A comprehensive plan to modernize Idaho's nursing facility reimbursement system and unlock millions in federal funds
$259Current Medicaid Rate Per Day
45thNational Ranking (of 50 States)
$2.33Federal Return Per $1 State
$5.3MYear 1 Net State Cost
$32M+Federal Funds Generated
The Problem in Plain English: Idaho pays nursing facilities $259 per day to care for Medicaid residents - ranking 45th nationally. The actual cost of care exceeds $370 per day. Idaho's property reimbursement formula uses a $9.24/day base rate set in 1985 - 41 years ago. Meanwhile, Idaho leaves tens of millions in available federal matching funds unclaimed because our provider assessment is well below the federal safe harbor.
Why This Matters
Facilities Closing
Two facilities (157 beds) have closed since 2020. Good Samaritan Boise Village (127 beds, 2021) and Caribou Memorial (30 beds, 2021). More are at risk as margins compress toward zero.
Workers Leaving
CNAs earn $14-17/hour in nursing facilities while Walmart pays $15-19/hour. Idaho's 50.3% staff turnover rate is 9th highest nationally. We can't compete for caregivers.
Federal Dollars Lost
Idaho's 70.01% FMAP means every $1 invested generates $2.33 in federal funds. Our provider assessment at ~3.5% vs the 6% safe harbor leaves ~$45M/year unclaimed.
Residents at Risk
4,500+ Idaho residents depend on nursing facility care. When facilities close, elderly Idahoans must relocate - sometimes 50-100+ miles from family. Rural communities lose essential infrastructure.
Idaho Nursing Facility Sustainability & Quality Act - amending Title 56, Idaho Code (§56-260 through §56-274)
A
Modern Rate Enhancements Modernize the existing cost-based system with eight targeted enhancements. Replace the $9.24/day property base from 1985 with actual capital costs from audited cost reports.
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Eight Enhancements: (1) Assessment increase 3.5% to 5.5% - captures $28M+ in federal match. (2) Property formula modernization - replace 1985 base with actual capital costs, 75th percentile cap. (3) Rate floor - 95% of statewide median ($352/day). (4) Rural access supplement - +$10/day for counties under 50,000. (5) Sole community supplement - +$10/day. (6) High Medicaid supplement - +$5/day for 80%+ Medicaid census. (7) Quality incentive program - +$5 to +$35/day based on 100-point scorecard. (8) Rate cut protections - 180-day notice, impact study, JFAC review.
Model State: North Dakota ($586/day, cost-based, annual rebase)
B
Unlock Federal Funds Increase the provider assessment from ~3.5% to 5.5% (below the 6% federal safe harbor). Every $1 assessed generates $2.33 in federal matching funds.
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Current: ~3.5% of net patient revenue (~$28.5M/year). Proposed: 5.5% (~$40.7M/year). Still well below 6% federal safe harbor. Federal Return: $2.33 per $1 at 70.01% FMAP. Year 1: $32M+ in new federal funds. Not a tax on Idahoans - 47 of 50 states use this mechanism. Providers pay the assessment and receive back more through enhanced Medicaid rates.
Model State: Indiana (5.5% assessment, successful federal match optimization)
Tier 1 (90-100 points): $30/day bonus Tier 2 (80-89 points): $15/day bonus Below 80: No bonus (no penalty)
Model State: Colorado HB23-1228
D
Rate Floor & Protections No Medicaid rate below 90% of median documented cost. Comprehensive protections against mid-year rate cuts.
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Rate Floor: MAX(calculated rate, 90% × statewide median cost). Based on current data: ~$352/day minimum.
Mid-Year Cut Protections (all 5 required): 1. 180-day advance written notice 2. Access impact study published 3. 60-day public comment period 4. JFAC review and recommendation 5. Legislative leadership notification
Additional Hardening: Fund anti-raid (2/3 supermajority to redirect), assessment no-sunset, maintenance of effort, access monitoring triggers.
Model State: Colorado (rate floor + cut protections)
E
Workforce Pipeline Dedicated fund for CNA scholarships, wage pass-throughs, nurse loan repayment, and apprenticeships. Weighted toward rural areas.
