NYS DEPARTMENT OF HEALTH
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT CASE PAYMENT RATES - EFFECTIVE 1/1/2015 - 3/31/2015
(1)
(2)
(3)
(4)
(5)
(6)
(7)
DISCHARGE
RATES
STATEWIDE PRICE MA HMO
ISAF
HIGH COST
CC's
IME %'s
DME RATE
CAPITAL RATE PER DISCH
"DEFAULT &
CONTRACT"
DISCHARGE
"DEFAULT &
CASE PAYMENT
INSTITUTION HIGH COST
CONTRACT"
RATE
SPECIFIC
CHARGE
(INCLUDING PHL STATEWIDE BASE
§ 2807-c(33) PRICE (INCLUDING ADJUSTMENT CONVERTOR
PHL § 2807-c(33)) FACTOR (ISAF)
(2011)
Excluding IME)
OPCERT
1623001
0101000
0101000
0101003
1624000
0701000
0501000
3801000
7002001
1427000
3535001
7000001
7001002
5123000
7001003
0601000
4102004
4429000
5263000
5401001
0901001
0824000
4401000
3421000
4720001
1001000
7001009
5001000
1101000
3301008
5127000
3101000
4601001
7003000
1401005
3429000
3202003
7003001
7003013
2910000
3402000
2901000
5601000
4329000
5154001
HOSPITAL NAME
ADIRONDACK MEDICAL CENTER
ALBANY MEDICAL CTR HOSP
ALBANY MEDICAL CTR SO CLINICAL
ALBANY MEMORIAL HOSPITAL
ALICE HYDE MEDICAL CENTER
ARNOT OGDEN MEDICAL CTR
AUBURN COMMUNITY HOSPITAL
AURELIA OSBORN FOX MEM HOSP
BELLEVUE HOSPITAL CENTER
BERTRAND CHAFFEE HOSPITAL
BON SECOURS COMMUNITY HOSP
BRONX-LEBANON HOSPITAL CTR
BROOKDALE HOSPITAL MED CTR
BROOKHAVEN MEMORIAL HOSP
BROOKLYN HOSPITAL CENTER
BROOKS MEMORIAL HOSPITAL
BURDETT CARE CENTER
CANTON-POTSDAM HOSPITAL
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
CONEY ISLAND HOSPITAL
CORNING HOSPITAL
CORTLAND REGIONAL MED CTR
CROUSE HOSPITAL
EASTERN LONG ISLAND HOSPITAL
EASTERN NIAGARA HOSPITAL
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
*Informational
Only*
INDIRECT
MEDICAL
EDUCATION
(IME) %
(8)
(9)
(10)
NON-COMPARABLE ADD-ONS
*Informational
CAPITAL PER
Only*
DISCHARGE
DIRECT MEDICAL (EXCLUDING NONEDUCATION
COMPARABLE AMBULANCE
(DME) ADD-ON
ADD-ONS)
ADD-ON
(11)
(12)
CAPITAL RATE PER DIEM
STERILIZATION
TEACHING
ELECTION
AMENDMENT
PHYSICIANS
ADD-ON
SCHOOL OF
NURSING
ADD-ON
CAPITAL PER
DIEM
(13)
(14)
ALC
HCRA
SURCHARGE
STERILIZATION
DURING
INDIGENT
DELIVERY
CARE AND
(MANAGED CARE
HEALTH
ENROLLEES OF
ALC
CARE
FIDELIS CARE
PRICE
INITIATIVE
ONLY)
PER DAY SURCHARGE
$5,706.48
$5,750.22
$5,750.22
$5,450.91
$5,565.13
$5,569.11
$5,956.04
$5,462.57
$7,475.55
$4,886.24
$6,441.54
$7,205.27
$7,404.40
$6,874.81
$7,049.63
$5,072.91
$5,472.93
$5,558.88
$6,369.29
$6,111.43
$5,858.96
$5,265.59
$5,182.65
$4,565.62
$5,432.05
$5,575.13
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
0.8374
0.8517
0.8517
0.7926
0.7729
0.8116
0.8414
0.7557
1.1058
0.6505
0.9593
1.0639
1.0407
1.0249
1.0527
0.7444
0.7728
0.8181
0.9159
0.8478
0.8563
0.7376
0.7363
0.6894
0.7900
0.8209
0.550690
0.329874
0.329874
0.444638
0.595070
0.441410
0.445645
0.645624
0.773995
0.597355
0.272206
0.862280
0.490403
0.193638
0.223376
0.678877
0.707292
0.571952
0.385795
0.748430
0.410036
0.470507
0.611839
0.542357
1.064008
0.428438
0.00%
19.39%
19.39%
0.00%
0.00%
0.00%
0.00%
0.00%
35.27%
0.00%
0.00%
27.64%
18.54%
3.05%
24.02%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
$0.00
$1,396.77
$1,396.77
$0.00
$0.00
$0.00
$0.00
$0.00
$1,974.01
$0.00
$0.00
$2,669.77
$1,266.81
$121.86
$868.54
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
**(PER DISCH)**
$451.65
$1,358.97
$1,358.97
$449.11
$220.99
$346.70
$270.30
$428.55
$730.84
$180.74
$562.89
$502.32
$481.26
$394.55
$447.56
$232.58
$146.08
$457.93
$429.65
$430.85
$825.31
$324.87
$590.96
$364.75
$239.34
$344.41
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$61.15
$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
$520.82
$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
$219.11
$0.00
$71.12
$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**)
$106.29
$237.50
$237.50
$102.31
$59.40
$77.17
$63.30
$95.14
$118.14
$37.70
$138.34
$114.05
$87.68
$65.38
$80.77
$60.30
$67.10
$142.27
$97.42
$110.58
$147.42
$97.69
$138.61
$81.55
$27.58
$78.10
(2290)
$762.13
$767.97
$767.97
$727.99
$743.25
$743.78
$795.46
$729.55
$998.39
$652.58
$860.30
$962.30
$988.89
$918.16
$941.51
$677.51
$730.93
$742.41
$850.65
$816.21
$782.49
$703.24
$692.17
$609.76
$725.47
$744.58
$187.52
$187.52
$187.52
$187.52
$187.52
$187.52
$187.52
$187.52
$254.96
$187.52
$254.96
$254.96
$254.96
$254.96
$254.96
$187.52
$187.52
$187.52
$187.52
$187.52
$187.52
$187.52
$187.52
$187.52
$187.52
$187.52
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%
$7,358.29
$6,071.62
$5,520.54
$6,292.89
$7,011.01
$5,520.64
$5,901.06
$7,665.95
$6,080.80
$4,922.88
$5,704.40
$7,127.91
$7,772.22
$7,098.79
$5,205.98
$7,923.90
$5,651.18
$7,245.58
$6,970.27
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
1.0779
0.8494
0.7625
0.8831
0.9871
0.7803
0.8364
1.1016
0.9020
0.7290
0.8396
1.0050
1.1350
1.0325
0.7594
1.1263
0.8031
1.0583
1.0250
0.749279
0.433032
0.650282
0.488251
0.227798
0.548871
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
14.88%
0.00%
0.00%
3.96%
0.00%
0.00%
4.85%
24.98%
20.94%
0.00%
0.79%
18.42%
6.17%
0.86%
0.00%
4.08%
0.00%
0.00%
6.56%
$1,097.16
$0.00
$0.00
$190.87
$0.00
$0.00
$98.26
$780.27
$1,042.85
$0.00
$0.03
$683.56
$201.98
$52.16
$0.00
$119.55
$0.00
$0.00
$210.30
$913.08
$583.88
$572.65
$417.16
$471.60
