SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT CASE PAYMENT RATES ‐ EFFECTIVE 4/1/2014 ‐ 6/30/2014
NYSDOH
OPCERT
1623001
0101000
0101000
1624000
0701000
0501000
3801000
7002001
1427000
7001041
7002002
3535001
7000001
7001002
5123000
7001003
0601000
4102004
4429000
2238001
5263000
5401001
0901001
0824000
4401000
3421000
4720001
1001000
2625000
7001009
5001000
1101000
3301008
5127000
3101000
HOSPITAL NAME
ADIRONDACK MEDICAL CENTER
ALBANY MEDICAL CTR HOSP
ALBANY MEDICAL CTR SO CLINICAL
ALICE HYDE MEDICAL CENTER
ARNOT OGDEN MEDICAL CTR
AUBURN COMMUNITY HOSPITAL
AURELIA OSBORN FOX MEM HOSP
BELLEVUE HOSPITAL CENTER
BERTRAND CHAFFEE HOSPITAL
BETH ISRAEL / KINGS HIGHWAY
BETH ISRAEL MEDICAL CENTER
BON SECOURS COMMUNITY HOSP
BRONX‐LEBANON HOSPITAL CTR
BROOKDALE HOSPITAL MED CTR
BROOKHAVEN MEMORIAL HOSP
BROOKLYN HOSPITAL
BROOKS MEMORIAL HOSPITAL
BURDETT CARE CENTER
CANTON‐POTSDAM HOSPITAL
CARTHAGE AREA HOSPITAL INC
CATSKILL REGIONAL MED CTR
CAYUGA MEDICAL CENTER
CHAMPLAIN VALLEY PHYS
CHENANGO MEMORIAL HOSP
CLAXTON‐HEPBURN MED CTR
CLIFTON SPRINGS HOSPITAL
COBLESKILL REGIONAL HOSP
COLUMBIA MEMORIAL HOSPITAL
COMMUNITY MEMORIAL HOSPITAL
CONEY ISLAND HOSPITAL
CORNING HOSPITAL
CORTLAND REGIONAL MED CTR
CROUSE HOSPITAL
EASTERN LONG ISLAND HOSPITAL
EASTERN NIAGARA HOSPITAL
(1)
(2)
(3)
(4)
(5)
(6)
(7)
DISCHARGE RATES
"DEFAULT & CONTRACT" DISCHARGE CASE PAYMENT RATE (INCLUDING PHL § 2807‐c(33) ‐
Excluding IME)
STATEWIDE PRICE ‐
MA HMO
ISAF
HIGH COST CC's
IME %'s
DME RATE
CAPITAL RATE ‐
PER DISCH
$5,572.95
$5,870.82
$5,870.82
$5,455.16
$5,475.10
$5,858.71
$5,391.06
$6,927.93
$4,715.97
$7,951.26
$7,653.50
$6,078.73
$7,164.51
$7,117.13
$6,774.84
$6,965.32
$4,959.41
$5,429.95
$5,360.38
$4,902.14
$6,234.19
$5,992.05
$5,714.23
$5,171.09
$5,091.67
$4,444.27
$5,192.98
$5,453.86
$5,458.92
$6,858.28
$5,978.54
$5,413.12
$6,408.04
$6,758.78
$5,441.97
CAPITAL PER *Informational *Informational Only* DISCHARGE Only* "DEFAULT & INSTITUTION (EXCLUDING DIRECT INDIRECT CONTRACT" SPECIFIC HIGH COST NON‐
MEDICAL MEDICAL STATEWIDE BASE ADJUSTMENT CHARGE COMPARABLE EDUCATION PRICE (INCLUDING FACTOR CONVERTOR EDUCATION ADD‐ONS)
(DME) ADD‐ON
(IME) %
PHL § 2807‐c(33))
(ISAF)
(2011)
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
0.8232
0.8689
0.8689
0.8048
0.8033
0.8622
0.7930
1.0233
0.6991
1.1652
1.1304
0.9175
1.0648
1.0476
1.0183
1.0296
0.7324
0.7951
0.7934
0.7348
0.9149
0.8812
0.8403
0.7620
0.7692
0.6948
0.7604
0.8205
0.8044
1.0110
0.8778
0.8030
0.9458
0.9904
0.8083
0.550690
0.329874
0.329874
0.595070
0.441410
0.445645
0.645624
0.773995
0.597355
0.183347
0.308539
0.272206
0.862280
0.490403
0.193638
0.455530
0.678877
0.707292
0.571952
0.581448
0.385795
0.748430
0.410036
0.470507
0.611839
0.542357
1.064008
0.428438
0.577756
0.749279
0.433032
0.650282
0.488251
0.227798
0.548871
0.00%
19.41%
19.41%
0.00%
0.00%
0.00%
0.00%
26.17%
0.00%
0.20%
24.35%
0.00%
27.13%
20.83%
1.87%
20.55%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
16.91%
0.00%
0.00%
5.23%
0.00%
0.00%
1 of 5
$0.00
$591.51
$591.51
$0.00
$0.00
$0.00
$0.00
$2,425.49
$0.00
$608.61
$1,139.90
$0.00
$2,011.28
$1,318.01
$0.00
$611.53
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,175.65
$0.00
$0.00
$128.81
$0.00
$0.00
**(PER DISCH)**
$443.18
$1,453.45