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Funding: Workforce Development Fund from assessment revenue + federal match. NOT general fund. Year 1: $7.27M
Programs: • CNA training scholarships and certification costs • Wage pass-through requirements (funds must reach direct caregivers) • Nurse loan repayment (RN/LPN working in NFs) • Apprenticeship programs • Rural weighting (higher per-worker allocation for rural/frontier facilities)
Context: CNA wages in Idaho NFs: $14-17/hr. Walmart starting: $15-19/hr. 50.3% total staff turnover (9th highest nationally).
Model State: Montana (workforce fund, recent 33% rate increase)
F
Transparent Process Annual rate calendar published by January 1. Two public hearings, 60-day comment period, JFAC oversight, all data published online.
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Rate-Setting Calendar: Published by January 1 each year. No surprise rate changes. Public Input: Minimum 2 public hearings + 60-day written comment period before any rate change. JFAC Oversight: Joint Finance-Appropriations Committee reviews annually. Data Transparency: All rate methodology data, cost reports, and calculations published online. Annual Report: DHW publishes annual report on rate adequacy, quality outcomes, workforce trends, and federal fund utilization.
Context: Idaho recently cut NF rates on holiday weekends with no advance notice. This reform prevents that.
3-Year Phase-In
Phase 1: FY 2028
Assessment increases to 5.5%. Workforce fund launches. DHW develops methodology. SPA submitted to CMS. Interim rate increases.
Net State Cost: $5.3M
Phase 2: FY 2029
Enhanced rates go live. Budget Adjustment Factor eliminated. Property base modernized from $9.24. Geographic adjustments active.
Net State Cost: $14.6M
Phase 3: FY 2030
Quality scorecard published. Incentive payments begin. Full methodology operational. Acuity add-ons phased in.
Net State Cost: $26.7M
Fiscal Impact
FY 2028
FY 2029
FY 2030
Assessment Revenue
$40.7M
$41.5M
$42.3M
Federal Match
$32.0M
$54.0M
$82.0M
Total Program
$72.7M
$95.5M
$124.3M
Net State General Fund
$5.3M
$14.6M
$26.7M
Year 1 cost of $5.3M = $2.80 per Idaho resident per year. FY2026 Idaho General Fund surplus: $943M - this bill costs 0.56% of surplus.
Geographic Adjustments
1.00×Urban (≥50,000 pop)
+5%Rural (10K-49K pop)
+10%Frontier (<10K pop)
+5%Sole Community (additional)
Acuity Add-Ons (Phased In FY 2029-2031)
$35Bariatric Per Day
$30Behavioral Per Day
$50Complex Medical Per Day
$5Access Incentive Per Day
The Numbers That Matter
Data from CMS cost reports, Idaho DHW rate schedules, and CMS Care Compare July 2026
$9.24Property base rate set in 1985 - 41 years ago
69¢Of every $1 of cost covered by Medicaid
47States use provider assessment (Idaho leaves $ on table)
$2.33Federal return per $1 state investment
$2.80Cost per Idaho resident per year
CNA vs. Retail Wages
Idaho CNA Wages$14 - $17/hr
$14-17/hr
Walmart Starting Wage$15 - $19/hr
$15-19/hr
Cost of Care vs. Medicaid Rate
Actual Cost of Care (108-bed Urban SNF)$373/day
$373.21/day
Medicaid Reimbursement Rate$259/day
$259/day (69.4% of cost)
Reformed Rate (Rate Floor)$333/day
$333/day (+$74, +28.6%)
Real Facility Case Study
SNF 1 - 108-Bed Urban Facility
From verified CMS-2540-24 cost report (CY2025). Filed May 2026.
$373Total Cost Per Day
$259Medicaid Rate Per Day
69.4%Cost Coverage
+$1.39MAnnual Reform Benefit
Property Formula: Current property reimbursement = $9.24 × 3.2 × 0.25 = $7.39/day. Actual capital cost: $53.57/day. Formula covers just 13.8% of true capital costs. The $9.24 base hasn't changed since 1985.
Facilities Lost Since 2020
Good Samaritan Society - Boise Village
127 beds - Closed May 20, 2021. CMS terminated certification after persistent compliance failures. 64 years of service ended. Building converted to senior housing.