$237.08
$430.91
$505.22
$948.36
$471.59
$569.70
$438.72
$357.12
$456.80
$465.40
$592.28
$614.64
$427.30
$410.65
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$222.41
$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
$171.98
$0.00
$0.00
$47.64
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$80.90
$0.00
$0.00
$0.00
$0.00
$137.72
$172.17
$90.99
$84.32
$120.86
$48.25
$99.87
$111.26
$160.98
$123.57
$125.32
$83.75
$81.14
$90.60
$97.19
$122.82
$132.13
$107.84
$82.98
$982.73
$810.89
$737.29
$840.44
$936.35
$737.31
$788.11
$1,023.82
$812.12
$657.47
$761.85
$951.96
$1,038.01
$948.08
$695.28
$1,058.27
$754.74
$967.68
$930.91
$254.96
$187.52
$187.52
$187.52
$254.96
$187.52
$187.52
$254.96
$187.52
$187.52
$187.52
$254.96
$254.96
$254.96
$187.52
$254.96
$187.52
$254.96
$254.96
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%
Page 1 of 8
NYS DEPARTMENT OF HEALTH
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT CASE PAYMENT RATES - EFFECTIVE 1/1/2015 - 3/31/2015
(1)
(2)
(3)
(4)
(5)
(6)
(7)
DISCHARGE
RATES
STATEWIDE PRICE MA HMO
ISAF
HIGH COST
CC's
IME %'s
DME RATE
CAPITAL RATE PER DISCH
"DEFAULT &
CONTRACT"
DISCHARGE
"DEFAULT &
CASE PAYMENT
INSTITUTION HIGH COST
CONTRACT"
RATE
SPECIFIC
CHARGE
(INCLUDING PHL STATEWIDE BASE
§ 2807-c(33) PRICE (INCLUDING ADJUSTMENT CONVERTOR
PHL § 2807-c(33)) FACTOR (ISAF)
(2011)
Excluding IME)
OPCERT
7002009
5501001
5501000
2701001
7002012
5153000
7001046
5022000
7000002
7003003
5149000
0228000
1401014
1401014
1401002
1404000
7001016
7001033
7002017
2424000
7000008
7003004
7001019
7001020
3824000
4402000
3622000
1401008
2909000
7002021
HOSPITAL NAME
HARLEM HOSPITAL CENTER
HEALTHALLIANCE HOSP BROADWAY CAMPUS
HEALTHALLIANCE HOSP MARYS AVE CAMPUS
HIGHLAND HOSP OF ROCHESTER
HOSPITAL FOR SPECIAL SURGERY
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
LENOX HILL HOSPITAL
LEWIS COUNTY GENERAL HOSP
LINCOLN MEDICAL
LONG ISLAND JEWISH
LUTHERAN MEDICAL CENTER
MAIMONIDES MEDICAL CENTER
MARY IMOGENE BASSETT HOSP
MASSENA MEMORIAL HOSPITAL
MEDINA MEMORIAL HOSPITAL
MERCY HOSPITAL OF BUFFALO
MERCY MEDICAL CENTER
METROPOLITAN HOSPITAL CENTER
5957001
MID-HUDSON VALLEY DIV OF WESTCHESTER MED CTR
7000006
5903001
5904001
7002002
7001041
7002024
7002024
7002032
3121001
2950002
1701000
7002054
MONTEFIORE MEDICAL CENTER
MONTEFIORE MOUNT VERNON HOSP
MONTEFIORE NEW ROCHELLE HOSP
MOUNT SINAI BETH ISRAEL
MOUNT SINAI BETH ISRAEL/KINGS HWY
MOUNT SINAI HOSPITAL
MOUNT SINAI HOSPITAL OF QUEENS
MOUNT SINAI ST LUKES / ROOSEVELT
MOUNT ST MARYS HOSPITAL
NASSAU UNIV MED CTR
NATHAN LITTAUER HOSPITAL
NEW YORK DOWNTOWN HOSPITAL
7002026
NEW YORK EYE AND EAR INFIRMARY OF MOUNT SINAI
*Informational
Only*
INDIRECT
MEDICAL
EDUCATION
(IME) %
(8)
(9)
(10)
(12)
CAPITAL RATE PER DIEM
STERILIZATION
NON-COMPARABLE ADD-ONS
*Informational
CAPITAL PER
Only*
DISCHARGE
DIRECT MEDICAL (EXCLUDING NONEDUCATION
COMPARABLE AMBULANCE
(DME) ADD-ON
ADD-ONS)
ADD-ON
(11)
TEACHING
ELECTION
AMENDMENT
PHYSICIANS
ADD-ON
SCHOOL OF
NURSING
ADD-ON
CAPITAL PER
DIEM
(13)
(14)
ALC
HCRA
SURCHARGE
STERILIZATION
DURING
INDIGENT
DELIVERY
CARE AND
(MANAGED CARE
HEALTH
ENROLLEES OF
ALC
CARE
FIDELIS CARE
PRICE
INITIATIVE
ONLY)
PER DAY SURCHARGE
$7,560.52
$6,152.04
$5,915.68
$5,769.44
$8,053.09
$7,267.14
$6,985.20
$5,160.86
$7,421.74
$7,434.75
$7,163.85
$5,153.91
$6,401.23
$6,401.23
$6,484.08
$5,982.84
$7,069.08
$8,624.69
$7,318.93
$5,622.60
$7,388.79
$7,684.11
$7,044.16
$8,214.53
$5,291.20
$5,539.67
$4,431.49
$5,993.19
$7,042.48
$7,582.38
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
1.0535
0.8535
0.8757
0.8421
1.1823
1.0800
0.9996
0.7291
1.1100
1.0875
1.0229
0.7001
0.9443
0.9443
0.9516
0.8711
1.0327
1.0762
1.0842
0.8118
1.0851
1.1306
1.0319
1.1460
0.7968
0.7946
0.6394
0.8971
0.9825
1.0610
1.037858
0.255361
0.343464
0.591136
0.391481
0.320920
0.292808
0.522758
0.859302
0.454197
0.294673
0.535979
0.427742
0.427742
0.440617
0.450264
0.974490
0.293080
0.247374
0.779088
0.946222
0.262745
0.510266
0.286038
0.473270
0.651479
0.658814
0.463990
0.286411
0.874182
30.48%
5.32%
2.50%
11.26%
21.98%
0.85%
29.59%
0.00%
33.28%
20.32%
6.54%
0.00%
12.98%
12.98%
23.93%
0.00%
29.74%
10.31%
17.95%
0.00%
29.22%
28.17%
33.06%
24.42%
12.30%
0.00%
0.00%
2.80%
0.03%
34.19%
$2,113.86
$175.31
$136.12
$248.73
$1,698.99
$8.61
$1,356.17
$0.00
$2,307.06
$894.46
$339.63
$0.00
$344.80
$344.80
$483.24
$0.00
$2,689.49
$645.67
$552.72
$0.00
$1,229.20
$1,391.66
$1,158.75
$949.30
$563.77
$0.00
$0.00
$60.11
$9.23
$1,137.09
**(PER DISCH)**
$2,039.78
$288.29
$926.56
$446.71
$2,059.75
$574.83
$818.84
$427.35
$1,009.33
$251.64
$655.27
$210.51
$921.53
$921.53
$390.62
$491.27
$982.82
$441.11
$1,264.07
$465.66
$381.02
$845.06
$260.77
$899.41
$538.12
$405.25
$165.61
$462.16
$444.33
$262.87
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$424.03
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$217.48
$0.00
$0.00
$0.00
$152.07
$109.62
$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
$489.58
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$763.06
$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
$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**)
$464.80