$1,453.45
$138.50
$316.45
$527.41
$411.08
$744.69
$218.27
$192.97
$788.55
$498.01
$523.27
$435.37
$431.25
$435.05
$208.35
$146.09
$314.35
$280.45
$600.16
$433.78
$1,009.16
$248.49
$485.05
$318.70
$317.35
$419.87
$257.84
$908.38
$383.83
$493.09
$456.67
$654.82
$173.84
(8)
(9)
(10)
(11)
(12)
(13)
CAPITAL RATE ‐
PER DIEM
STERILIZATION
ALC
STERILIZATION DURING DELIVERY TEACHING (MANAGED ELECTION CARE AMENDMENT SCHOOL OF ENROLLEES OF AMBULANCE PHYSICIANS NURSING CAPITAL PER FIDELIS CARE ALC PRICE ADD‐ON
ADD‐ON
ADD‐ON
DIEM
ONLY)
PER DAY
NON‐COMPARABLE ADD‐ONS
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$11.35
$0.00
$0.00
$0.00
$0.00
$0.00
$56.84
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$456.66
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$40.00
$0.00
$0.00
$0.00
$0.00
$0.00
$78.91
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$86.18
$0.00
$0.00
**(PER DAY**)
$108.24
$248.40
$248.40
$41.80
$80.14
$124.54
$88.92
$126.93
$48.05
$31.03
$175.26
$112.50
$121.06
$80.00
$72.95
$84.42
$51.59
$63.81
$103.59
$78.67
$126.53
$114.49
$179.33
$77.68
$100.07
$78.22
$30.36
$97.60
$86.24
$151.79
$109.67
$74.58
$96.26
$156.18
$37.06
(2290)
$769.37
$810.50
$810.50
$753.11
$755.86
$808.82
$744.26
$956.43
$651.06
$1,097.71
$1,056.60
$839.20
$989.10
$982.55
$935.30
$961.60
$684.67
$749.63
$740.03
$676.76
$860.66
$827.23
$788.88
$713.89
$702.93
$613.55
$716.92
$752.93
$753.63
$946.82
$825.37
$747.31
$884.66
$933.08
$751.29
$171.74
$171.74
$171.74
$171.74
$171.74
$171.74
$171.74
$261.20
$171.74
$261.20
$261.20
$171.74
$261.20
$261.20
$261.20
$261.20
$171.74
$171.74
$171.74
$171.74
$171.74
$171.74
$171.74
$171.74
$171.74
$171.74
$171.74
$171.74
$171.74
$261.20
$171.74
$171.74
$171.74
$261.20
$171.74
(14)
HCRA SURCHARGE
INDIGENT CARE AND HEALTH CARE INITIATIVE SURCHARGE
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT CASE PAYMENT RATES ‐ EFFECTIVE 4/1/2014 ‐ 6/30/2014
NYSDOH
OPCERT
4601001
7003000
1401005
3429000
3202003
7003001
7003013
2910000
3402000
2901000
5601000
4329000
5154001
7002009
HOSPITAL NAME
ELLIS HOSPITAL
ELMHURST HOSPITAL CTR
ERIE COUNTY MEDICAL CENTER
F F THOMPSON HOSPITAL
FAXTON‐ST LUKES HEALTHCARE
FLUSHING HOSPITAL
FOREST HILLS HOSPITAL
FRANKLIN HOSPITAL
GENEVA GENERAL HOSPITAL
GLEN COVE HOSPITAL
GLENS FALLS HOSPITAL
GOOD SAMARITAN / SUFFERN
GOOD SAMARITAN / WEST ISLIP
HARLEM HOSPITAL CENTER
5501001 HEALTHALLIANCE HOSP BROADWAY CAMPUS
5501000 HEALTHALLIANCE HOSP MARYS AVE CAMPUS
2701001
7002012
5901000
5153000
7001046
5022000
7000002
7003003
5149000
0228000
1401014
1401014
1401002
1404000
7001016
7001033
5922000
HIGHLAND HOSP OF ROCHESTER
HOSPITAL FOR SPECIAL SURGERY
HUDSON VALLEY HOSPITAL CTR
HUNTINGTON HOSPITAL
INTERFAITH MEDICAL CENTER
IRA DAVENPORT MEMORIAL HOSP
JACOBI MEDICAL CENTER
JAMAICA HOSPITAL
JOHN T MATHER MEMORIAL HOSP
JONES MEMORIAL HOSPITAL
KALEIDA HEALTH
KALEIDA HEALTH (MILLARD)
KALEIDA HLTH/WOMAN&CHILDRENS
KENMORE MERCY HOSPITAL
KINGS COUNTY HOSPITAL CENTER
KINGSBROOK JEWISH MED CTR
LAWRENCE HOSPITAL
(1)
(2)
(3)
(4)
(5)
(6)
(7)
DISCHARGE RATES
"DEFAULT & CONTRACT" DISCHARGE CASE PAYMENT RATE (INCLUDING PHL § 2807‐c(33) ‐
Excluding IME)
STATEWIDE PRICE ‐
MA HMO
ISAF
HIGH COST CC's
IME %'s
DME RATE
CAPITAL RATE ‐
PER DISCH
