Skilled nursing Medicaid rates in North Dakota are high by national standards. The state's published daily rate for a nursing home stay is $393.14, effective January 1, 2026, compared with a national median of $282.59 among states with a comparable figure. North Dakota is not part of the 21-state ranking, but its daily rate is higher than every ranked state except New Mexico and Colorado.
For a North Dakota operator, the more distinctive story is how the rate is built and how it moves. North Dakota sets nursing facility rates through a detailed administrative rule, raises them on a calendar-year cycle, and has been reworking how residents are classified and how incentive dollars are shared.
The $393.14 per diem is the amount North Dakota Medicaid pays for one resident day in a nursing facility. Like any nursing facility per diem, it bundles nursing care at three licensure levels with room and board, dietary, housekeeping, activities, administration and the cost of the building.
North Dakota publishes its rates in Nursing Facility Rates by Location, issued by the HHS Medical Services Division with rates effective January 1, 2026. Payment is differentiated by resident classification, and the state's nursing facility line holds 1,880 current rates, so each facility's own rates by classification are what it should budget.
North Dakota is not among the 21 states whose daily rate is ranked directly, out of 44 states with a published nursing home rate. Its figure can still be read against the ranked group.
| State | Daily rate |
|---|---|
| New Mexico | $826.00 |
| Colorado | $419.22 |
| North Dakota (not ranked) | $393.14 |
| Rhode Island | $381.06 |
| Washington | $373.84 |
| National median | $282.59 |
At $393.14, North Dakota sits in the same band as the top-ranked states other than New Mexico. It is far above the bottom of the ranking, where Connecticut lists $107.21, Michigan $99.90 and Arkansas $70.00. For a facility, a per diem at this level means Medicaid days are much closer to covering the full cost of care than in most of the country.
A rate well above the median changes the economics of a Medicaid-heavy building. Long-stay Medicaid residents, who make up much of the census in many rural facilities, generate revenue closer to the full cost of their care.
Less reliance on other payers
In low-rate states, Medicare short stays and private-pay residents subsidize Medicaid days. In North Dakota that subsidy is smaller, which lowers the risk of a high Medicaid share and makes small rural buildings more viable.
Fixed costs in small buildings
Many North Dakota facilities are small and serve wide areas. Small buildings carry high fixed cost per bed for administration, dietary and plant operations, which is part of why a high per diem matters. Occupancy still decides the margin: each empty bed spreads fixed staffing across fewer paying residents.
North Dakota's nursing facility payment system is governed by NDAC chapter 75-02-06, the state's ratesetting rule for nursing facilities. The rule was amended effective January 1, 2024 and again effective January 1, 2026.
SPA ND-24-0003, approved February 27, 2024 and effective January 1, 2024, implemented a 3.2% inflationary increase and updated the cost base year to June 30, 2023. Moving the base year refreshes the cost data rates are built on, which generally helps facilities whose costs rose since the earlier base.
SPA ND-26-0001, approved by CMS on April 24, 2026 and effective January 1, 2026, updates the resident classification requirements used in nursing facility payment. Classification drives which rate a resident day earns, so the update matters directly to revenue.
Because North Dakota pays by resident classification, the classification each resident receives is as important to revenue as the rate attached to it. The 2026 update makes this a good moment to review the process end to end.
Assessments and documentation
Classification rests on resident assessments. When an assessment misses a need, such as a change in mobility, cognition or clinical treatments, the resident lands in a lower-paying group than the care provided justifies. The clinical record has to support every item on the assessment, both to earn the right classification and to withstand review.
Timing of reassessments
Residents' needs change. A facility that reassesses promptly after a significant change keeps its classifications current; one that waits for the next scheduled assessment can be paid at an outdated level for weeks.
Comparing before and after
Facilities should compare their classification mix and resulting revenue before and after January 1, 2026. If the mix shifted under the updated requirements, the cause should be understood, whether it reflects real changes in residents or gaps in documentation.