$60.97
$172.93
$117.42
$562.27
$131.39
$135.83
$124.61
$176.10
$51.45
$115.99
$53.44
$176.09
$176.09
$84.98
$118.46
$171.10
$80.25
$289.50
$117.54
$101.38
$185.88
$60.35
$194.55
$109.22
$109.38
$30.13
$107.19
$89.43
$69.79
(2290)
$1,009.74
$821.63
$790.07
$770.53
$1,075.53
$970.56
$932.90
$689.26
$991.21
$992.94
$956.76
$688.33
$854.91
$854.91
$865.98
$799.03
$944.11
$1,151.87
$977.48
$750.92
$986.81
$1,026.25
$940.78
$1,097.09
$706.66
$739.85
$591.85
$800.42
$940.56
$1,012.66
$254.96
$187.52
$187.52
$187.52
$254.96
$254.96
$254.96
$187.52
$254.96
$254.96
$254.96
$187.52
$187.52
$187.52
$187.52
$187.52
$254.96
$254.96
$254.96
$187.52
$254.96
$254.96
$254.96
$254.96
$187.52
$187.52
$187.52
$187.52
$254.96
$254.96
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%
$7,786.80
$7,692.13
$7,354.55
$6,487.51
$8,070.05
$8,996.61
$7,333.47
$7,333.47
$8,480.92
$5,919.59
$7,144.54
$5,363.89
$7,716.11
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
1.1410
1.1300
1.0154
1.0106
1.1082
1.1310
1.0801
1.0801
1.1643
0.8399
1.1122
0.7562
1.1302
0.303204
0.272430
0.539888
0.528855
0.308539
0.183347
0.384940
0.384940
0.340470
0.587047
0.501971
0.439216
0.364115
22.03%
28.56%
11.01%
11.38%
26.62%
0.38%
25.76%
25.76%
25.10%
0.00%
25.88%
0.00%
26.54%
$2,018.94
$3,092.37
$1,113.04
$957.05
$681.76
$0.00
$1,430.47
$1,430.47
$1,079.42
$0.00
$1,620.79
$0.00
$1,549.47
$2,499.44
$778.03
$326.30
$404.76
$788.53
$181.01
$796.61
$796.61
$771.66
$332.26
$374.23
$216.70
$1,179.81
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$160.50
$0.00
$120.75
$0.00
$284.17
$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
$81.31
$89.39
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$310.83
$145.22
$58.34
$91.99
$181.32
$30.84
$152.82
$152.82
$179.34
$80.16
$89.53
$57.72
$207.84
$1,039.96
$1,027.32
$982.23
$866.44
$1,077.79
$1,201.54
$979.42
$979.42
$1,132.66
$790.59
$954.18
$716.37
$1,030.52
$254.96
$254.96
$254.96
$254.96
$254.96
$254.96
$254.96
$254.96
$254.96
$187.52
$254.96
$187.52
$254.96
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%
$7,545.30
$6,931.12
0.9806
0.444781
31.64%
$744.74
$689.21
$0.00
$0.00
$0.00
$291.92
$1,007.71
$254.96
7.04%
Page 2 of 8
NYS DEPARTMENT OF HEALTH
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT CASE PAYMENT RATES - EFFECTIVE 1/1/2015 - 3/31/2015
(1)
(2)
(3)
(4)
(5)
(6)
(7)
DISCHARGE
RATES
STATEWIDE PRICE MA HMO
ISAF
HIGH COST
CC's
IME %'s
DME RATE
CAPITAL RATE PER DISCH
"DEFAULT &
CONTRACT"
DISCHARGE
"DEFAULT &
CASE PAYMENT
INSTITUTION HIGH COST
CONTRACT"
RATE
SPECIFIC
CHARGE
(INCLUDING PHL STATEWIDE BASE
§ 2807-c(33) PRICE (INCLUDING ADJUSTMENT CONVERTOR
PHL § 2807-c(33)) FACTOR (ISAF)
(2011)
Excluding IME)
OPCERT
*Informational
Only*
INDIRECT
MEDICAL
EDUCATION
(IME) %
NEW YORK-PRESBYTERIAN HUDSON VALLEY HOSPITAL
5922000
5820000
3102000
2527000
7000024
2951001
1327000
5920000
7001008
7003010
7001021
7002054
7002054
7002054
4324000
7002053
7002053
0401001
2601001
3523000
3702000
0301001
5155000
5932000
2952005
3950000
7003007
7004010
2701003
3201002
4102002
2201000
4501000
7000014
1401013
2950001
5126000
5154000
3529000
5157003
5149001
3202002
2953000
5002001
NEW YORK-PRESBYTERIAN LAWRENCE HOSPITAL
NEWARK WAYNE COMMUNITY HOSPITAL
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 MED CTR OF QUEENS
NY METHODIST HOSP / BROOKLYN
NY PRESBYTERIAN HOSPITAL
NY PRESBYTERIAN HOSPITAL (ALLEN)
NY PRESBYTERIAN HOSPITAL (PRESBY)
NYACK HOSPITAL
NYU HOSPITALS CENTER
NYU HOSPITALS CENTER/HOSP FOR JOINT DIS
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
SBH HEALTH SYSTEM
SISTERS OF CHARITY HOSPITAL
SOUTH NASSAU COMMUNITIES
SOUTHAMPTON HOSPITAL
SOUTHSIDE HOSPITAL
ST ANTHONY COMMUNITY HOSP
ST CATHERINE OF SIENA
ST CHARLES HOSPITAL
ST ELIZABETH MEDICAL CENTER
ST FRANCIS HOSP / ROSLYN
ST JAMES MERCY HOSPITAL
(9)
(10)
NON-COMPARABLE ADD-ONS
*Informational
CAPITAL PER
Only*
DISCHARGE
DIRECT MEDICAL (EXCLUDING NONEDUCATION
COMPARABLE AMBULANCE
(DME) ADD-ON
ADD-ONS)
ADD-ON
HOSPITAL NAME
5901000
(8)
TEACHING
ELECTION
AMENDMENT
PHYSICIANS
ADD-ON
SCHOOL OF
NURSING
ADD-ON
**(PER DISCH)**
$6,591.75
$6,960.30
$5,610.08
$5,359.79
$5,064.10
$7,445.79
$8,125.19
$6,617.61
$6,977.45
$7,799.69
$7,378.19
$7,226.72
$7,716.11
$7,716.11
$7,716.11
$6,697.31
$7,292.31
$7,292.31
$5,134.95
$5,167.43
$6,885.93
$5,683.39
$5,616.41
$6,923.39
$6,881.28
$7,454.57
$7,051.38
$7,770.79
$6,760.69
$5,739.32
$5,516.53
$5,444.43
$5,667.54
$5,763.88
$6,917.69
$5,827.94
$6,667.91
$6,257.05
$7,362.25
$6,252.50
$7,207.79
$6,792.53
$5,654.11
$7,505.09
$4,492.00
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
0.9520
0.9741
0.8253
0.7814
0.7217
1.0688
1.1350
0.9658
0.9786
1.0923
1.0850
1.0639
1.1302
1.1302
1.1302
0.9587
1.0547
1.0547
0.7463
0.7618
0.9946
0.7821
0.8242
1.0128
1.0142
1.0962
1.0153
1.1427
0.9926
0.8156
0.8040
0.7728
0.8022
0.8480
1.0233
0.8522
0.9679
1.0044
1.0844
0.9649
1.0560
0.9786
0.8072
1.0915
0.6710
0.282930
0.348137
0.439657
0.545618
0.442823
0.741199
0.254440
0.366251
0.509174
0.517469
0.404466
0.445267
0.364115
0.364115
0.364115
0.221363
0.313593
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
0.300863