CAPITAL PER *Informational *Informational Only* DISCHARGE Only* "DEFAULT & INSTITUTION (EXCLUDING DIRECT INDIRECT CONTRACT" SPECIFIC HIGH COST NON‐
MEDICAL MEDICAL STATEWIDE BASE ADJUSTMENT CHARGE COMPARABLE EDUCATION PRICE (INCLUDING FACTOR CONVERTOR EDUCATION ADD‐ONS)
(DME) ADD‐ON
(IME) %
PHL § 2807‐c(33))
(ISAF)
(2011)
(8)
(9)
(10)
(11)
(12)
(13)
CAPITAL RATE ‐
PER DIEM
STERILIZATION
ALC
STERILIZATION DURING DELIVERY TEACHING (MANAGED ELECTION CARE AMENDMENT SCHOOL OF ENROLLEES OF AMBULANCE PHYSICIANS NURSING CAPITAL PER FIDELIS CARE ALC PRICE ADD‐ON
ADD‐ON
ADD‐ON
DIEM
ONLY)
PER DAY
NON‐COMPARABLE ADD‐ONS
(14)
HCRA SURCHARGE
INDIGENT CARE AND HEALTH CARE INITIATIVE SURCHARGE
$5,737.27
$7,313.10
$6,182.69
$4,719.04
$5,611.88
$7,014.71
$7,688.43
$6,712.49
$4,966.31
$7,703.20
$5,539.65
$6,953.64
$6,840.74
$7,109.18
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
0.8401
1.0763
0.9218
0.7053
0.8308
1.0332
1.1309
0.9829
0.7297
1.1288
0.8148
1.0239
1.0148
1.0509
0.280787
0.679995
0.548935
0.585654
0.401787
0.500323
0.314304
0.279524
0.568222
0.303907
0.456191
0.220855
0.225889
1.037858
5.19%
22.43%
21.68%
0.00%
0.66%
17.85%
7.13%
1.40%
0.00%
4.10%
0.00%
0.00%
5.49%
31.20%
$154.39
$1,218.67
$547.75
$0.00
$0.13
$658.46
$124.15
$206.33
$0.00
$130.56
$0.00
$0.00
$212.39
$2,721.29
**(PER DISCH)**
$311.13
$565.01
$795.96
$515.20
$448.43
$412.41
$323.53
$383.69
$373.13
$550.17
$493.60
$501.06
$397.59
$1,185.63
$0.00
$0.00
$0.00
$0.00
$0.00
$308.06
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$28.92
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$45.07
$0.00
$0.00
$0.00
$0.00
$16.07
**(PER DAY**)
$68.49
$128.52
$128.62
$135.06
$99.52
$77.67
$75.51
$69.63
$93.03
$105.28
$106.56
$126.25
$80.43
$236.77
(2290)
$792.06
$1,009.61
$853.55
$651.49
$774.75
$968.42
$1,061.43
$926.69
$685.62
$1,063.46
$764.78
$959.98
$944.40
$981.46
$171.74
$261.20
$171.74
$171.74
$171.74
$261.20
$261.20
$261.20
$171.74
$261.20
$171.74
$261.20
$261.20
$261.20
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
$5,957.16
$6,829.27
0.8734
0.255361
5.30%
$219.93
$290.84
$0.00
$0.00
$0.00
$62.80
$822.42
$171.74
7.04%
$5,845.26
$5,850.00
$7,988.87
$6,496.49
$7,089.83
$7,137.71
$5,068.22
$7,538.87
$7,635.40
$6,989.01
$5,041.01
$6,249.29
$6,249.29
$6,192.38
$5,588.74
$6,905.02
$7,745.75
$6,789.42
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
0.8726
0.8599
1.1809
0.9564
1.0624
1.0538
0.7532
1.1093
1.1241
1.0286
0.7428
0.9274
0.9274
0.9147
0.8193
1.0145
1.1482
0.9974
0.343464
0.591136
0.391481
0.282930
0.320920
0.292808
0.522758
0.859302
0.454197
0.294673
0.535979
0.427742
0.427742
0.440617
0.451042
0.974490
0.293080
0.348137
2.09%
10.42%
20.75%
0.00%
0.76%
31.03%
0.00%
27.30%
16.18%
0.00%
0.00%
12.35%
12.35%
26.52%
0.00%
33.45%
14.58%
0.00%
$81.52
$103.08
$1,544.31
$0.00
$12.07
$873.56
$0.00
$1,983.37
$693.84
$0.00
$0.00
$301.05
$301.05
$359.21
$0.00
$2,408.63
$1,083.10
$0.00
$857.05
$410.25
$1,655.82
$786.78
$381.36
$472.87
$382.98
$894.10
$204.31
$582.61
$342.08
$853.84
$853.84
$294.65
$406.67
$919.23
$454.78
$486.61
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$329.15
$0.00
$0.00
$0.00
$0.00
$0.00
$90.35
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$338.52
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$460.72
