Skilled nursing payer mix and occupancy by state

At the median US skilled nursing facility, Medicaid pays for about 62% of patient days and Medicare for about 7.5%, according to the cost reports in CMS’s newest skilled nursing file, which cover fiscal years ending August 2024 through August 2025. A Medicare day pays about $627 at the median facility, against about $351 of net revenue per day across all payers, so census that moves between payers moves revenue per day.

Where the days come from

The cost report counts patient days by program: Title XVIII for Medicare, Title XIX for Medicaid, and everything else together. Medians by state:

• Most Medicaid-heavy: West Virginia (82.9% of days), the District of Columbia (80.2%) and Mississippi (77.9%).
• Least Medicaid-heavy among states that report the column fully: Ohio (46.6%), Nebraska (50.1%) and Iowa (51.2%).
• Most Medicare days: California (15.0%), Maryland (13.7%) and New Jersey (13.5%).
• Fewest Medicare days: Iowa (4.8%), Colorado (4.9%) and Alabama (5.0%).

California and Vermont reports put few or no days in the Medicaid column, so their Medicaid share in this data is not comparable with other states. Their benchmark pages say so.

What a Medicare day is worth

The cost report also carries each facility’s Medicare prospective payment amount. Divided by its Medicare days, the median is about $627 a Medicare day nationally. The state medians run from about $507 in Mississippi to about $893 in California, which reflects wage index differences and the acuity of each state’s Medicare patients. The median facility’s net revenue across all payers is about $351 a day.

Moving five points of census from Medicaid to Medicare adds 5% of days times the gap between the two rates to average revenue per day. Losing Medicare referrals costs the same in reverse.

Occupancy

The median US facility filled 82.6% of its bed days, up from 80.0% in the prior year’s reports. State medians range from 94.6% in North Dakota to 61.7% in Oklahoma. Low state medians often say as much about licensed beds that are not staffed or not used as about demand, so compare your building with its own market as well.

Highest median occupancy		Lowest median occupancy
North Dakota	94.6%	Oklahoma	61.7%
West Virginia	93.8%	Oregon	63.6%
New York	92.5%	Texas	66.8%

Using this for a refinance or sale

Lenders underwrite the building’s own trailing census and payer mix, then ask whether it is sustainable against the market. A lender will ask why a building sits far above its state’s median occupancy or Medicare share, and what the plan is if it sits below. Check your numbers against your state’s benchmarks, then run them through the valuation calculator.