0.468327
0.303927
0.337423
0.321029
0.277194
0.233955
0.262866
0.447837
0.264425
0.470863
0.00%
0.00%
0.00%
2.26%
0.00%
12.07%
15.84%
0.00%
0.00%
0.00%
18.22%
18.07%
26.54%
26.54%
26.54%
0.00%
22.19%
22.19%
1.10%
0.00%
0.00%
0.00%
3.30%
3.73%
8.11%
6.34%
0.00%
19.86%
14.22%
9.91%
0.00%
0.00%
2.56%
0.00%
31.35%
4.94%
3.34%
11.96%
3.75%
0.00%
0.00%
1.18%
5.84%
0.09%
0.00%
Page 3 of 8
$0.00
$0.00
$0.00
$147.98
$0.00
$1,094.47
$861.05
$0.00
$0.00
$0.00
$727.95
$879.19
$1,549.47
$1,549.47
$1,549.47
$0.00
$1,506.07
$1,506.07
$12.42
$0.00
$0.00
$0.00
$9.43
$73.08
$180.32
$171.89
$0.00
$1,055.31
$854.45
$347.96
$0.00
$0.00
$65.75
$0.00
$1,134.78
$173.29
$127.68
$368.83
$112.75
$0.00
$0.00
$0.00
$299.77
$6.18
$0.00
$1,296.00
$558.30
$263.30
$522.44
$404.51
$574.82
$696.24
$323.69
$614.71
$374.53
$836.30
$291.92
$1,179.81
$1,179.81
$1,179.81
$301.38
$1,987.98
$1,987.98
$328.01
$587.36
$1,113.86
$572.73
$324.12
$689.57
$773.06
$289.76
$699.34
$590.50
$322.75
$643.41
$184.93
$292.46
$482.54
$518.86
$548.28
$313.73
$757.34
$720.43
$543.96
$437.76
$597.46
$492.78
$542.45
$1,361.99
$188.88
(11)
CAPITAL RATE PER DIEM
STERILIZATION
CAPITAL PER
DIEM
**(PER DAY**)
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$578.59
$0.00
$0.00
$0.00
$217.44
$0.00
$284.17
$284.17
$284.17
$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
$378.76
$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
$412.87
$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
$352.16
$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
$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
$2.23
$0.00
$118.88
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$139.07
$0.00
$0.00
(12)
$309.50
$120.32
$65.82
$142.82
$107.59
$117.05
$138.34
$99.54
$152.82
$60.83
$169.95
$62.12
$207.84
$207.84
$207.84
$72.81
$485.67
$485.67
$72.06
$153.04
$266.80
$140.17
$76.46
$160.48
$175.23
$60.96
$179.05
$117.56
$68.14
$123.73
$46.00
$62.14
$126.48
$101.33
$120.33
$68.28
$150.54
$209.35
$123.30
$106.06
$121.24
$111.87
$104.27
$222.81
$70.91
(13)
(14)
ALC
HCRA
SURCHARGE
STERILIZATION
DURING
INDIGENT
DELIVERY
CARE AND
(MANAGED CARE
HEALTH
ENROLLEES OF
ALC
CARE
FIDELIS CARE
PRICE
INITIATIVE
ONLY)
PER DAY SURCHARGE
(2290)
$880.36
$929.58
$749.25
$715.82
$676.33
$994.42
$1,085.16
$883.81
$931.87
$1,041.68
$985.39
$965.16
$1,030.52
$1,030.52
$1,030.52
$894.46
$973.92
$973.92
$685.80
$690.13
$919.65
$759.04
$750.10
$924.65
$919.03
$995.59
$941.74
$1,037.82
$902.92
$766.51
$736.76
$727.13
$756.93
$769.79
$923.89
$778.35
$890.53
$835.66
$983.26
$835.05
$962.63
$907.17
$755.13
$1,002.34
$599.93
$254.96
$254.96
$187.52
$187.52
$187.52
$254.96
$254.96
$254.96
$254.96
$254.96
$254.96
$254.96
$254.96
$254.96
$254.96
$254.96
$254.96
$254.96
$187.52
$187.52
$254.96
$187.52
$187.52
$254.96
$254.96
$254.96
$254.96
$254.96
$254.96
$187.52
$187.52
$187.52
$187.52
$187.52
$254.96
$187.52
$254.96
$254.96
$254.96
$254.96
$254.96
$254.96
$187.52
$254.96
$187.52
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%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
NYS DEPARTMENT OF HEALTH
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT CASE PAYMENT RATES - EFFECTIVE 1/1/2015 - 3/31/2015
(1)
(2)
(3)
(4)
(5)
(6)
(7)
DISCHARGE
RATES
STATEWIDE PRICE MA HMO
ISAF
HIGH COST
CC's
IME %'s
DME RATE
CAPITAL RATE PER DISCH
"DEFAULT &
CONTRACT"
DISCHARGE
"DEFAULT &
CASE PAYMENT
INSTITUTION HIGH COST
CONTRACT"
RATE
SPECIFIC
CHARGE
(INCLUDING PHL STATEWIDE BASE
§ 2807-c(33) PRICE (INCLUDING ADJUSTMENT CONVERTOR
PHL § 2807-c(33)) FACTOR (ISAF)
(2011)
Excluding IME)
OPCERT
7001024
5907001
2952006
0701001
3301003
5907002
3522000
2801001
4102003
0101004
7001037
7004003
2701005
2754001
0427000
1227001
0303001
1801000
5151001
3301007
3301007
1302001
5957001
0632000
5902001
2908000
0602001
7001045
7001035
6027000
HOSPITAL NAME
ST JOHNS EPISCOPAL SO SHORE
ST JOHNS RIVERSIDE HOSPITAL
ST JOSEPH HOSPITAL
ST JOSEPHS HOSP / ELMIRA
ST JOSEPHS HOSP HLTH CTR
ST JOSEPHS MEDICAL CENTER
ST LUKES CORNWALL HOSPITAL
ST MARYS HEALTHCARE
ST MARYS HOSPITAL
ST PETERS HOSPITAL
STATE UNIV HOSP / DOWNSTATE
STATEN ISLAND UNIV HOSP
STRONG MEMORIAL HOSPITAL
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
WESTCHESTER MEDICAL CENTER
WESTFIELD MEMORIAL HOSP
WHITE PLAINS HOSPITAL
WINTHROP UNIVERSITY HOSPITAL
WOMANS CHRISTIAN ASSOC
WOODHULL MEDICAL
WYCKOFF HEIGHTS HOSPITAL
WYOMING CO COMMUNITY HOSP
$7,627.28
$6,784.54
$7,035.85
$5,107.58
$5,977.03
$7,162.12
$6,551.66
$5,204.49
$5,385.57
$5,915.97
$6,611.11
$7,032.70
$6,001.76
$5,252.52
$4,814.37
$5,978.78
$5,809.71
$5,279.27
$6,934.06
$6,613.56
$6,613.56
$6,814.77
$7,786.80
$4,721.06
$7,116.89
$7,100.39
$5,116.40
$6,746.89
$7,157.33
$5,392.08
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
1.0138
1.0008
1.0196
0.7570
0.8693
0.9716
0.9797
0.7462
0.8040
0.8412
1.1106
1.0293
0.8764
0.7642
0.7015
0.8626
0.8542
0.7560
1.0181
0.9392
0.9392
1.0064
1.1410
0.7029
0.9862
1.0394
0.7224
1.0415
1.0022
0.7890
0.388042
0.331763
0.292909
0.390802
0.436160
0.507587
0.281003
0.455570
0.356760
0.319609
0.700687
0.325427
0.536664
0.502218
0.609655
0.000000
0.459060
0.442346
0.358170