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$160.50
$108.26
$435.16
$170.18
$86.64
$84.58
$111.86
$182.93
$48.33
$104.81
$106.53
$154.10
$154.10
$64.98
$100.35
$172.48
$82.26
$100.53
$806.97
$807.62
$1,102.90
$896.87
$978.79
$985.40
$699.69
$1,040.78
$1,054.10
$964.87
$695.94
$862.75
$862.75
$854.89
$771.55
$953.27
$1,069.34
$937.31
$171.74
$171.74
$261.20
$261.20
$261.20
$261.20
$171.74
$261.20
$261.20
$261.20
$171.74
$171.74
$171.74
$171.74
$171.74
$261.20
$261.20
$261.20
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
2 of 5
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT CASE PAYMENT RATES ‐ EFFECTIVE 4/1/2014 ‐ 6/30/2014
NYSDOH
OPCERT
7002017
2424000
7000008
2902000
7003004
7001019
7001020
3824000
4402000
3622000
0101003
1401008
2909000
7002021
7000006
5903001
5904001
7003015
7002024
3121001
2950002
1701000
7002000
3102000
2527000
7000024
2951001
1327000
5920000
7001008
7002026
7003010
7001021
7002054
7002054
HOSPITAL NAME
LENOX HILL HOSPITAL
LEWIS COUNTY GENERAL HOSP
LINCOLN MEDICAL
LONG BEACH MEDICAL CENTER
LONG ISLAND JEWISH
LUTHERAN MEDICAL CENTER
MAIMONIDES MEDICAL CENTER
MARY IMOGENE BASSETT HOSP
MASSENA MEMORIAL HOSPITAL
MEDINA MEMORIAL HOSPITAL
MEMORIAL HOSP OF ALBANY
MERCY HOSPITAL OF BUFFALO
MERCY MEDICAL CENTER
METROPOLITAN HOSPITAL CENTER
MONTEFIORE MEDICAL CENTER
MONTEFIORE MOUNT VERNON HOSP
MONTEFIORE NEW ROCHELLE HOSP
MOUNT SINAI HOSP OF QUEENS
MOUNT SINAI HOSPITAL
MOUNT ST MARYS HOSPITAL
NASSAU UNIV MED CTR
NATHAN LITTAUER HOSPITAL
NEW YORK DOWNTOWN HOSP
NIAGARA FALLS MEMORIAL
NICHOLAS H NOYES MEMORIAL
NORTH CENTRAL BRONX HOSPITAL
NORTH SHORE UNIVERSITY HOSP
NORTHERN DUTCHESS HOSPITAL
NORTHERN WESTCHESTER HOSP
NY COMMUNITY / BROOKLYN
NY EYE AND EAR INFIRMARY
NY MED CTR OF QUEENS
NY METHODIST HOSP / BROOKLYN
NY PRESBYTERIAN HOSPITAL
NY PRESBYTERIAN HOSPITAL (ALLEN)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
DISCHARGE RATES
"DEFAULT & CONTRACT" DISCHARGE CASE PAYMENT RATE (INCLUDING PHL § 2807‐c(33) ‐
Excluding IME)
STATEWIDE PRICE ‐
MA HMO
ISAF
HIGH COST CC's
IME %'s
DME RATE
CAPITAL RATE ‐
PER DISCH
$6,987.73
$5,526.23
$6,980.64
$6,083.33
$7,335.25
$6,883.75
$8,129.56
$5,088.32
$5,484.38
$4,417.85
$5,367.72
$5,848.07
$6,851.65
$6,885.69
$7,589.13
$7,123.95
$6,969.64
$7,547.00
$7,547.00
$5,795.27
$7,605.48
$5,269.89
$7,124.02
$5,233.57
$4,951.73
$7,628.03
$7,866.85
$6,492.55
$6,874.11
$7,599.61
$6,933.83
$7,399.95
$7,202.89
$7,592.51
$7,592.51
CAPITAL PER *Informational *Informational Only* DISCHARGE Only* "DEFAULT & INSTITUTION (EXCLUDING DIRECT INDIRECT CONTRACT" SPECIFIC HIGH COST NON‐
MEDICAL MEDICAL STATEWIDE BASE ADJUSTMENT CHARGE COMPARABLE EDUCATION PRICE (INCLUDING FACTOR CONVERTOR EDUCATION ADD‐ONS)
(DME) ADD‐ON
(IME) %
PHL § 2807‐c(33))
(ISAF)
(2011)
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
1.0407
0.8163
1.0321
0.9032
1.0882
1.0172
1.1904
0.7538
0.8040
0.6469
0.8062
0.8840
1.0167
1.0211
1.1229
1.0550
1.0294
1.1206
1.1206
0.8495
1.1324
0.7774
1.0608
0.7768
0.7411
1.1408
1.1617
0.9546
1.0116
1.1128
1.0217
1.0990
1.0683
1.1184
1.1184
0.247374
0.779088
0.946222
0.308383
0.262745
0.510266
0.286038
0.473270
0.651479
0.658814
0.444638
0.464171
0.286411
0.874182
0.272430
0.539888
0.528855
0.417467
0.382416
