Skilled nursing Medicaid rates in Hawaii are among the highest published anywhere. Hawaii Med-QUEST lists $504.80 a day for a nursing home stay, effective July 1, 2026. Hawaii is not one of the 21 states in the daily-rate ranking, but that figure sits far above the national median of $282.59 and above every ranked state except New Mexico.
What makes Hawaii different is the layer on top of the per diem. Every year since at least 2023, CMS has approved a value-based directed payment for nursing facilities that flows through Hawaii's QUEST Integration managed-care plans. For an operator, the daily rate is only part of Medicaid revenue; the directed payment, tied to performance, is the other part.
The $504.80 figure is published without a billing code, as is common for facility per diems, and covers a full Medicaid resident day. The Hawaii Medicaid rates page shows it with its source document.
Against the ranked states, Hawaii's figure stands out:
| State | Daily figure |
|---|---|
| New Mexico | $826.00 |
| Hawaii (not ranked) | $504.80 |
| Colorado | $419.22 |
| Washington | $373.84 |
| National median | $282.59 |
| Arkansas | $70.00 |
Washington is a useful Pacific comparison: ranked 4th at $373.84, it is a high-paying state by national standards and still well below Hawaii's published figure.
Med-QUEST announces fee-for-service rates through numbered memos, labeled QI for QUEST Integration. For nursing facilities, three memos matter:
- QI-2532: Medicaid FFS rates for all nursing and hospice facilities effective January 1, 2026.
- QI-2614: Medicaid FFS rates effective July 1, 2026, with a 3.42% change.
- QI-2615: Medicaid FFS hospice inpatient nursing facility rates effective July 1, 2026, with a 0.42% change.
The pattern suggests two update points a year, in January and July, with the July 2026 memo carrying the current per diem. Operators should keep each memo on file, since the memo is the document that ties a rate to its effective date. A claim for a June 2026 day and a claim for a July 2026 day can carry different rates.
Hawaii's change record is a run of CMS approvals for the same program, a 438.6(c) preprint for nursing facilities. A 438.6(c) preprint is the federal approval document for a state directed payment, which requires managed-care plans to pay providers in a specified way.
- 2026: CMS approval of HI_VBP.Fee_NF_Renewal_20260101-20261231, approved February 4, 2026, effective January 1, 2026.
- 2025: CMS approval of HI_VBP.Fee_NF_Renewal_20250101-20251231, approved May 22, 2025.
- 2024: CMS approval of HI_VBP.Fee_NF_Renewal_20240101-20241231, approved January 11, 2024.
- 2023: CMS approval of HI-VBP-Fee-NF-Renewal-20230101-20231231, approved May 1, 2023.
- 2022: CMS approval of HI_Fee_NF.Oth_Amend_20220701-20221231, approved November 22, 2023, effective July 1, 2022.
The "VBP" in each preprint name marks it as value-based, and the program is named Hawaii QUEST Integration directed payments - nursing facilities. The payments are expressed as a percentage of average commercial rates, a common benchmark in directed payment programs.
The steady annual renewal is a signal operators can plan around, though each year still needs its own approval. The 2025 approval arrived in May, months into the year it covered, and the 2022 amendment was approved more than a year after its effective date. Payment timing can therefore lag the period the money covers.
That has practical consequences for finance teams:
- Book conservatively. Recognize directed payment revenue once the year's preprint is approved, not before.
- Plan cash flow. Expect directed payments to arrive in larger, less regular amounts than per diem payments.
- Track performance measures. Because the program is value-based, quality results affect what a facility receives.
The other item on file is SPA HI-23-0014, "Nursing Facility Payment Methodology Change," a public notice with an effective date of October 1, 2023. That is the most recent change to how the base per diem itself is calculated.
A methodology change can matter more than any single rate update, because it changes how every future rate is built. Operators should read the methodology alongside each new memo, so they understand which of their own costs and resident characteristics feed the rate.
Our data counts 9 plans in Hawaii, including AlohaCare, Hawaii Medical Service Association (HMSA), Kaiser Foundation Health Plan, UnitedHealthcare Community Plan and 'Ohana Health Plan. For nursing facilities, the managed-care rule is that the state sets the rate plans pay. Hospice follows the same rule.