0.470865
0.470865
0.280449
0.303204
0.628960
0.419909
0.303881
0.471825
0.908330
0.407080
0.954952
*Informational
Only*
INDIRECT
MEDICAL
EDUCATION
(IME) %
28.47%
0.00%
0.10%
0.00%
6.16%
8.44%
0.00%
0.00%
0.00%
2.42%
25.92%
18.37%
31.27%
8.03%
0.00%
0.00%
7.31%
0.00%
26.81%
20.71%
20.71%
0.00%
22.03%
0.00%
0.00%
16.78%
0.00%
19.40%
20.13%
0.00%
Page 4 of 8
(8)
**(PER DISCH)**
$411.31
$332.00
$498.63
$754.35
$788.44
$626.52
$667.52
$207.25
$630.71
$909.94
$1,139.40
$350.93
$837.53
$833.31
$482.13
$233.34
$452.36
$316.77
$501.17
$852.40
$852.40
$464.71
$2,499.44
$2,795.58
$562.08
$717.51
$402.78
$467.37
$517.18
$527.52
(10)
NON-COMPARABLE ADD-ONS
*Informational
CAPITAL PER
Only*
DISCHARGE
DIRECT MEDICAL (EXCLUDING NONEDUCATION
COMPARABLE AMBULANCE
(DME) ADD-ON
ADD-ONS)
ADD-ON
$1,058.92
$0.00
$6.83
$0.00
$96.63
$163.70
$0.00
$0.00
$0.00
$78.67
$3,552.62
$575.98
$1,112.55
$229.90
$0.00
$0.00
$355.27
$0.00
$1,311.46
$744.10
$744.10
$0.00
$2,018.94
$0.00
$0.00
$947.46
$0.00
$1,987.71
$684.51
$0.00
(9)
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$144.90
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$250.52
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$152.83
$0.00
TEACHING
ELECTION
AMENDMENT
PHYSICIANS
ADD-ON
SCHOOL OF
NURSING
ADD-ON
$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
$625.76
$0.00
$0.00
$0.00
$189.08
$0.00
$0.00
$143.32
$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
(11)
(12)
CAPITAL RATE PER DIEM
STERILIZATION
CAPITAL PER
DIEM
**(PER DAY**)
$70.52
$74.15
$92.39
$232.00
$156.16
$108.03
$145.65
$51.02
$128.77
$204.71
$199.16
$77.23
$129.64
$191.56
$119.98
$466.67
$90.50
$86.57
$95.90
$151.14
$151.14
$95.31
$310.83
$349.45
$123.01
$143.98
$106.65
$99.26
$108.81
$126.98
(13)
(14)
ALC
HCRA
SURCHARGE
STERILIZATION
DURING
INDIGENT
DELIVERY
CARE AND
(MANAGED CARE
HEALTH
ENROLLEES OF
ALC
CARE
FIDELIS CARE
PRICE
INITIATIVE
ONLY)
PER DAY SURCHARGE
(2290)
$1,018.66
$906.11
$939.67
$682.14
$798.26
$956.53
$875.00
$695.08
$719.27
$790.10
$882.94
$939.25
$801.56
$701.50
$642.98
$798.49
$775.91
$705.07
$926.08
$883.27
$883.27
$910.14
$1,039.96
$630.52
$950.49
$948.29
$683.32
$901.08
$955.89
$720.14
$254.96
$254.96
$254.96
$187.52
$187.52
$254.96
$254.96
$187.52
$187.52
$187.52
$254.96
$254.96
$187.52
$187.52
$187.52
$187.52
$187.52
$187.52
$254.96
$187.52
$187.52
$254.96
$254.96
$187.52
$254.96
$254.96
$187.52
$254.96
$254.96
$187.52
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%
NYS DEPARTMENT OF HEALTH
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT EXEMPT UNIT RATES - EFFECTIVE 1/1/2015 - 12/31/2015
(1)
(2)
(3)
(4)
(5)
SPECIALTY HOSPITAL
(6)
(7)
(8)
PSYCHIATRIC
(9)
(10)
(11)
CHEMICAL DEPENDENCY REHAB
(12)
SPECIALTY
SPECIALTY
ACUTE, LONG*Informational
ACUTE, LONGTERM CARE Only* SPECIALTY TERM CARE
*Informational
AND
ACUTE, LONGAND
PSYCHIATRIC
CHEMICAL
Only*
CRITICAL
CHILDREN'S
TERM CARE AND CHILDREN'S
NON*Informational
DEPENDENCY
CHEMICAL
CHEMICAL
ACCESS
HOSPITAL
CHILDREN'S
HOSPITAL
PSYCHIATRIC OPERATING
Only*
PSYCHIATRIC
REHAB
DEPENDENCY DEPENDENCY
HOSPITAL
BILLING RATE HOSPITAL DME ALC PER DIEM
OPERATING BILLING RATE PSYCHIATRIC
ECT
PSYCHIATRIC BILLING RATE
REHAB
REHAB
BILLING RATE
(w/out DME)
Add-on
(w/out DME)
BILLING RATE (w/out DME)
DME Add-on
PAYMENT
ALC PER DIEM (w/out DME)
DME Add-on ALC PER DIEM (w/out DME)
OPCERT
HOSPITAL NAME
1623001 ADIRONDACK MEDICAL CENTER
0101000 ALB MED CTR SO CLINICAL CAMP
0101000 ALBANY MEDICAL CTR HOSP
0101003 ALBANY MEMORIAL HOSPITAL
1624000 ALICE HYDE MEDICAL CENTER
0701000 ARNOT OGDEN MEDICAL CTR
0501000 AUBURN MEMORIAL HOSPITAL
3801000 AURELIA OSBORN FOX MEM HOSP
7002001 BELLEVUE HOSPITAL CENTER
1427000 BERTRAND CHAFFEE HOSPITAL
5957000 BLYTHEDALE CHILDRENS HOSP
3535001 BON SECOURS COMMUNITY HOSP
7000001 BRONX-LEBANON HOSPITAL CTR
7001002 BROOKDALE HOSPITAL MED CTR
5123000 BROOKHAVEN MEMORIAL HOSP
7001003 BROOKLYN HOSPITAL CENTER
0601000 BROOKS MEMORIAL HOSPITAL
7000011 CALVARY HOSPITAL
4429000 CANTON-POTSDAM HOSPITAL
2238700 CARTHAGE AREA HOSPITAL INC
5263700 CATSKILL REGIONAL / G HERMANN
5263000 CATSKILL REGIONAL MED CTR
5401001 CAYUGA MEDICAL CENTER
0901001 CHAMPLAIN VALLEY PHYS
0824000 CHENANGO MEMORIAL HOSP
4401000 CLAXTON-HEPBURN MED CTR
3421000 CLIFTON SPRINGS HOSPITAL
4458701 CLIFTON-FINE HOSPITAL
4720001 COBLESKILL REGIONAL HOSP
7002051 COLER MEMORIAL HOSP
1001000 COLUMBIA MEMORIAL HOSPITAL
2625700 COMMUNITY MEMORIAL HOSPITAL
7001009 CONEY ISLAND HOSPITAL
5001000 CORNING HOSPITAL
1101000 CORTLAND REGIONAL MED CTR
3301008 CROUSE HOSPITAL
0226700 CUBA MEMORIAL HOSPITAL
1229700 DELAWARE VALLEY HOSPITAL
5127000 EASTERN LONG ISLAND HOSPITAL
3101000 EASTERN NIAGARA HOSPITAL
1552701 ELIZABETHTOWN COMMUNITY HOSP
5526700 ELLENVILLE REGIONAL HOSPITAL
4601001 ELLIS HOSPITAL
7003000 ELMHURST HOSPITAL CTR
1401005 ERIE COUNTY MEDICAL CENTER
3429000 F F THOMPSON HOSPITAL
3202003 FAXTON-ST LUKES HEALTHCARE
7003001 FLUSHING HOSPITAL
7003013 FOREST HILLS HOSPITAL
2910000 FRANKLIN HOSPITAL
3402000 GENEVA GENERAL HOSPITAL
2901000 GLEN COVE HOSPITAL
5601000 GLENS FALLS HOSPITAL
4329000 GOOD SAMARITAN / SUFFERN
5154001 GOOD SAMARITAN / WEST ISLIP