0.587047
0.501971
0.439216
0.586127
0.545618
0.442823
0.741199
0.254440
0.366251
0.509174
0.517469
0.444781
0.404466
0.445267
0.357925
0.357925
15.32%
0.00%
24.42%
11.04%
29.02%
24.00%
23.15%
12.95%
0.00%
0.00%
0.00%
3.01%
0.30%
27.91%
28.96%
9.54%
10.85%
32.88%
32.88%
0.00%
21.68%
0.00%
18.06%
4.15%
0.00%
12.87%
16.19%
0.00%
0.00%
0.00%
16.08%
16.54%
16.78%
27.06%
27.06%
3 of 5
$1,063.05
$0.00
$1,164.62
$420.24
$1,031.21
$956.70
$1,010.91
$353.17
$0.00
$0.00
$0.00
$44.23
$55.78
$1,897.21
$2,362.58
$978.81
$628.88
$1,243.60
$1,243.60
$0.00
$834.88
$0.00
$665.85
$78.96
$0.00
$1,258.85
$1,202.02
$0.00
$0.00
$0.00
$2,244.99
$738.30
$779.41
$1,344.29
$1,344.29
**(PER DISCH)**
$1,033.34
$433.07
$464.97
$525.41
$794.22
$269.29
$830.31
$515.45
$405.67
$104.25
$378.11
$426.01
$497.33
$248.61
$730.99
$305.71
$476.72
$488.19
$717.34
$231.67
$392.05
$237.61
$1,184.64
$464.64
$412.98
$531.27
$694.59
$369.20
$709.35
$345.85
$606.90
$813.36
$306.78
$1,184.64
$1,184.64
(8)
(9)
(10)
(11)
(12)
(13)
CAPITAL RATE ‐
PER DIEM
STERILIZATION
ALC
STERILIZATION DURING DELIVERY TEACHING (MANAGED ELECTION CARE AMENDMENT SCHOOL OF ENROLLEES OF AMBULANCE PHYSICIANS NURSING CAPITAL PER FIDELIS CARE ALC PRICE ADD‐ON
ADD‐ON
ADD‐ON
DIEM
ONLY)
PER DAY
NON‐COMPARABLE ADD‐ONS
$209.96
$0.00
$0.00
$0.00
$0.00
$203.36
$116.44
$0.00
$0.00
$0.00
$0.00
$21.60
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$109.11
$0.00
$166.72
$0.00
$0.00
$0.00
$411.20
$0.00
$0.00
$0.00
$0.00
$171.83
$0.00
$258.17
$258.17
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$267.66
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$144.18
$0.00
$0.00
$0.00
$0.00
$342.60
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
**(PER DAY**)
$233.59
$134.28
$122.65
$83.74
$169.60
$62.17
$178.42
$106.49
$102.81
$21.37
$83.24
$97.84
$92.96
$73.29
$125.68
$54.50
$109.01
$81.23
$145.79
$53.88
$87.78
$69.58
$215.72
$128.07
$120.79
$125.36
$133.04
$104.84
$181.01
$58.29
$320.48
$151.64
$63.73
$215.72
$215.72
(2290)
$964.69
$762.92
$963.71
$839.83
$1,012.67
$950.34
$1,122.33
$702.47
$757.15
$609.91
$741.04
$807.35
$945.90
$950.60
$1,047.72
$983.50
$962.19
$1,041.90
$1,041.90
$800.07
$1,049.97
$727.53
$983.51
$722.52
$683.61
$1,053.09
$1,086.06
$896.33
$949.00
$1,049.16
$957.25
$1,021.60
$994.39
$1,048.18
$1,048.18
$261.20
$171.74
$261.20
$261.20
$261.20
$261.20
$261.20
$171.74
$171.74
$171.74
$171.74
$171.74
$261.20
$261.20
$261.20
$261.20
$261.20
$261.20
$261.20
$171.74
$261.20
$171.74
$261.20
$171.74
$171.74
$261.20
$261.20
$171.74
$261.20
$261.20
$261.20
$261.20
$261.20
$261.20
$261.20
(14)
HCRA SURCHARGE
INDIGENT CARE AND HEALTH CARE INITIATIVE SURCHARGE
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT CASE PAYMENT RATES ‐ EFFECTIVE 4/1/2014 ‐ 6/30/2014
NYSDOH
OPCERT
HOSPITAL NAME
7002054 NY PRESBYTERIAN HOSPITAL (PRESBY)
4324000 NYACK HOSPITAL
7002053 NYU HOSPITALS CENTER
7002053 NYU HOSPITALS CENTER/HOSP FOR JOINT DIS
0401001
2601001
3523000
3702000
0301001
5155000
5932000
2952005
3950000
7003007
7004010
2701003
3201002
4102002
2201000
4501000
4102003
1401013
2950001
5126000
5154000
3529000
7000014
5157003
5149001
3202002
1302000
2953000
5002001
7001024
OLEAN GENERAL HOSPITAL
ONEIDA HEALTHCARE
ORANGE REGIONAL MED CTR
OSWEGO HOSPITAL
