($1.99), I 47 ($0).

Eligibility

All Medicaid-contracted homes. No survey/SFF disqualifier was found in statute or the state plan.

Cadence

Scored and reset semiannually (Jan 1 and Jul 1); paid daily in the rate.

Scores published

Partly: the QE amount per home is a column in the posted rate file (https://www.dshs.wa.gov/sites/default/files/2026-09/9-1-26%20…). No published per-measure scorecard was found.

Notes

Separate from the safety-net-assessment-funded 'quality incentive' design in RCW 74.48.090, which was never implemented as a separate pool.

Verified October 11, 2026

Provider tax

Charged

per non-Medicare day

Standard amount

$29.00 per non-Medicare resident day, effective 3/1/2024 (raised from $23.00 so the SNA would yield the $66.68M the FY2024 budget assumed). Still $29 in July 2026.

Tiers

Who	Test	Amount
Homes with >= 27,300 Medicaid days on the prior-year cost report (threshold raised from 26,000 in July 2025; 19 homes flagged for FY2027)	medicaid_utilization	$1.00 per non-Medicare day
Homes with more than 203 licensed beds (4 homes flagged)	size	$1.00
Homes with 35 or fewer licensed beds (9 homes)	size	exempt
Continuing care retirement communities and 'CCRC-like' homes (4 + 30)	ccrc	exempt
State, tribal and county-operated homes (7 + 1 + 2)	public	exempt
Public hospital district and hospital-based homes (6)	hospital_based	exempt

Lower for high-Medicaid homes

yes

Returned in the rate

Per-day SNA add-on on each Medicaid day equal to the home's SNA level ($29, $1 or $0), outside the budget-dial average. FY2027: 128 homes $29, 16 homes $1, 39 homes $0.

Source

https://www.dshs.wa.gov/safety-net-assessment-sna ; https://app.leg.wa.gov/RCW/default.aspx?cite=74.48.050 ; https://www.dshs.wa.gov/sites/default/files/2026-08/Facilitit… ; https://www.dshs.wa.gov/sites/default/files/2026-08/Dear-Admi…

Verified October 11, 2026

Provider tax notes

Skilled Nursing Facility Safety Net Assessment (SNA), chapter 74.48 RCW, since 7/1/2011. Charged per non-Medicare resident day: $29.00 upper level (since 3/1/2024; was $23), $1.00 lower level, or exempt. The Medicaid share comes back as a separate per-day SNA add-on equal to the home's SNA level ($29/$1/$0; Medicaid-day weighted average $20.67, about $59.7M/yr), outside the budget dial. Revenue in the SNF Safety Net Trust Account ($133.4M state appropriation in 2025-27) supports NF rates.

Verified October 11, 2026

Supplemental payments

(1) Proportionate-share UPL supplemental payments to nursing homes operated by public hospital districts (4.19-D Section XVII and Supplement A; WAC 388-96-785). They are paid by HCA, funded by the districts' certified public expenditures/nonfederal share, limited to Medicaid routine cost minus Medicaid routine payments, and cost-settled from the Medicare 2552-10/2540-10. The 2026 budget gives $7,000,000 GF-federal for 2025-27 (ESSB 5998 sec. 211(15)). (2) Tribal (IHS/638) nursing homes are paid a negotiated all-inclusive per diem (CY2019 base $639.57, indexed to the IHS inpatient rate; specialty file lists $1,048.63 for SFY2026-27) at 100% federal match. (3) No MCO directed payments for NFs were found.

Verified October 11, 2026

Other add-ons

On the posted rate (9/1/2026 file): Minimum Wage add-on (MW) $0.76; ESSB 6168 Inflation add-on (IA) $3.84, which statute keeps through FY2028; FY2027 Hold Harmless add-on (HH) for 78 homes, $0.03-$30.99; Budget Dial Reduction (BR) negative add-on for 105 homes; Bed License Fee add-on (BL) $1.30 (FY2026 $1.25), for homes paying the $834/bed FY2027 license fee, outside the dial; SNA payback $29/$1/$0. Wage equity funding (2022 budget, up to $4/hr raises for low-wage workers, WAC 388-96-918) is built into DC and ID (50% each in FY2027) and is shown as columns (about $5-7 DC + $0.70 ID per day). Resident-specific exceptional care add-ons (WAC 388-96-781/782; specialty file eff. 7/1/2026): ventilator $192/day and trach $123/day at designated ventilator-weaning centers; Expanded Community Services $80; Enhanced Behavior Support+ (EBS+) $175 and EBS+ specialized services $235; DOC Extraordinary Medical Placement $45; 'Specialty Facility' $587 (cc91). The TBI facility rate no longer exists, and the $300 hospital-exceptional-care add-on is unused. COVID add-ons ended 6/30/2024.

