S5130 Medicaid reimbursement rate by state (2026)

• Order. States are listed from the highest published rate to the lowest. A like-for-like rank only counts states that use the same unit: 23 of the 27 states publish S5130 per 15 min, enough to rank them against each other.
• Medicaid rate. The most the state's fee-for-service program pays for one unit, as published. 19 of the 27 states list more than one rate for S5130, 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 27 states, 23 publish S5130 per 15 min, 1 per staff hour and 1 per hour, and 2 schedules print no unit at all (a flat amount per service).
• Per hour. Time-based units are converted to an hour of service (four 15-minute units make an hour). 24 of the 27 states bill S5130 by time, with a median of $28.28 per hour.
• 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 S5130, 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 S5130 run from $2.07 in Virginia to $31.34 in Montana. The two publish it in different units (Staff Hour versus 15 min), so part of that gap is the unit rather than the price. Half the states pay more than the median of $7.16 and half pay less. The usual reasons for a spread like this in personal care & attendant rates:

• The same service can be paid under the state plan, under one or more waivers or under a separate state program, each with its own rate.
• Agency-delivered and self-directed (consumer-directed) care are usually paid at different rates.
• Some states require a share of the rate to go to direct-care wages, and minimum wage changes push personal care rates up.

Timing matters too. 11 states set the current rate for S5130 in 2026 or later, while 3 states 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 S5130 is negotiated privately, but the state decides how much room there is to negotiate. Here is how the rules break down across the 27 states.

In 5 states, the published rate binds plans: a floor, a pass-through or a state-set rate. In 3 states, plans negotiate and the published rate is a benchmark or out-of-network default. In 10 states, the service is paid outside the plans or through a state-directed payment. The rule for the remaining 9 states is not classified yet.

• Paid by the state, outside the plans (10 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 (4 states). 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 (3 states). 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.
• Plans are expected to pay at least the published rate (1 state). Treat the published rate as a strong anchor, and confirm the minimum is written into your own plan agreement.

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 Montana managed care.

S5130 is a HCPCS Level II temporary national code in the personal care & attendant line, billed mostly by home care and personal care agencies and self-directed attendants. 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.

Personal care is commonly billed in 15-minute units, though some states pay per hour or per day. Modifiers distinguish agency from self-directed care and, in some states, the number of people served at once.

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.