4423701 GOUVERNEUR HOSPITAL (formerly EJ Noble)
7002009 HARLEM HOSPITAL CENTER
5501001 HEALTHALLIANCE HOSP BROADWAY CAMPUS
5501000 HEALTHALLIANCE HOSP MARYS AVE CAMPUS
4322000 HELEN HAYES HOSPITAL
7002050 HENRY J CARTER SPECIALTY HOSPITAL
2701001 HIGHLAND HOSP OF ROCHESTER
7002012 HOSPITAL FOR SPECIAL SURGERY
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,629.26
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,064.14
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$540.58
$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
$861.74
$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
$79.14
$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
$56.88
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$254.96
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$254.96
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$254.96
$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
$254.96
$0.00
$0.00
$651.19
$0.00
$558.41
$0.00
$0.00
$0.00
$682.04
$0.00
$657.63
$0.00
$0.00
$589.64
$684.30
$673.25
$654.42
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$723.73
$697.07
$664.72
$0.00
$608.48
$446.52
$0.00
$0.00
$0.00
$649.06
$0.00
$649.73
$0.00
$635.21
$0.00
$0.00
$0.00
$636.49
$519.46
$0.00
$0.00
$539.90
$691.69
$592.40
$0.00
$657.20
$664.00
$0.00
$631.67
$0.00
$725.43
$644.55
$0.00
$0.00
$0.00
$675.37
$0.00
$690.27
$0.00
$0.00
$0.00
$0.00
$41.79
$0.00
$73.60
$0.00
$0.00
$0.00
$29.34
$0.00
$37.90
$0.00
$0.00
$34.22
$65.32
$41.02
$35.14
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$22.41
$39.82
$63.36
$0.00
$45.34
$18.93
$0.00
$0.00
$0.00
$23.17
$0.00
$54.53
$0.00
$107.55
$0.00
$0.00
$0.00
$37.47
$8.46
$0.00
$0.00
$46.08
$49.86
$38.15
$0.00
$60.66
$54.84
$0.00
$41.49
$0.00
$46.92
$67.73
$0.00
$0.00
$0.00
$115.74
$0.00
$30.72
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$29.80
$0.00
$0.00
$0.00
$0.00
$0.00
$129.33
$0.00
$0.00
$0.00
$187.61
$86.84
$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
$116.79
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.81
$257.88
$35.05
$0.00
$0.03
$108.17
$0.00
$0.08
$0.00
$0.51
$0.00
$0.00
$0.00
$0.00
$212.95
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$231.32
$0.00
$244.16
$0.00
$0.00
$0.00
$242.28
$0.00
$287.55
$0.00
$0.00
$257.82
$299.21
$294.38
$286.14
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$257.09
$247.62
$236.12
$0.00
$216.15
$195.24
$0.00
$0.00
$0.00
$230.56
$0.00
$284.09
$0.00
$225.64
$0.00
$0.00
$0.00
$278.30
$227.13
$0.00
$0.00
$236.07
$302.44
$259.03
$0.00
$233.45
$290.33
$0.00
$276.19
$0.00
$317.19
$228.96
$0.00
$0.00
$0.00
$295.30
$0.00
$245.20
$0.00
$0.00
$0.00
$0.00
Page 5 of 8
$187.52
$0.00
$187.52
$0.00
$0.00
$0.00
$187.52
$0.00
$254.96
$0.00
$0.00
$187.52
$254.96
$254.96
$254.96
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$187.52
$187.52
$187.52
$0.00
$187.52
$187.52
$0.00
$0.00
$0.00
$187.52
$0.00
$254.96
$0.00
$187.52
$0.00
$0.00
$0.00
$254.96
$187.52
$0.00
$0.00
$187.52
$254.96
$187.52
$0.00
$187.52
$254.96
$0.00
$254.96
$0.00
$254.96
$187.52
$0.00
$0.00
$0.00
$254.96
$0.00
$187.52
$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
$548.29
$353.45
$0.00
$0.00
$0.00
$0.00
$0.00
$459.42
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$281.65
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$392.68
$0.00
$1,085.19
$620.86
$296.28
$0.00
$0.00
$0.00
$0.00
$291.30
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$583.65
$0.00
$0.00
$0.00
$0.00
$323.09
$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
$321.87
$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
$1.45
$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
$187.52
$254.96
$0.00
$0.00
$0.00
$0.00
$0.00
$187.52
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$187.52
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$187.52
$0.00
$187.52
$254.96
$187.52
$0.00
$0.00
$0.00
$0.00
$187.52
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$254.96
$0.00
$0.00
$0.00
$0.00
$187.52
$0.00
$0.00
$0.00
$0.00
(13)
CRITICAL ACCESS HOSPITAL
$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
$2,329.82
$2,375.42
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$2,310.80
$0.00
$0.00
$0.00
$2,345.81
$0.00
$0.00
$0.00
$0.00
$2,295.40
$1,085.19
$0.00
$0.00
$1,956.96
$1,789.11
$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
$2,115.43
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
CRITICAL
ACCESS
HOSPITAL
ALC PER
DIEM
$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
$187.52
$187.52
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$187.52
$0.00
$0.00
$0.00
$187.52
$0.00
$0.00
$0.00
$0.00
$187.52
$187.52
$0.00
$0.00
$187.52
$187.52
$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
$187.52
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
(14)
(15)
(16)
MEDICAL REHABILITATION
(17)
(18)
DETOX
(19)
HCRA SURCHARGE
MEDICAL *Informational
DETOXDETOX REHAB
Only*
MEDICAL
MEDICALLY
MEDICALLY
INDIGENT CARE
BILLING
MEDICAL
REHAB
MANAGED
SUPERVISED AND HEALTH CARE
RATE (w/out REHAB DME ALC PER WITHDRAWAL WITHDRAWAL
INITIATIVE
DME)
Add-on
DIEM
BILLING RATE BILLING RATE