Verified October 11, 2026

Units paid separately

(1) Pediatric NF (Bridges to Home, Shoreline, 12 beds): flat $1,554.57/day for SFY2026-27, paid at the Oregon Medicaid rate under WAC 388-96-782(1). (2) Tribal NFs: negotiated IHS-indexed per diem (4.19-D p.23). (3) State-operated DDA nursing facilities (e.g. Lakeland Village, Fircrest, Yakima Valley School) use a separate cost-based method in 4.19-D Part II. State veterans homes use the standard method (WAC 388-96-757). (4) Swing beds: one statewide rate equal to the prior-year Medicaid-day weighted average NF rate, $375.08 for 7/1/2026-6/30/2027 ($357.36 FY2026). (5) Exceptional-care add-ons are layered on the facility rate rather than separate units (see other_add_ons). (6) Transitional Care Center of Seattle (state-run NF) is funded by budget proviso. (7) Specialized add-on services for PASRR residents with intellectual disabilities are paid by fee schedule (4.19-D Section XIX).

Verified October 11, 2026

Payment rules

Managed care for long-term care

Status

short_stay

Detail

AH-IMC contract (rev. 7/1/2026) section 14.19: the MCO pays medically necessary skilled nursing or rehabilitative care in a SNF/NF, at a 'negotiated SNF daily rate'. 'If the Enrollee remains in the SNF/NF, the Enrollee remains enrolled in AH-IMC and ALTSA is responsible for payment of SNF/NF room and board beginning on the date it is determined the Enrollee does not meet or no longer meets criteria for the rehabilitative or skilled benefit.' Section 17.5.4.2: 'Nursing facility stays that do not meet rehabilitative or skilled criteria are covered through ALTSA.' There is no fixed day limit; the handoff is set by skilled/rehab criteria. DSHS also pays from admission when the admission came before managed care enrollment was completed (16.4.4). There is no MLTSS program for custodial nursing home care. Duals are mostly outside AH-IMC.

Verified October 11, 2026

Who pays

Mixed, but long-stay nursing home care is fee-for-service. DSHS/ALTSA (Aging and Long-Term Support Administration) sets the rate and pays the nursing facility daily rate through ProviderOne. Apple Health Integrated Managed Care (AH-IMC) plans pay only for medically necessary skilled/rehab stays. Room and board shifts to ALTSA fee-for-service once the resident no longer meets skilled or rehab criteria. The resident stays enrolled in the plan for drugs, equipment and other services not included in the NF rate.

Verified October 11, 2026

Managed care rate floor

No floor found. AH-IMC plans pay skilled/rehab NF stays at a 'negotiated SNF daily rate' (IMC contract 14.19). No contract term or budget proviso was found requiring MCOs to pay at least the DSHS NF rate. Long-stay custodial days are paid by DSHS at the DSHS rate, so a floor question does not arise for them. Source: https://www.hca.wa.gov/assets/billers-and-providers/imc-medic…

Verified October 11, 2026

Included in the daily rate

Included: nursing, routine (non-rehabilitative) PT/OT/speech therapy and therapy consulting, food, dietary, laundry (direct care), plus administration, housekeeping and maintenance (indirect) and capital. Paid separately: prescription drugs, medical equipment, specialty beds, specialty wheelchairs, IV medications and other medically necessary services not in the ALTSA NF rate. These are billed to the resident's Apple Health MCO or to HCA fee-for-service (IMC contract 14.19, 16.4). Physician/professional services and rehabilitative therapy beyond routine are also separate. Sources: 4.19-D Section VI; https://www.hca.wa.gov/assets/billers-and-providers/imc-medic…

Verified October 11, 2026

Bed hold

Hospital stays

Not paid as far as found. No Medicaid NF bed-hold payment for hospital stays appears in WAC 388-96, WAC 388-97-0160 or 4.19-D Part I. Washington's paid bed-hold rule for hospital stays (WAC 388-105-0045) covers assisted living and adult family homes, not NFs.

