CMS does not set a per-visit day rate for home health. Instead, Medicare pays agencies a risk-adjusted lump sum for each 30-day period under the Patient-Driven Groupings Model (PDGM).
If you searched "does CMS set a day rate for home health visits," you are not alone -- it is one of the most common questions from new agency owners and billing staff. This article explains exactly how the payment system works, what the 2026 numbers are, and what drives the actual dollar amount your agency receives.
How CMS Pays: The 30-Day Payment Period
Since January 2020, Medicare home health has operated on 30-day payment periods rather than the old 60-day episode model. When a Medicare-eligible patient is admitted to home health, the agency receives a single lump-sum payment to cover all skilled services delivered during that 30-day window.
Here is what that looks like in practice:
- A physician orders home health care and certifies the patient is homebound and needs skilled services.
- The agency submits a Notice of Admission (NOA) within 5 calendar days of the start of care.
- CMS pays a base rate, adjusted by the patient's case-mix group and local wage index.
- The agency delivers all visits within the 30-day period under that payment -- whether the patient receives 4 visits or 14.
If the patient needs continued care, a new 30-day period begins and generates a new payment. There is no limit on consecutive periods as long as the patient continues to meet eligibility criteria.
The critical point for agency owners: The payment is the same whether you send a clinician 5 times or 12 times in that window. This is why visit utilization management -- scheduling the right number of visits without over- or under-serving -- directly impacts your margin.
What Is PDGM?
The Patient-Driven Groupings Model (PDGM) is the case-mix classification system CMS uses to adjust the base payment for each 30-day period. Rather than paying every patient the same flat amount, PDGM sorts each period into one of 432 case-mix groups based on five clinical dimensions:
| Dimension | Options | What It Captures |
|---|---|---|
| Admission source | Community or institutional | Was the patient referred from the community or discharged from an inpatient facility? |
| Timing | Early or late | Is this the first or second 30-day period in the certification, or a later one? |
| Clinical grouping | 12 categories | Primary diagnosis mapped to groups like musculoskeletal rehab, neuro/stroke rehab, wounds, cardiac/endocrine MMTA, respiratory, behavioral health, complex nursing interventions, etc. |
| Functional impairment level | Low, medium, or high | Patient's functional status scored from OASIS assessment items covering ADLs and hospitalization risk |
| Comorbidity adjustment | None, low, or high | Whether secondary diagnoses indicate higher resource needs -- based on 20 low and 98 high comorbidity interaction subgroups |
That gives you 2 x 2 x 12 x 3 x 3 = 432 possible payment groups.
Each group has a case-mix weight -- a multiplier applied to the base payment rate. A weight of 1.0 means the standard payment. Weights above 1.0 increase payment for higher-acuity patients; weights below 1.0 decrease it. For CY 2026, CMS recalibrated all 432 case-mix weights using CY 2024 claims data with a case-mix budget neutrality factor of 1.0052.
Example: A community-admitted, early-period patient with a musculoskeletal diagnosis, high functional impairment, and high comorbidity will have a weight well above 1.0 -- meaning the agency receives significantly more than the base rate. A late-period, low-functional, no-comorbidity patient in a routine MMTA group will land below 1.0.
2026 National Standardized Payment Rate
The CY 2026 national standardized 30-day period payment rate is $2,038.22, as finalized in the CY 2026 Home Health PPS Final Rule (CMS-1828-F).
This rate is the product of several layered adjustments:
| Component | Impact |
|---|---|
| Market basket update (gross) | +3.2% |
| Productivity adjustment | -0.8% |
| Net payment update | +2.4% (~$405 million) |
| Permanent PDGM behavioral adjustment | -1.023% (-$150 million) |
| Temporary CY 2026 adjustment | -3.0% (-$460 million) |
| Fixed-dollar loss ratio update (outliers) | -0.1% (-$15 million) |
| Net aggregate change vs. CY 2025 | -1.3% (-$220 million) |
The temporary -3.0% adjustment is part of CMS's effort to recoup an estimated $4.76 billion in retrospective overpayments from CYs 2020 through 2024 that resulted from PDGM behavioral changes. This reduction applies to CY 2026 only -- future years will have their own temporary adjustments set through annual rulemaking.
For agencies that do not submit required quality data, the payment update drops from 2.4% to just 0.4%, producing a lower base rate of $1,895.85 vs. $1,933.61 for compliant agencies (before case-mix and wage index adjustments).
Per-Visit Rates by Discipline
CMS publishes national per-visit rates that apply in specific situations -- primarily for Low-Utilization Payment Adjustments (LUPA). A LUPA kicks in when a patient receives fewer visits than the threshold for their case-mix group, replacing the full 30-day lump sum with a per-visit calculation.
