S5116 Medicaid reimbursement rate by state (2026)

• Order. States are listed from the highest published rate to the lowest. No single unit is shared by 8 or more states for S5116, so the order is by published amount and is not a like-for-like rank.
• Medicaid rate. The most the state's fee-for-service program pays for one unit, as published. 6 of the 6 states list more than one rate for S5116, by modifier, provider type or setting; the table shows the one that matches the provider level and setting used across states, without add-ons.
• Unit. Of the 6 states, 1 publish S5116 per unit, 1 per per authorization year, 1 per visit and 1 in other units, and 2 schedules print no unit at all (a flat amount per service).
• Per hour. S5116 is not billed in time units in these states, so no hourly figure is shown.
• Managed-care plans. The rule the state sets for its plans on this rate. What each rule means is explained below.
• % of Medicare. No Medicare physician fee schedule amount is on file for S5116, so there is no percentage.
• Source and date. Each Source link opens the state's own document; “since” is the date the rate took effect.

Published rates for S5116 run from $48.15 in Illinois to $2,000.00 in Indiana. The two publish it in different units (unit versus Client Hour), so part of that gap is the unit rather than the price. Half the states pay more than the median of $79.21 and half pay less. The usual reasons for a spread like this in private duty nursing rates:

• Group nursing, where one nurse cares for more than one patient, is paid at a reduced rate in many states.
• Nursing rates compete with hospital wages, so states facing shortages have raised them out of step with the rest of the schedule.
• Registered nurse and licensed practical nurse services carry different rates, and many states add an amount for ventilator, tracheostomy or other high-acuity care.

Timing matters too. 1 state set the current rate for S5116 in 2026 or later, while 1 state still pay a rate that took effect in 2022 or earlier. A state that has not updated its rate in years will drift down the ranking as others raise theirs.

What a plan pays for S5116 is negotiated privately, but the state decides how much room there is to negotiate. Here is how the rules break down across the 6 states.

In 1 state, the published rate binds plans: a floor, a pass-through or a state-set rate. In 1 state, plans negotiate and the published rate is a benchmark or out-of-network default. In 3 states, the service is paid outside the plans or through a state-directed payment. The rule for the remaining 1 state is not classified yet.

• Paid by the state, outside the plans (3 states). Bill the state's Medicaid program, not the plan, at the published rate. There is no plan contract to negotiate for this service.
• Plans must pay at least the published rate (1 state). The published rate is your floor. Negotiate up from it, and if a plan pays less, the contract provision is the basis for a payment dispute.
• Plans negotiate; the published rate applies out of network (1 state). In-network rates can be above or below the published rate. The published rate is the benchmark both sides know, and the fallback if no contract is signed.

Plan-negotiated rates are never estimated here. To see the rule and its citation for a particular state, open that state's managed-care page, for example Indiana managed care.

S5116 is a HCPCS Level II temporary national code in the private duty nursing line, billed mostly by home nursing agencies and independent nurses. S codes were created for private payers and are widely used by Medicaid programs for services Medicare does not cover, such as home nursing and home infusion. Units range from 15 minutes to a day.

Shift nursing is billed in 15-minute units under some codes and per hour under others, so convert to an hourly rate before comparing. Prior authorization usually sets the number of hours per week that can be billed.

Before billing, confirm the rate, unit and any modifier with the state's current schedule or the plan: the amounts here are as published, not a guarantee of payment.