SURCHARGE
$0.00
$0.00
$967.78
$0.00
$0.00
$0.00
$0.00
$0.00
$1,035.49
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,310.80
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$986.78
$0.00
$0.00
$887.20
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,025.29
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,194.69
$1,005.39
$0.00
$948.91
$0.00
$0.00
$0.00
$1,205.38
$1,068.10
$1,069.38
$0.00
$0.00
$0.00
$1,758.47
$0.00
$987.31
$1,271.21
$0.00
$0.00
$0.00
$0.00
$0.00
$91.89
$0.00
$0.00
$0.00
$0.00
$0.00
$120.71
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$4.02
$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
$95.78
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$257.66
$70.64
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$6.82
$0.00
$0.00
$0.00
$0.00
$456.19
$0.00
$0.00
$2.16
$0.00
$0.00
$0.00
$0.00
$0.00
$187.52
$0.00
$0.00
$0.00
$0.00
$0.00
$254.96
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$254.96
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$187.52
$0.00
$0.00
$187.52
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$254.96
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$254.96
$187.52
$0.00
$187.52
$0.00
$0.00
$0.00
$187.52
$254.96
$187.52
$0.00
$0.00
$0.00
$254.96
$0.00
$187.52
$254.96
$0.00
$0.00
$0.00
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
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%
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%
NYS DEPARTMENT OF HEALTH
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT EXEMPT UNIT RATES - EFFECTIVE 1/1/2015 - 12/31/2015
(1)
(2)
(3)
(4)
(5)
SPECIALTY HOSPITAL
(6)
(7)
(8)
PSYCHIATRIC
(9)
(10)
(11)
CHEMICAL DEPENDENCY REHAB
(12)
(13)
CRITICAL ACCESS HOSPITAL
SPECIALTY
SPECIALTY
ACUTE, LONG*Informational
ACUTE, LONGTERM CARE Only* SPECIALTY TERM CARE
*Informational
AND
ACUTE, LONGAND
PSYCHIATRIC
CHEMICAL
Only*
CRITICAL
CHILDREN'S
TERM CARE AND CHILDREN'S
NON*Informational
DEPENDENCY
CHEMICAL
CHEMICAL
ACCESS
HOSPITAL
CHILDREN'S
HOSPITAL
PSYCHIATRIC OPERATING
Only*
PSYCHIATRIC
REHAB
DEPENDENCY DEPENDENCY
HOSPITAL
BILLING RATE HOSPITAL DME ALC PER DIEM
OPERATING BILLING RATE PSYCHIATRIC
ECT
PSYCHIATRIC BILLING RATE
REHAB
REHAB
BILLING RATE
(w/out DME)
Add-on
(w/out DME)
BILLING RATE (w/out DME)
DME Add-on
PAYMENT
ALC PER DIEM (w/out DME)
DME Add-on ALC PER DIEM (w/out DME)
CRITICAL
ACCESS
HOSPITAL
ALC PER
DIEM
(14)
(15)
(16)
MEDICAL REHABILITATION
(17)
(18)
DETOX
(19)
HCRA SURCHARGE
MEDICAL *Informational
DETOXDETOX REHAB
Only*
MEDICAL
MEDICALLY
MEDICALLY
INDIGENT CARE
BILLING
MEDICAL
REHAB
MANAGED
SUPERVISED AND HEALTH CARE
RATE (w/out REHAB DME ALC PER WITHDRAWAL WITHDRAWAL
INITIATIVE
DME)
Add-on
DIEM
BILLING RATE BILLING RATE
SURCHARGE
OPCERT
HOSPITAL NAME
5153000
7001046
5022000
7000002
7003003
5149000
0228000
1401014
1401002
1404000
7001016
7001033
7002017
2424000
7000008
2129700
7003004
7001019
7001020
1226701
3824000
4402000
3622000
7002020
1401008
2909000
7002021
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 HLTH/WOMAN&CHILDRENS
KENMORE MERCY HOSPITAL
KINGS COUNTY HOSPITAL CENTER
KINGSBROOK JEWISH MED CTR
LENOX HILL HOSPITAL
LEWIS COUNTY GENERAL HOSP
LINCOLN MEDICAL
LITTLE FALLS HOSPITAL
LONG ISLAND JEWISH
LUTHERAN MEDICAL CENTER
MAIMONIDES MEDICAL CENTER
MARGARETVILLE HOSPITAL
MARY IMOGENE BASSETT HOSP
MASSENA MEMORIAL HOSPITAL
MEDINA MEMORIAL HLTH CARE
MEMORIAL HOSP FOR CANCER
MERCY HOSPITAL OF BUFFALO
MERCY MEDICAL CENTER
METROPOLITAN HOSPITAL CENTER
$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
$2,913.50
$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
$236.79
$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
$254.96
$0.00
$0.00
$0.00
$679.93
$677.24
$0.00
$712.90
$722.41
$661.04
$0.00
$0.00
$0.00
$0.00
$651.98
$737.90
$668.82
$0.00
$663.29
$0.00
$699.34
$653.71
$765.02
$0.00
$596.29
$0.00
$0.00
$0.00
$0.00
$653.39
$656.22
$62.45
$67.65
$0.00
$156.18
$21.78
$66.97
$0.00
$0.00
$0.00
$0.00
$169.70
$25.25
$160.87
$0.00
$51.12
$0.00
$62.43
$36.14
$60.90
$0.00
$45.83
$0.00
$0.00
$0.00
$0.00
$35.49
$24.82
$0.05
$0.73
$0.00
$98.71
$215.50
$0.00
$0.00
$0.00
$0.00
$0.00
$159.72
$23.66
$88.11
$0.00
$236.99
$0.00
$73.43
$65.98
$39.56
$0.00
$6.41
$0.00
$0.00
$0.00
$0.00
$2.31
$267.98
$297.30
$296.12
$0.00
$311.71
$315.87
$289.04
$0.00
$0.00
$0.00
$0.00
$285.07
$322.64
$292.44
$0.00
$290.02
$0.00
$305.78
$285.83
$334.50
$0.00
$211.82
$0.00
$0.00
$0.00
$0.00
$285.69
$286.93
$254.96
$254.96
$0.00
$254.96
$254.96
$254.96
$0.00
$0.00
$0.00
$0.00
$254.96
$254.96
$254.96
$0.00
$254.96
$0.00
$254.96
$254.96
$254.96
$0.00
$187.52
$0.00
$0.00
$0.00
$0.00
$254.96
$254.96
$0.00
$514.90
$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
$0.30
$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
$254.96
$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
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,510.81
$0.00
$0.00
$0.00
$2,071.02
$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
$187.52
$0.00
$0.00
$0.00
$187.52
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,277.53
$1,184.27
$0.00
$0.00
$838.60
$0.00
$729.54
$1,668.35
