PDGM Calculator
Price a Medicare home health 30-day period on the CMS calendar year 2026 rates: the case-mix and wage-adjusted payment for the patient’s county, and, from the period’s visits, whether it is a LUPA and any outlier payment.
How PDGM payment works
How is a home health 30-day period paid under PDGM?
The national, standardized 30-day period payment ($2,038.22 for calendar year 2026) times the case-mix weight of the period's PDGM group. The labor-related share, 74.9 percent, is then adjusted by the wage index of the county where the patient is served.
What is a LUPA in home health?
A low-utilization payment adjustment. When a 30-day period has fewer visits than its group's threshold, between 2 and 6 visits depending on the group, Medicare pays each visit at a national per-visit rate instead of the 30-day payment. The first skilled nursing, physical therapy, occupational therapy or speech-language pathology visit of an only or initial period is paid more, using an add-on factor.
How are home health outlier payments calculated?
The period's estimated cost is the visit time in 15-minute units times a cost per unit for each discipline, wage adjusted. If it exceeds the 30-day payment plus a fixed-dollar loss amount (0.37 times the wage-adjusted national 30-day rate in 2026), Medicare pays 80 percent of the excess. This calculator uses the national average minutes per visit; a claim uses the actual minutes, capped at 8 hours a day.
What is a home health HIPPS code?
A five-character code for the period's payment group. The first character is the admission source and timing (1 to 4), the second the clinical group (A to L), the third the functional impairment level (A low, B medium, C high), the fourth the comorbidity adjustment (1 none, 2 low, 3 high), and the fifth is always 1.
Which wage index applies to a home health period?
The one for the county where the patient receives care. Urban counties use their area's index and rural counties their state's rural index. Since 2025 CMS caps any county's drop at 5 percent from the year before, so a few counties use their own transition code; the calculator handles those from the county you pick.
What changed in the 2026 home health rates?
The 30-day rate fell from $2,057.35 to $2,038.22 after a 2.4 percent payment update, a permanent -1.023 percent behavior adjustment and a one-year -3 percent temporary adjustment. Agencies that do not submit the required quality data are paid $1,998.41.
Does the calculator include sequestration?
Not in the rate. Sequestration withholds a flat percentage from the Medicare payment after the rate is set, so it is optional here and you enter the percentage in effect for your dates.
Skilled nursing too
Pricing a skilled nursing stay instead? The PDPM Calculator does the same for Medicare Part A SNF stays, on the current fiscal year’s rates.
Estimate only. Rates, case-mix weights, LUPA thresholds and wage index are the published CMS
figures for calendar year 2026 (CY 2026 home health PPS final rule, CMS-1828-F, and change
request 14304), effective January 1, 2026.
It does not assign the HIPPS group: CMS’s grouper does that from the claim’s diagnoses,
the OASIS assessment and the period’s admission source and timing. It also applies no partial
period (PEP) adjustment, no Home Health Value-Based Purchasing adjustment and no separate payment
for disposable negative pressure wound therapy. Outlier estimates use national average minutes
per visit. This page looks nothing up for a particular agency, beneficiary or date, and is not a
payment determination — verify against the CMS final rule before relying on a number.
BARA Analytics is independent and is not affiliated with or endorsed by CMS.