Caribou Memorial Living Center
~30 beds - Closed May 1, 2021, Soda Springs. Hospital subsidized $2M annual loss; Medicaid covered only 25% of costs. Nearest nursing facility now 30 miles away over a mountain pass.
Campaign Documents
Complete legislative package - ready for IHCA review and distribution
Legislative
Draft Bill Text
Complete 18-section legislative language for the Idaho NF Sustainability & Quality Act. Amends Title 56 (§56-260 through §56-274).
Subject: Support Idaho's Nursing Facility Sustainability Act
Dear [Legislator Name],
I am writing to ask for your support of the Idaho Nursing Facility Sustainability & Quality Act, legislation that will modernize how Idaho reimburses nursing facilities for Medicaid resident care.
THE PROBLEM: Idaho pays nursing facilities $259 per day - ranking 45th nationally. The actual cost of care exceeds $370 per day. Our property reimbursement formula uses a base rate of $9.24 per day, set in 1985 and never updated. Two facilities have already closed, eliminating 157 beds. Staff turnover exceeds 50% because CNAs earn less than retail workers.
THE SOLUTION: This bill implements a modern, transparent rate methodology aligned with federal standards. It increases the provider assessment from 3.5% to 5.5% - still well below the 6% federal safe harbor - which unlocks $32 million in new federal matching funds at a net state cost of just $5.3 million ($2.80 per Idaho resident per year).
THE OPPORTUNITY: Idaho's FMAP of 70.01% means every $1 invested generates $2.33 in federal funds. Forty-seven states already use this approach. Idaho is leaving tens of millions in federal healthcare dollars on the table while our nursing facilities struggle to keep their doors open.
I respectfully ask that you support this legislation to protect Idaho's most vulnerable residents, strengthen our healthcare workforce, and capture federal funds that Idaho is currently forfeiting.
Thank you for your service to Idaho.
Sincerely,
[Your Name]
[Your City, Idaho]
Email the Governor
Email Governor Brad Little
Subject: Idaho Nursing Facility Reform - $2.33 Federal Return on Investment
Dear Governor Little,
I am writing to bring your attention to the Idaho Nursing Facility Sustainability & Quality Act, a proposal to modernize nursing facility Medicaid reimbursement that aligns with your priorities of fiscal responsibility, rural community support, and federal fund maximization.
KEY FACTS:
- Idaho ranks 45th nationally in Medicaid nursing facility rates ($259/day)
- Idaho's 70.01% FMAP generates $2.33 in federal funds per $1 state investment
- Year 1 net state cost: $5.3 million ($2.80 per Idaho resident)
- Year 1 federal funds generated: $32 million+
- 47 of 50 states already use this provider assessment mechanism
This reform protects Idaho jobs (9,400+ healthcare workers), prevents rural facility closures, and captures federal dollars that Idaho is currently leaving unclaimed - all while maintaining fiscal discipline.
I ask for your support of this commonsense reform.
Respectfully,
[Your Name]
[Your City, Idaho]
Email DHW Director
Request a Meeting with the Department of Health & Welfare
Subject: Request for Meeting - NF Rate Reform Proposal
Dear Director,
On behalf of the Idaho Health Care Association, I am writing to request a meeting to discuss a collaborative proposal to modernize Idaho's nursing facility Medicaid reimbursement methodology.
We have developed a comprehensive reform framework - the Idaho Nursing Facility Sustainability & Quality Act - that addresses rate adequacy, quality incentives, workforce investment, and federal fund optimization. The proposal has been developed with careful attention to federal requirements, including State Plan Amendment compliance, UPL analysis, and tribal consultation needs.
We believe DHW's input is essential to developing effective implementation pathways and would welcome the opportunity to share our research, data, and proposed approach. We are prepared to provide complete cost report analyses, 50-state comparison data, and draft implementation timelines.
We are flexible on scheduling and happy to meet at your convenience anytime in September or October 2026.
Thank you for your consideration.
Sincerely,
Robert Vande Merwe
Executive Director
Idaho Health Care Association
(208) 343-9735
robert@idhca.org
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Letter Templates
Copy, customize, and send to your legislator.