Leave days

Paid. Social/therapeutic leave up to 18 days per calendar year per resident; more with prior authorization from DSHS Home and Community Services (WAC 388-97-0160). Paid at the regular rate as far as found (no reduced percentage stated).

Occupancy rule

None.

Notes

Assisted living/ARC/EARC/AFH bed hold (WAC 388-105-0045) is 70% of the resident's Medicaid daily rate for days 1-7 and $11.66/day for days 8-20, when the resident is in a hospital or NF short-term.

Source

https://app.leg.wa.gov/WAC/default.aspx?cite=388-97-0160

Verified October 11, 2026

Personal needs allowance

Per month

108.74

Effective

2026-01-01

Notes

HCA LTSS standards chart: 'All other PNA Medical Institutions (1/1/26) $108.74'. State Veterans Home max $160 for a client without a needs-based VA pension (WAC 182-513-1105). Indexed to the SS COLA each Jan 1 since 2024 (WAC 182-513-1105).

Confidence

confirmed

Source

https://www.hca.wa.gov/assets/free-or-low-cost/income-standar…

Verified October 11, 2026

Medicare coinsurance days

Method

lesser_of

Rule

State plan Supplement 1 to Attachment 4.19-B (TN 03-019), covering Medicare Part A/B cost-sharing for QMB/QMB-plus: payment is limited to the State Plan rate. Where the Medicaid rate exceeds what Medicare paid, Medicaid pays the difference between Medicare's payment and the Medicaid rate, capped at the cost-sharing. For other full-benefit Medicaid recipients, Part A/B coinsurance is paid 'S/P' (state plan rates). For Medicare Advantage (Part C): the lesser of the billed cost-sharing; Medicare plan payment vs the Medicaid maximum allowable; or what Medicaid would owe under Part A/B. No NF-specific crossover rule was found in WAC 388-96, so the general rule is applied to SNF coinsurance days (likely).

Effect

Medicare's PDPM SNF per diem is well above the facility's Medicaid rate (about $382-404), so on day 21-100 coinsurance days the home usually gets $0 from Medicaid.

Confidence

likely

Source

https://www.hca.wa.gov/assets/program/SP_Att_4_Payment_for_Se… (Supplement 1 to Attachment 4.19-B, pp. 2-5)

Verified October 11, 2026

Required care spending

Applies

yes

Rule

Direct care settlement (RCW 74.46.022(6), 74.46.561(9); WAC 388-96-208(8), -218; 4.19-D Section XIII). Each calendar year, direct care payments are compared with the home's audited allowable direct care spending at the lower of cost or rate. The home must return unspent direct care money above 1% of its weighted average direct care component rate. Homes with substandard quality of care, or not in substantial compliance during the period, must return all unspent direct care money. Indirect, capital and QE have no settlement, so savings there are kept. Recoveries go to the NF quality enhancement account (RCW 74.46.581). Also: (a) the low-wage worker add-on must be spent on CNA/low-wage wages, benefits or CNA staffing, with unspent amounts recouped (WAC 388-96-758/759); (b) wage equity funding must go to raises for low-wage workers up to $4/hr, with the shortfall recovered (WAC 388-96-918); (c) department-initiated add-ons not used for their purpose are recouped (WAC 388-96-777); (d) the 3.4 HPRD minimum direct care staffing standard carries fines up to 200% of the missing wages and benefits (RCW 74.42.360).

Source

https://www.hca.wa.gov/assets/program/SP_Att_4_Payment_for_Se… (4.19-D Part I Section XIII) ; https://app.leg.wa.gov/WAC/default.aspx?cite=388-96-208

Verified October 11, 2026

Occupancy rules

Applies

yes

Rule

Indirect care: cost per day uses the greater of actual days or 90% occupancy of licensed beds for FY2027 (statutory default 90%; temporarily 75% FY2023, 80% FY2024-25). The statewide indirect median is also built on imputed days. Capital (FRV): divided by the greater of prior-calendar-year census or 90% occupancy. Direct care: no minimum occupancy. Banked beds are excluded from licensed beds. There are no rate cuts or occupancy tests for leave days.