OUR LADY OF LOURDES MEMORIAL
PECONIC BAY MED CTR
PHELPS MEMORIAL HOSP
PLAINVIEW HOSPITAL
PUTNAM COMMUNITY HOSPITAL
QUEENS HOSPITAL CENTER
RICHMOND UNIV MED CTR
ROCHESTER GENERAL HOSPITAL
ROME HOSPITAL AND MURPHY
SAMARITAN HOSPITAL OF TROY
SAMARITAN MEDICAL CENTER
SARATOGA HOSPITAL
SETON HEALTH SYSTEMS
SISTERS OF CHARITY HOSPITAL
SOUTH NASSAU COMMUNITIES
SOUTHAMPTON HOSPITAL
SOUTHSIDE HOSPITAL
ST ANTHONY COMMUNITY HOSP
ST BARNABAS HOSPITAL
ST CATHERINE OF SIENA
ST CHARLES HOSPITAL
ST ELIZABETH MEDICAL CENTER
ST FRANCIS HOSP / POUGH
ST FRANCIS HOSP / ROSLYN
ST JAMES MERCY HOSPITAL
ST JOHNS EPISCOPAL SO SHORE
(1)
(2)
(3)
(4)
(5)
(6)
(7)
DISCHARGE RATES
"DEFAULT & CONTRACT" DISCHARGE CASE PAYMENT RATE (INCLUDING PHL § 2807‐c(33) ‐
Excluding IME)
STATEWIDE PRICE ‐
MA HMO
ISAF
HIGH COST CC's
IME %'s
DME RATE
CAPITAL RATE ‐
PER DISCH
CAPITAL PER *Informational *Informational Only* DISCHARGE Only* "DEFAULT & INSTITUTION (EXCLUDING DIRECT INDIRECT CONTRACT" SPECIFIC HIGH COST NON‐
MEDICAL MEDICAL STATEWIDE BASE ADJUSTMENT CHARGE COMPARABLE EDUCATION PRICE (INCLUDING FACTOR CONVERTOR EDUCATION ADD‐ONS)
(DME) ADD‐ON
(IME) %
PHL § 2807‐c(33))
(ISAF)
(2011)
(8)
(9)
(10)
(11)
(12)
(13)
CAPITAL RATE ‐
PER DIEM
STERILIZATION
ALC
STERILIZATION DURING DELIVERY TEACHING (MANAGED ELECTION CARE AMENDMENT SCHOOL OF ENROLLEES OF AMBULANCE PHYSICIANS NURSING CAPITAL PER FIDELIS CARE ALC PRICE ADD‐ON
ADD‐ON
ADD‐ON
DIEM
ONLY)
PER DAY
NON‐COMPARABLE ADD‐ONS
(14)
HCRA SURCHARGE
INDIGENT CARE AND HEALTH CARE INITIATIVE SURCHARGE
$7,592.51
$6,572.37
$7,250.51
$6,829.27
$6,829.27
$6,829.27
1.1184
0.9750
1.0701
0.357925
0.221363
0.313593
27.06%
0.00%
19.78%
$1,344.29
$0.00
$1,818.53
**(PER DISCH)**
$1,184.64
$320.93
$2,133.71
$258.17
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
**(PER DAY**)
$215.72
$69.95
$488.02
(2290)
$1,048.18
$907.35
$1,000.97
$261.20
$261.20
$261.20
7.04%
7.04%
7.04%
$7,250.51
$5,129.86
$4,876.31
$6,753.55
$5,593.57
$5,447.70
$6,785.72
$6,713.36
$7,436.38
$6,934.15
$7,695.41
$6,763.72
$5,738.58
$5,251.01
$5,417.94
$5,726.17
$5,614.12
$5,333.79
$5,610.66
$6,539.51
$6,807.82
$7,051.91
$6,174.66
$6,888.42
$7,034.07
$6,575.60
$5,685.31
$5,895.89
$7,277.27
$4,405.40
$8,052.04
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
$6,829.27
1.0701
0.7681
0.7242
0.9958
0.8229
0.8047
1.0002
1.0000
1.1043
1.0257
1.1398
0.9998
0.8491
0.7707
0.7951
0.8444
0.8322
0.8048
0.8265
0.9632
1.0076
1.0468
0.9563
1.0267
1.0579
0.9651
0.8391
0.8640
1.0656
0.6610
1.1937
0.313593
0.594815
0.483423
0.286532
0.542099
0.477509
0.272183
0.364645
0.322045
0.322545
0.797790
0.309371
0.436120
0.454182
0.398224
0.552261
0.393532
0.356760
0.468307
0.303927
0.337423
0.321029
0.277194
0.300863
0.233955
0.262866
0.447837
0.254641
0.264425
0.470863
0.388042
19.78%
0.00%
0.00%
0.00%
0.00%
2.17%
0.00%
6.37%
4.08%
0.00%
17.94%
15.31%
10.08%
0.00%
0.00%
0.96%
0.00%
0.00%
4.24%
3.42%
4.35%
4.78%
0.00%
26.30%
0.00%
0.92%
5.73%
0.00%
0.52%
0.00%
25.33%
$1,818.53
$0.00
$0.00
$0.00
$0.00
$5.14
$0.00
$76.96
$149.59
$0.00
$1,015.88
$453.87
$210.18
$0.00
$0.00
$24.42
$0.00
$0.00
$133.88
$106.37
$0.00
$145.78
$0.00
$1,041.00
$0.00
$77.23
$117.46
$0.00
$189.78
$0.00
$738.37
$2,133.71
$527.41
$534.54
$1,187.77
$652.26
$300.04
$525.76