Family Member Letter
Dear [Legislator Name],
My [mother/father/loved one] lives at [facility name] in [city], Idaho. Every day, the staff there provide essential care - helping with meals, medications, mobility, and dignity. I am grateful for their dedication.
But I am deeply concerned about the future of nursing facility care in Idaho. Idaho ranks 45th nationally in how much it pays facilities to care for Medicaid residents - just $259 per day, while the actual cost exceeds $370. Staff turnover is over 50% because caregivers can earn more at Walmart than caring for our parents and grandparents.
The Idaho Nursing Facility Sustainability & Quality Act would modernize reimbursement, invest in workforce training, and unlock $32 million in federal funds - at a cost of just $2.80 per Idaho resident per year. This isn't about profits. It's about whether my [loved one] will continue to have a safe, staffed place to live.
Please support this legislation. Our families are counting on you.
Sincerely,
[Your Name]
[City, Idaho]
CNA / Employee Letter
Dear [Legislator Name],
I am a [CNA/nurse/healthcare worker] at [facility name] in [city], Idaho. I chose this career because I care about our elderly residents. But I'm struggling.
I earn $[14-17] per hour. Walmart starts at $15-19. I work 12-hour shifts caring for people who depend on me for everything - and I can barely pay my bills. Many of my coworkers have left for retail jobs that pay more and demand less. We're constantly short-staffed, which means more work and less time with each resident.
This isn't just about wages. When we're short-staffed, residents wait longer for help. Falls increase. Care suffers. And it's getting worse - Idaho ranks 45th nationally in nursing facility Medicaid rates, and two facilities have already closed.
The Idaho Nursing Facility Sustainability & Quality Act includes a Workforce Development Fund for CNA training, scholarships, and wage improvements. It generates $32 million in federal funds at just $5.3 million in state cost. Please support this legislation - for healthcare workers and the residents we serve.
Sincerely,
[Your Name]
[Title, Facility Name]
Administrator Letter
Dear [Legislator Name],
As the administrator of [facility name] in [city], Idaho, I am writing to ask for your support of the Idaho Nursing Facility Sustainability & Quality Act.
Our facility cares for [X] residents, [Y]% of whom are on Medicaid. Idaho pays us $259 per day for their care. Our actual cost is over $[350-380] per day. We lose money on every Medicaid resident, every day.
Our property reimbursement is calculated using a $9.24 per day base rate set in 1985. Our actual building costs are [$40-55] per day. The formula covers less than 15% of our real capital expenses.
Staff turnover exceeds [X]% because we cannot compete with retail wages. We need [X] more RN hours per year to meet proposed federal staffing mandates - an additional $[X] in annual cost with no Medicaid offset.
This reform generates $32 million in federal funds, creates a quality incentive program, and invests in workforce development - all at $2.80 per Idaho resident per year. Please support this commonsense legislation.
Sincerely,
[Your Name]
Administrator, [Facility Name]
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Twitter/X
Idaho ranks 45th nationally in nursing facility Medicaid rates. $259/day vs $373 actual cost. CNAs earn less than Walmart workers. The Idaho NF Sustainability Act generates $32M in federal funds at $2.80/resident/year. Time for reform. #IDAleg #IdahoHealthcare
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Did you know Idaho's nursing facility property reimbursement rate is based on $9.24 per day - set in 1985? That's 41 years without an update.
Idaho ranks 45th nationally in Medicaid nursing facility rates. Two facilities have already closed. CNA wages can't compete with retail.
The Idaho Nursing Facility Sustainability & Quality Act would modernize reimbursement, generate $32 million in federal funds, and invest in our healthcare workforce - all at a cost of $2.80 per Idaho resident per year.
Learn more at ihcareform.org and contact your legislator today.
LinkedIn
Idaho's nursing facility Medicaid reimbursement system is in crisis. At $259/day (45th nationally), rates cover just 69% of the actual $373/day cost of care. The property formula uses a $9.24 base from 1985.
The Idaho Nursing Facility Sustainability & Quality Act proposes a modern, data-driven solution: an 8-enhancement rate reform package, quality incentive scorecard, and workforce development fund. Net state cost: $5.3M. Federal funds generated: $32M+. ROI: 233%.
47 states already use this approach. Idaho is leaving federal healthcare dollars on the table.
ihcareform.org
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