Source

https://app.leg.wa.gov/RCW/default.aspx?cite=74.46.561 ; https://www.dshs.wa.gov/sites/default/files/2026-08/Dear-Admi…

Verified October 11, 2026

MDS accuracy penalties

DSHS quality assurance nurses do periodic on-site case mix accuracy reviews of MDS assessments (WAC 388-96-905). Findings change residents' classifications, which feeds the home's Medicaid CMI and direct care rate. Appeal is within 10 days to the case mix accuracy review administrator. No fixed percentage penalty or error-rate threshold was found. Untimely assessments are counted at the default group (WAC 388-96-738). Direct care money is also settled at the lower of cost or rate, which limits gains from upcoding.

Verified October 11, 2026

Published rates and changes

How often rates change

A home's rate changes

semiannual

When

Jul 1: full rate setting (capital rebased yearly, direct and indirect medians rebased in even years, budget dial and add-ons reset) plus the direct care case-mix and quality-enhancement update. Jan 1: direct care updated for the new semiannual Medicaid CMI and QE re-tiered. Off-cycle: mid-year SNA changes (e.g. 3/1/2024), CHOW and new-home rates, re-posted files (e.g. 9/1/2026). Pay does not change with each resident's assessment.

Verified October 11, 2026

When rates change

July 1 (state fiscal year) and January 1 semiannual updates; dear administrator rate letters dated about June 25 and December 29. Mid-year changes for SNA level changes, CHOW and corrections. Biennial rebasing in even-numbered years per statute, often overridden by budget language.

Verified October 11, 2026

Posted rates

Home-level rates published

Yes

Where

https://www.dshs.wa.gov/adult-and-aging-services/information-…

Format

xls and pdf (current rate file with specialty rates), plus a weighted-average-rate pdf

Cadence

Re-posted whenever rates change (e.g. 'Effective 9/1/26' file run 9-1-26 contains 7/1/2026 rates); main updates Jul 1 and Jan 1.

History

The page posts only the current file. History is in the DSHS 'Rate History' searchable database (https://fortress.wa.gov/dshs/adsaapps/professional/rates/rate…), by Medicaid vendor number. Its start year was not checked. A 'Medicaid Revenue & Census' database gives Medicaid days and payments by vendor and year.

Home identifier

Vendor ID (DSHS Medicaid vendor number), state license number, NPI, ProviderOne ID (P1), DSHS location ID, name and city. No CCN.

Verified October 11, 2026

Rate build-ups

Published

No

Where

Each home gets its own rate letter with a rate calculation attachment (dear administrator letters at https://www.dshs.wa.gov/adult-and-aging-services/information-…); the attachments are not posted publicly. The public rate file shows each component.

What they show

The public file shows, per home: licensed beds, cost report year, Medicaid days, DC, ID, FR, QE, MW, IA, HH, BR, total after budget dial (TL), BL, SNA, total payment rate (TR), and wage equity amounts in DC/ID. Not shown: the medians/prices, CMI, wage index, 118% cap test or FRV inputs. Quarterly case mix (CMID) reports with facility vs Medicaid CMI are posted on the Case Mix page.

Format

xls/pdf

Example file

https://www.dshs.wa.gov/sites/default/files/2026-09/9-1-26%20…

Verified October 11, 2026

Recent changes

Verified October 11, 2026

Assisted living

Medicaid assisted living

Covered

yes

Program

DSHS/ALTSA Home and Community Services pays contracted assisted living facilities for three Medicaid service contracts: Assisted Living (AL), Adult Residential Care (ARC) and Enhanced Adult Residential Care (EARC), plus Specialized Dementia Care. Authority: COPES 1915(c) waiver and Community First Choice 1915(k) / Medicaid Personal Care (state plan). Rates in WAC 388-105.