North Dakota adjusts nursing facility rates on the calendar year, not a July fiscal year.
- 2024: a public notice published December 29, 2023 and SPA ND-24-0003 delivered a 3.2% increase.
- 2025: a public notice published January 10, 2025 and SPA ND-25-0001, approved April 2, 2025, delivered a 3.0% inflationary increase for all nursing facility services.
- 2026: a public notice published December 29, 2025 carried a 3.2% change, effective January 1, 2026.
The pattern is steady: increases in the 3.0% to 3.2% range each January, with CMS approval arriving in the spring. Operators can plan budgets around that calendar and book the increase from January 1, while recognizing that the amendment is formally approved a few months later.
SPA ND-24-0002, approved April 15, 2024 and effective January 1, 2024, implemented a nursing facility incentive program for in-state facilities. SPA ND-25-0002, approved April 1, 2025, updated the program's distribution methodology from January 1, 2025.
An incentive program pays additional amounts to facilities that meet defined goals, separate from the base per diem. A change to the distribution method does not change the total, but it does change which facilities receive how much. Operators should read the methodology to see what earns incentive dollars and whether their facility's results position it to gain or lose under the new formula.
SPA ND-24-0006, effective January 1, 2024, increased nursing facility therapeutic leave days from 24 to 30. Therapeutic leave covers days a resident spends away from the facility, such as a home visit, while the bed is held.
For a facility, more paid leave days protect revenue when residents are temporarily away and make it easier to support family visits without losing the bed. Billing staff should apply the current limit and track each resident's leave days through the year so that paid days are not missed and the limit is not exceeded.
North Dakota's May 2025 wage data has an unusual shape.
- Registered nurses: $38.81 an hour, against a national median of $46.90.
- Licensed practical nurses: $29.95, against $30.96.
- Nursing assistants (CNAs): $22.03, against $20.32.
Registered nurses and licensed practical nurses earn less than the national median, but nursing assistants earn more. Because aides provide the largest share of direct-care hours in a nursing home, an above-median CNA wage weighs heavily on a facility's labor budget. For operators, cost pressure is concentrated at the front-line aide level rather than in licensed nursing, and retention of aides is the staffing priority. In areas with strong competing employers, aide wages can run well above even the statewide median.
North Dakota Medicaid pays nursing facilities on a fee-for-service basis. Our data classifies only two North Dakota service lines under managed care rules, and nursing facilities are not among them, so the published per diem is the rate that applies to a Medicaid resident day. We record 5 plans and care-management arrangements in the state, including Blue Cross Blue Shield of North Dakota and Northland PACE, which covers long-term care for its own enrollees under its own contract.
The North Dakota managed care page summarizes those arrangements, and the North Dakota state page lists every published rate.
North Dakota's 1915(c) HCBS waiver for aged and physically disabled adults and the state-funded Service Payments for the Elderly and Disabled (SPED) program support people at home who might otherwise enter a facility. See North Dakota home care rates and North Dakota home health rates. Neighboring Minnesota and Nebraska offer useful regional comparisons for skilled nursing.
- Budget on a calendar year. Book the January increase from January 1 and track CMS approval in the spring.
- Check classification under SPA ND-26-0001. It determines which rate each resident day earns.
- Read the incentive methodology. Know what earns incentive dollars under the 2025 formula.
- Track leave days. Thirty paid therapeutic leave days are available; record them per resident.
- Prioritize aide retention. Above-median CNA wages make turnover expensive.
Rates on this page are compiled from official state Medicaid publications, and each rate links to its source document. The North Dakota figure comes from ND HHS Medical Services Division, Nursing Facilities, Rates effective January 1, 2026. North Dakota's nursing facility line is part of all 19,715 current North Dakota Medicaid rates, with history back to 2023.
The skilled nursing industry hub compares every state, our methodology explains how states are ranked, and pricing covers access to the full North Dakota dataset.