Nursing Standard Payments and Operating Cost Standard Payments

(1) Nursing Standard Payments. (a) Nursing Standard Payment Calculation. Beginning October 1, 2025, nursing facilities will receive the following nursing standard payments: PDPM Nursing HIPPS Code (Acuity Level) PDPM Nursing Case Mix Index (2024) Nursing Standard Payment A (ES3) B (ES2) C (ES1) PDPM Nursing HIPPS Code (Acuity Level) PDPM Nursing Case Mix Index (2024) Nursing Standard Payment D (HDE2) E (HDE1) F (HBC2) G (HBC1) H (LDE2) I (LDE1) J (LBC2) K (LBC1) L (CDE2) M (CDE1) N (CBC2) O (CA2) P (CBC1) Q (CA1) R (BAB2) S (BAB1) T (PDE2) U (PDE1) V (PBC2) W (PA2) X (PBC1) Y (PA1) (b) Nursing Standard Payment Adjustment. Beginning October 1, 2025, eligible nursing facilities will receive adjustments to their standard nursing payments at 101 CMR 206.04(1)(a), which will be calculated and determined as follows. 1. Calculate each facility’s average nursing standard payment rate in effect as of September 30, 2025, weighted by the facility’s average PDPM nursing case mix during the period of January 1, 2024, through December 31, 2024. For each facility, add this value to the facility’s average Nursing Standard Payment Adjustment in effect as of September 30, 2025, weighted by the facility’s average PDPM nursing case mix during the period of January 1, 2024, through December 31, 2024. 2. Calculate each facility’s average proposed nursing standard payment rate, beginning October 1, 2025, using the nursing rates as defined in 101 CMR 206.04(1)(a) and weighted by the facility’s average PDPM nursing case mix during the period of January 1, 2024, through December 31, 2024. 3. To determine a facility’s eligibility for the Nursing Standard Payment Adjustment a. First, determine whether the facility is a pediatric facility. If the facility is a pediatric facility, then i. Determine whether the value calculated in 101 CMR 206.04(1)(b)2. is less than the value calculated in 101 CMR 206.04(1)(b)1. ii. If the value calculated in 101 CMR 206.04(1)(b)2. is less than the value calculated in 101 CMR 206.04(1)(b)1., then calculate an “average nursing rate adjustment” such that the sum of this adjustment and the value calculated in 101 CMR 206.04(1)(b)2. will be equal to the value calculated in 101 CMR 206.04(1)(b)1. iii. Divide the “average nursing rate adjustment” by the value calculated in 101 CMR 206.04(1)(b)2. The resulting percentage, rounded to the nearest hundredth of a percent, will be the Nursing Standard Payment Adjustment. b. If the facility is not a pediatric facility, then determine whether the facility is a High Medicaid facility. For the purposes of the Nursing Standard Payment Adjustment, a High Medicaid facility is defined as a facility for which Massachusetts Medicaid days are at least 75.00% of its total resident days, as reported on quarterly User Fee Assessment Forms for the period April 1, 2024, through March 31, 2025. If the facility is a High Medicaid facility, then i. Determine whether the value calculated in 101 CMR 206.04(1)(b)2. is less than the value calculated in 101 CMR 206.04(1)(b)1. ii. If the value calculated in 101 CMR 206.04(1)(b)2. is less than the value calculated in 101 CMR 206.04(1)(b)1., then calculate an “average nursing rate adjustment” such that the sum of this adjustment and the value calculated in 101 CMR 206.04(1)(b)2. will be equal to the value calculated in 101 CMR 206.04(1)(b)1. iii. Divide the “average nursing rate adjustment” by the value calculated in 101 CMR 206.04(1)(b)2. The resulting percentage, rounded to the nearest hundredth of a percent, will be the Nursing Standard Payment Adjustment. 4. For eligible facilities, the Nursing Standard Payment Adjustment will be applied as an upward adjustment to the nursing standard payment rate at each PDPM nursing case mix category. (2) Operating Cost Standard Payments. Beginning October 1, 2025, nursing facilities will receive operating cost standard payments of $127.26.