Here are the CY 2026 national per-visit rates:
| Discipline | Per-Visit Rate | LUPA Add-On Factor |
|---|---|---|
| Skilled Nursing (SN) | $176.96 | 1.7200 |
| Physical Therapy (PT) | $193.42 | 1.6225 |
| Occupational Therapy (OT) | $194.74 | 1.7238 |
| Speech-Language Pathology (SLP) | $210.25 | 1.6696 |
| Medical Social Services (MSW) | $283.64 | -- |
| Home Health Aide (HHA) | $80.12 | -- |
Source: CMS Transmittal MM14304 -- HH PPS CY 2026 Rate Update
How LUPA add-on factors work: The add-on factor is multiplied against the per-visit rate for the first skilled visit in a LUPA period. This compensates for the higher cost of the initial assessment. For example, if a SN visit is the first visit in a LUPA period, the first visit payment would be $176.96 x 1.7200 = $304.37, with subsequent SN visits paid at the standard $176.96.
CY 2026 is the first year CMS has finalized a separate LUPA add-on factor for occupational therapy (1.7238), recognizing that OT evaluations carry distinct resource costs from PT.
For CY 2026, CMS updated LUPA thresholds using CY 2024 claims data, with 18 case-mix groups seeing their threshold shift by one visit. Falling one visit short of the threshold -- delivering 5 visits when the LUPA threshold is 6 -- can mean losing hundreds or thousands of dollars per period.
What Affects How Much Your Agency Gets Paid?
Beyond the base rate and case-mix weight, several factors shape your actual reimbursement:
Wage index adjustment. CMS adjusts the labor portion of the payment (approximately 76%) by the Core-Based Statistical Area (CBSA) wage index for the patient's location. Agencies in high-cost urban markets receive higher payments; rural agencies receive lower payments for identical case-mix groups. For CY 2026, CMS maintains a 5% cap on year-over-year wage index decreases.
LUPA thresholds. Each of the 432 case-mix groups has a visit threshold. Fall below it and your payment drops from the full 30-day amount to the sum of per-visit rates -- often a significant revenue reduction. Tracking visits against these thresholds in real time is one of the most effective ways to protect revenue.
Outlier payments. If a patient's estimated cost of care significantly exceeds the case-mix-adjusted payment, CMS provides an outlier add-on payment. The CY 2026 fixed-dollar loss (FDL) ratio is 0.37. These payments are relatively rare but serve as a safety net for unusually resource-intensive patients.
Value-Based Purchasing (VBP). Under the Expanded Home Health VBP Model, all Medicare-certified agencies receive a payment adjustment of up to +5% or -5% based on quality performance. CY 2026 adjustments use CY 2024 as the performance year, measured against OASIS-based outcomes, claims-based measures, and HHCAHPS patient satisfaction scores. CMS projects $3.376 billion in gross fee-for-service savings over five years through this model.
What Patients Pay
Under Original Medicare, beneficiaries pay $0 for covered home health services. There are no copays, no deductibles, and no coinsurance for skilled nursing, physical therapy, occupational therapy, speech-language pathology, medical social services, or home health aide visits -- as long as the patient meets eligibility requirements.
The only exception is durable medical equipment (DME), which carries a 20% coinsurance under Part B.
Patients enrolled in Medicare Advantage plans may have different cost-sharing structures, but MA plans are required to cover at least the same home health benefits as Original Medicare.
Frequently Asked Questions
Is there a CMS "day rate" for home health visits?
No. CMS does not publish or use a per-day rate for home health. Medicare home health is paid per 30-day period under the HH PPS, adjusted by patient acuity through PDGM. The concept of a "day rate" applies to some facility-based settings (like skilled nursing facilities), not home health.
What is the average Medicare payment per home health visit?
If you divide the CY 2026 base rate of $2,038.22 by a typical 8 to 10 visits, you get roughly $200 to $255 per visit. But this is not how CMS calculates payment -- the agency receives the full period amount regardless of visit count, unless the LUPA threshold is triggered.
How do per-visit rates compare to what clinicians actually earn?
Per-visit rates ($176.96 for SN, $193.42 for PT, etc.) represent what Medicare pays the agency, not what the clinician takes home. Agencies typically pay clinicians between $50 and $100 per visit depending on discipline, geography, and visit type. The difference covers overhead, travel, documentation time, supervision, and administrative costs.
Are home health payments going up or down in 2026?
Down, in aggregate. Despite a +2.4% market basket update, the permanent adjustment (-1.023%) and temporary adjustment (-3.0%) result in a net 1.3% decrease ($220 million reduction) compared to CY 2025. This is the fourth consecutive year of aggregate payment reductions for Medicare home health.
How can my agency avoid LUPA revenue losses?
Three steps: (1) know the LUPA threshold for each patient's case-mix group, (2) track visit counts per 30-day period in real time, and (3) schedule proactively so you do not accidentally fall one visit short. Scheduling software that surfaces LUPA risk before the period closes is the most reliable safeguard against accidental revenue loss.
Sources
- CY 2026 Home Health PPS Final Rule Fact Sheet (CMS-1828-F)
- CMS Transmittal MM14304 -- HH PPS CY 2026 Rate Update
- CMS Home Health PPS Regulations and Notices
- CMS Home Health Patient-Driven Groupings Model
- Federal Register: CY 2026 HH PPS Final Rule (2025-21767)
This article is for informational purposes and does not constitute legal or billing advice. Always consult your Medicare Administrative Contractor (MAC) for jurisdiction-specific guidance.
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