$774.54
$307.28
$608.72
$734.32
$359.20
$671.78
$320.40
$293.67
$453.72
$422.12
$388.48
$336.96
$615.19
$735.21
$512.80
$541.29
$471.48
$497.91
$472.04
$475.22
$998.22
$1,489.00
$173.43
$262.87
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$318.78
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$36.77
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$242.94
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$22.03
$6.22
$0.00
$49.98
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$162.13
$0.00
$0.00
$0.00
$0.00
$488.02
$98.91
$147.94
$280.18
$160.30
$72.09
$117.49
$179.72
$62.48
$139.38
$152.40
$72.86
$135.43
$78.21
$68.04
$117.16
$80.04
$80.19
$75.00
$119.17
$200.71
$119.98
$128.10
$96.28
$99.83
$105.85
$92.64
$183.70
$245.76
$59.59
$48.57
$1,000.97
$708.20
$673.20
$932.36
$772.22
$752.08
$936.80
$926.81
$1,026.63
$957.29
$1,062.39
$933.76
$792.24
$724.93
$747.97
$790.53
$775.06
$736.36
$774.58
$902.81
$939.85
$973.55
$852.44
$950.98
$971.09
$907.79
$784.88
$813.96
$1,004.66
$608.19
$1,111.62
$261.20
$171.74
$171.74
$171.74
$171.74
$171.74
$261.20
$261.20
$261.20
$171.74
$261.20
$261.20
$171.74
$171.74
$171.74
$171.74
$171.74
$171.74
$171.74
$261.20
$261.20
$261.20
$171.74
$261.20
$261.20
$261.20
$171.74
$171.74
$261.20
$171.74
$261.20
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
4 of 5
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT CASE PAYMENT RATES ‐ EFFECTIVE 4/1/2014 ‐ 6/30/2014
NYSDOH
OPCERT
5907001
2952006
0701001
3301003
5907002
7002032
3522000
2801001
0101004
7001037
7004003
2701005
7001037
2754001
0427000
1227001
0303001
1801000
5151001
3301007
3301007
1302001
5820000
5957001
0632000
5902001
2908000
0602001
7001045
7001035
6027000
HOSPITAL NAME
ST JOHNS RIVERSIDE HOSPITAL
ST JOSEPH HOSPITAL
ST JOSEPHS HOSP / ELMIRA
ST JOSEPHS HOSP HLTH CTR
ST JOSEPHS MEDICAL CENTER
ST LUKES / ROOSEVELT HOSP
ST LUKES CORNWALL
ST MARYS HEALTHCARE
ST PETERS HOSPITAL
STATE UNIV HOSP / DOWNSTATE
STATEN ISLAND UNIV HOSP
STRONG MEMORIAL HOSPITAL
SUNY DOWNSTATE MED CTRAT LICH
THE UNITY HOSPITAL
TLC HEALTH NETWORK
TRI‐TOWN REGIONAL HEALTHCARE
UNITED HEALTH SERVICES INC
UNITED MEMORIAL MED CTR
UNIV HOSP AT STONY BROOK
UNIV HOSP SUNY HLTH SCI CTR
UPSTATE UNIV HOSPITAL AT COMM GEN
VASSAR BROTHERS MED CTR
WAYNE HEALTH CARE
WESTCHESTER MEDICAL CENTER
WESTFIELD MEMORIAL HOSP
WHITE PLAINS HOSPITAL
WINTHROP UNIVERSITY HOSPITAL
WOMANS CHRISTIAN ASSOC
WOODHULL MEDICAL
WYCKOFF HEIGHTS HOSPITAL
WYOMING CO COMMUNITY HOSP
(1)
(2)
(3)
(4)
(5)
(6)
(7)
DISCHARGE RATES
"DEFAULT & CONTRACT" DISCHARGE CASE PAYMENT RATE (INCLUDING PHL § 2807‐c(33) ‐
Excluding IME)
STATEWIDE PRICE ‐
MA HMO
ISAF
HIGH COST CC's
IME %'s
DME RATE
CAPITAL RATE ‐
PER DISCH
CAPITAL PER *Informational *Informational Only* DISCHARGE Only* "DEFAULT & INSTITUTION (EXCLUDING DIRECT INDIRECT CONTRACT" SPECIFIC HIGH COST NON‐
MEDICAL MEDICAL STATEWIDE BASE ADJUSTMENT CHARGE COMPARABLE EDUCATION PRICE (INCLUDING FACTOR CONVERTOR EDUCATION ADD‐ONS)
(DME) ADD‐ON
(IME) %
PHL § 2807‐c(33))
(ISAF)
(2011)
**(PER DISCH)**
$6,522.97
$6,829.27
0.9705
0.331763
0.00%
$0.00
$302.72
$6,886.18
$6,829.27
1.0095
0.292909
0.00%
$15.11
$478.96
$5,005.28
$6,829.27
0.7429
0.390802
0.00%
$0.00
$423.83
$6,025.06
$6,829.27
0.8836