What is paid

Services only. The resident pays room and board from their own income: the 'room and board standard' equals the SSI federal benefit rate minus the personal needs allowance (WAC 182-513-1105). CFC/MPC clients pay all income except the PNA to the facility (WAC 182-513-1205). Add-ons: capital add-on for AL contractors with at least 60% Medicaid occupancy (WAC 388-105-0035; $5.42/day in the high-cost area), a one-time 'bridge rate' for high-Medicaid AL/ARC/EARC in 2025-27, Expanded Community Services add-ons, and a $0.73 license-fee add-on.

Rate

Daily rates by 17 CARE classifications x 2 cost areas, unchanged from 1/1/2026 to 7/1/2026. High-cost area (King, Pierce, Snohomish): AL/EARC $118.80 (A Low) to $240.15; ARC $114.14-$227.70. Standard-cost area: AL/EARC $109.22-$214.53; ARC $105.17-$203.72. Bed hold for ALF residents: 70% of the daily rate for days 1-7, then $11.66/day for days 8-20.

Limits

No enrollment cap or waitlist found for the CFC/MPC personal care path (CFC is a state plan entitlement); COPES slot limits not checked. Statewide; rates vary by the two cost areas.

Source

https://www.dshs.wa.gov/sites/default/files/2026-09/All_HCS_R… ; https://app.leg.wa.gov/WAC/default.aspx?cite=388-105-0035

Verified October 11, 2026

Sources

1. RCW 74.46.561 Nursing home payment rates (as amended by 2026 c 268) · statute
2. RCW 74.46.485 Case mix method implementation (2024 c 246) · statute
3. RCW 74.46.501 Average case mix indexes · statute
4. RCW 74.46.421 Budget dial · statute
5. RCW 74.46.022 / 74.46.581 settlement and quality enhancement account · statute
6. RCW 74.42.360 3.4 HPRD minimum staffing · statute
7. Chapter 74.48 RCW Safety net assessment (74.48.030/.040/.050/.090) · statute
8. WAC 388-96 (sections 208, 218, 713, 723, 738, 739, 757, 758, 759, 760, 777, 781, 782, 785, 802, 905, 910, 917, 918) · regulation
9. WAC 388-97-0160 Discharge or leave of a nursing facility resident · regulation
10. WAC 388-105-0035 AL capital add-on; WAC 388-105-0045 residential bed hold · regulation
11. WAC 182-513-1105 / 182-513-1205 PNA, room and board, ALF eligibility · regulation
12. WA Medicaid State Plan Attachment 4 (4.19-D Part I through TN 25-0022; Supplement 1 to 4.19-B) · state plan
13. DSHS Nursing Facility Rates and Reports page · agency page
14. Current NF rate file, run 9-1-26 (7/1/2026 rates, with specialty) · rate file
15. NH Medicaid Weighted Average Rate, run 9/01/26 · rate file
16. NF Specialty Services Rates, updated 7/1/2026 · rate file
17. Dear Administrator letter NH Rates #2026-001, July 1, 2026 rate · agency page
18. Dear Administrator letter NH Rates #2025-002, January 1, 2026 rate · agency page
19. Dear Administrator letter NH Rates #2025-001, July 1, 2025 rate · agency page
20. Dear Administrator letter NH Rates #2024-002, July 1, 2024 rate · agency page
21. DSHS Patient-Driven Payment Model page · agency page
22. DSHS Case Mix page (CMID reports) · agency page
23. DSHS Safety Net Assessment page · agency page
24. SNA facilities exempted under waiver, effective 7/1/2026 · rate file
25. SNA change notice, Dec 5 2023 ($23 -> $29 eff. 3/1/2024) · agency page
26. 2026 supplemental operating budget ESSB 5998 (2026 c 268) secs. 204, 211 · statute
27. 2025-27 operating budget ESSB 5167 (2025 c 424) sec. 204 · statute
28. HCA Apple Health Integrated Managed Care model contract (rev. 7/1/2026) secs. 14.19, 16.4, 17.5 · agency page
29. DSHS All HCS Rates workbook (Community Rates July 2026, Bridge Rates, Bed Hold) · rate file
30. DSHS Office of Rates Management page · agency page
31. Personal needs allowance · regulation

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