So the structure has two parts. The base daily rate is state-set and flows through whichever plan a resident belongs to; the directed payment is layered on through the plans under the 438.6(c) approval. A facility does not negotiate its per diem plan by plan.
That combination is less common than it looks. In many states, plans either negotiate nursing facility rates or the state pays facilities directly, outside managed care. Hawaii keeps the rate under state control while routing payment, including the value-based add-on, through the plans. The Hawaii managed care page lists the plans and the directed payment programs.
Because the price is set by the state, a facility's relationship with each plan comes down to process.
Enrollment and authorization
Confirm each resident's plan at admission and at every eligibility renewal. The Community Care Services (CCS) program moves to AlohaCare effective November 1, 2026, under memo QI-2621 / CCS-2605, which is a reminder that plan assignments can change.
Claims
Track claim denials and payment times by plan. With identical rates, these are the measures that separate one plan from another.
Rate updates
After each memo, check that every plan has loaded the new rate. A plan still paying the January rate after July 1, 2026 owes the difference.
May 2025 federal occupational data puts Hawaii wages above the US median at all three nursing levels.
| Role | Hawaii | US median |
|---|---|---|
| Registered nurse | $65.54 | $46.90 |
| Licensed practical nurse | $34.20 | $30.96 |
| Nursing assistant (CNA) | $21.80 | $20.32 |
The registered nurse wage of $65.54 an hour is the outlier, far above the US median of $46.90. Nursing assistants, at $21.80, deliver most hands-on care and shape the bulk of direct care cost. The CNA and LPN premiums over the national median are modest compared with the RN premium.
That wage profile helps explain the high per diem. RN coverage is required and cannot be replaced with lower-cost staff, and in Hawaii each RN hour costs far more than the national median. A facility's other costs, from food and supplies to building upkeep, also have to fit inside the same daily rate.
Memo QI-2615 set hospice inpatient nursing facility rates effective July 1, 2026, with a 0.42% change, and memo QI-2532 covered both nursing and hospice facilities from January 1, 2026. Hospice and nursing facility payment meet whenever a resident elects hospice while living in a facility.
For a nursing home, that means two things. The hospice agreement should reflect current Med-QUEST rates, and billing staff should know which days are billed by the facility and which by the hospice. Because the state sets the rate plans pay for both lines, the numbers are predictable; the risk lies in coordination, not price.
Home and community-based services in Hawaii follow a different rule from nursing facilities: plans negotiate, and the published rate applies out of network. Med-QUEST also runs a community palliative care benefit and the Community Care Services program, along with health-related social needs services under the QUEST Integration section 1115 demonstration.
These programs shape who enters a nursing home. When more care is available at home, residents who need a facility tend to have higher needs, which raises the cost of each day. A facility planning staffing for the next few years should expect acuity to rise rather than fall.
For operators who compare markets, the Pacific states show how differently nursing home days are valued. Washington's ranked figure of $373.84 is high by national standards, and the Alaska skilled nursing page shows a published daily figure above every ranked state. The California skilled nursing page covers Medi-Cal's rate-group system. Hawaii sits between these markets, with a high base rate and a directed payment on top.
- Treat $504.80 as the base reference, then add the value-based directed payment when modeling Medicaid revenue.
- Confirm the current year's preprint approval before booking directed payment revenue.
- Bill by memo date, checking the July 1, 2026 effective date against each date of service.
- Monitor plan remittances after each memo, since every plan should pay the same state-set rate.
All 17,383 current Hawaii Medicaid rates, including the nursing facility memos and directed payment detail, are available with a MedicaidRate plan.
Rates on this page are compiled from official state Medicaid publications from Med-QUEST, including memo QI-2532 on nursing and hospice facility rates and memo QI-2614 on FFS rates effective July 1, 2026, and each rate links to its source document. Directed payment details come from CMS-approved 438.6(c) preprints. Wages are May 2025 federal occupational medians. The national skilled nursing overview compares all states, and the methodology explains why only 21 of 44 states can be ranked on a single figure.