0.436160
5.47%
$47.84
$673.41
$6,555.57
$6,829.27
0.9703
0.507587
8.01%
$563.18
$784.88
$8,205.34
$6,829.27
1.2181
0.340470
24.50%
$1,284.89
$993.24
$6,829.27
0.9024
0.281003
0.00%
$0.00
$603.56
$6,094.76
$5,111.33
$6,829.27
0.7556
0.455570
0.00%
$0.00
$203.70
$5,884.94
$6,829.27
0.8670
0.319609
2.24%
$57.02
$693.30
$6,829.27
1.0909
0.700687
25.55%
$1,885.32
$1,310.01
$7,376.46
$6,907.61
$6,829.27
1.0178
0.325427
17.29%
$509.17
$258.73
$6,119.54
$6,829.27
0.8996
0.536664
29.02%
$714.34
$749.90
$6,829.27
1.0909
0.700687
25.55%
$1,885.32
$1,310.01
$7,376.46
$5,291.58
$6,829.27
0.7752
0.502218
7.65%
$46.72
$771.94
$4,654.56
$6,829.27
0.6824
0.609655
0.00%
$0.00
$387.12
$6,829.27
$6,829.27
1.0000
0.000000
0.00%
$0.00
$0.00
$5,731.83
$6,829.27
0.8484
0.459060
7.53%
$199.73
$389.17
$6,829.27
0.7647
0.442346
0.00%
$0.00
$464.97
$5,190.50
$6,925.52
$6,829.27
1.0257
0.358170
28.73%
$1,053.67
$686.35
$6,225.54
$6,829.27
0.9184
0.470865
29.03%
$1,012.36
$918.52
$6,225.54
$6,829.27
0.9184
0.470865
29.03%
$1,012.36
$918.52
$6,668.69
$6,829.27
0.9923
0.280449
0.00%
$0.00
$662.95
0.7734
0.439657
0.00%
$0.00
$427.99
$6,829.27
$5,212.72
$7,729.72
$6,829.27
1.1393
0.303204
18.54%
$1,846.29
$2,527.40
0.7195
0.628960
0.00%
$0.00
$362.14
$6,829.27
$4,611.91
$6,979.90
$6,829.27
1.0231
0.419909
0.00%
$0.00
$445.53
$6,906.99
$6,829.27
1.0188
0.303881
16.50%
$687.16
$653.86
$5,012.60
$6,829.27
0.7416
0.471825
0.00%
$0.00
$426.70
$6,883.46
$6,829.27
1.0175
0.908330
20.72%
$1,664.49
$495.34
$7,165.16
$6,829.27
1.0677
0.407080
15.91%
$945.48
$576.86
$6,829.27
0.7759
0.954952
0.00%
$0.00
$537.30
$5,264.93
*Note: Effective 1/1/2011, Maimonides Capital per Discharge rate no longer includes a High Cost Outlier add‐on.
5 of 5
(8)
(9)
(10)
(11)
(12)
(13)
CAPITAL RATE ‐
PER DIEM
STERILIZATION
ALC
STERILIZATION DURING DELIVERY TEACHING (MANAGED ELECTION CARE AMENDMENT SCHOOL OF ENROLLEES OF AMBULANCE PHYSICIANS NURSING CAPITAL PER FIDELIS CARE ALC PRICE ADD‐ON
ADD‐ON
ADD‐ON
DIEM
ONLY)
PER DAY
NON‐COMPARABLE ADD‐ONS
$0.00
$0.00
$0.00
$0.00
$0.00
$179.84
$0.00
$0.00
$0.00
$0.00
$119.93
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$266.97
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$18.28
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$366.82
$0.00
$0.00
$94.27
$0.00
$0.00
$106.01
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
**(PER DAY**)
$60.31
$90.23
$90.44
$134.85
$144.68
$220.88
$147.40
$52.48
$152.17
$235.56
$56.88
$120.89
$235.56
$185.29
$73.05
$0.00
$82.62
$120.47
$129.14
$169.73
$169.73
$136.43
$104.45
$311.13
$368.49
$100.40
$133.35
$97.39
$103.20
$128.76
$122.36
(2290)
$900.53
$950.67
$691.00
$831.79
$905.03
$1,132.79
$841.41
$705.64
$812.44
$1,018.36
$953.63
$844.83
$1,018.36
$730.53
$642.58
$942.81
$791.31
$716.57
$956.10
$859.47
$859.47
$920.65
$719.64
$1,067.13
$636.70
$963.61
$953.54
$692.01
$950.30
$989.19
$726.85
$261.20
$261.20
$171.74
$171.74
$261.20
$261.20
$171.74
$171.74
$171.74
$261.20
$261.20
$171.74
$261.20
$171.74
$171.74
$171.74
$171.74
$171.74
$261.20
$171.74
$171.74
$171.74
$171.74
$261.20
$171.74
$261.20
$261.20
$171.74
$261.20
$261.20
$171.74
(14)
HCRA SURCHARGE
INDIGENT CARE AND HEALTH CARE INITIATIVE SURCHARGE
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%