$869.47
$0.00
$0.00
$0.00
$0.00
$0.00
$788.97
$0.00
$0.00
$0.00
$0.00
$772.03
$0.00
$935.60
$893.23
$843.68
$0.00
$0.00
$0.00
$115.13
$126.11
$0.00
$0.00
$64.73
$0.00
$0.00
$191.49
$187.91
$0.00
$0.00
$0.00
$0.00
$0.00
$24.28
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1.30
$263.74
$0.00
$0.00
$0.00
$254.96
$254.96
$0.00
$0.00
$187.52
$0.00
$187.52
$254.96
$254.96
$0.00
$0.00
$0.00
$0.00
$0.00
$254.96
$0.00
$0.00
$0.00
$0.00
$187.52
$0.00
$187.52
$254.96
$254.96
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
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%
5957001
2701006
7000006
5903001
5904001
1564701
7002002
7001041
7003015
7002024
7002032
3121001
2950002
1701000
7002000
5901000
5922000
5820000
3102000
2527000
7000024
2951001
1327000
5920000
7001008
7002026
7003010
7001021
7002054
7002054
4324000
7002053
7002053
1254700
0401001
MID-HUDSON VALLEY DIV OF WESTCHESTER MED CTR
MONROE COMMUNITY HOSPITAL
MONTEFIORE MEDICAL CENTER
MONTEFIORE MOUNT VERNON HOSP
MONTEFIORE NEW ROCHELLE HOSP
MOSES-LUDINGTON HOSPITAL
MOUNT SINAI BETH ISRAEL
MOUNT SINAI BETH ISRAEL BROOKLY
MOUNT SINAI HOSP OF QUEENS
MOUNT SINAI HOSPITAL
MOUNT SINAI ST LUKES / ROOSEVELT
MOUNT ST MARYS HOSPITAL
NASSAU UNIV MED CTR
NATHAN LITTAUER HOSPITAL
NEW YORK DOWNTOWN HOSP
NEW YORK-PRESBYTERIAN HUDSON VALLEY HOSPITAL
NEW YORK-PRESBYTERIAN LAWRENCE HOSPITAL
NEWARK WAYNE COMMUNITY HOSPITAL
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 (PRESBY)
NYACK HOSPITAL
NYU HOSPITALS CENTER
NYU HOSPITALS CENTER/HOSP FOR JOINT DIS
O'CONNOR HOSPITAL
OLEAN GENERAL HOSPITAL
$0.00
$2,162.78
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
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$0.00
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$0.00
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$187.52
$0.00
$0.00
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$0.00
$0.00
$0.00
$0.00
$555.26
$0.00
$721.64
$678.01
$0.00
$0.00
$726.46
$0.00
$0.00
$720.16
$782.82
$0.00
$727.75
$0.00
$0.00
$0.00
$0.00
$497.03
$499.22
$0.00
$733.15
$746.58
$0.00
$650.11
$0.00
$0.00
$0.00
$686.55
$718.75
$718.75
$626.59
$687.71
$687.71
$0.00
$607.61
$78.06
$0.00
$57.82
$28.63
$0.00
$0.00
$125.20
$0.00
$0.00
$145.99
$76.83
$0.00
$32.62
$0.00
$0.00
$0.00
$0.00
$22.02
$36.24
$0.00
$28.37
$51.30
$0.00
$83.26
$0.00
$0.00
$0.00
$70.21
$81.98
$81.98
$15.91
$186.32
$186.32
$0.00
$45.36
$0.00
$0.00
$538.26
$0.06
$0.00
$0.00
$180.18
$0.00
$0.00
$78.95
$44.74
$0.00
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$469.17
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$0.00
$81.23
$66.56
$66.56
$0.00
$391.91
$391.91
$0.00
$0.00
$242.78
$0.00
$315.53
$296.46
$0.00
$0.00
$317.64
$0.00
$0.00
$314.89
$342.29
$0.00
$318.20
$0.00
$0.00
$0.00
$0.00
$217.33
$218.28
$0.00
$320.56
$326.44
$0.00
$284.26
$0.00
$0.00
$0.00
$300.19
$314.27
$314.27
$273.98
$300.70
$300.70
$0.00
$215.84
$187.52
$0.00
$254.96
$254.96
$0.00
$0.00
$254.96
$0.00
$0.00
$254.96
$254.96
$0.00
$254.96
$0.00
$0.00
$0.00
$0.00
$187.52
$187.52
$0.00
$254.96
$254.96
$0.00
$254.96
$0.00
$0.00
$0.00
$254.96
$254.96
$254.96
$254.96
$254.96
$254.96
$0.00
$187.52
$317.27
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$0.00
$0.00
$0.00
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$670.54
$0.00
$0.00
$0.00
$606.07
$339.47
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$0.00
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$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
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$680.45
$680.45
$459.00
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$2.15
$2.15
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$187.52
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$187.52
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$0.00
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
Published Separately
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%
Page 6 of 8
NYS DEPARTMENT OF HEALTH
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT EXEMPT UNIT RATES - EFFECTIVE 1/1/2015 - 12/31/2015
(1)
(2)
(3)
(4)
(5)
SPECIALTY HOSPITAL
(6)
(7)
(8)
PSYCHIATRIC
(9)
(10)
(11)
CHEMICAL DEPENDENCY REHAB
(12)
SPECIALTY
SPECIALTY
ACUTE, LONG*Informational
ACUTE, LONGTERM CARE Only* SPECIALTY TERM CARE
*Informational
AND
ACUTE, LONGAND
PSYCHIATRIC
CHEMICAL
Only*
CRITICAL
CHILDREN'S
TERM CARE AND CHILDREN'S
NON*Informational
DEPENDENCY
CHEMICAL
CHEMICAL
ACCESS
HOSPITAL
CHILDREN'S
HOSPITAL
PSYCHIATRIC OPERATING
Only*
PSYCHIATRIC
REHAB
DEPENDENCY DEPENDENCY
HOSPITAL
BILLING RATE HOSPITAL DME ALC PER DIEM
OPERATING BILLING RATE PSYCHIATRIC
ECT
PSYCHIATRIC BILLING RATE
REHAB
REHAB
BILLING RATE
(w/out DME)
Add-on
(w/out DME)
BILLING RATE (w/out DME)
DME Add-on
PAYMENT
ALC PER DIEM (w/out DME)
DME Add-on ALC PER DIEM (w/out DME)
OPCERT
2601001
3523000
3702000
0301001
5155000
5932000
2952005
3950000
7003007
7004010
2221700
2701003
7002031
3201002
1401010
4102002
2201000
4501000
4823700
1401013
6120700
2950001
5126000
5154000
3529000
7000014
5157003
5149001
3202002
2953000
5002001
7001024
5907001
2952006
0701001
3301003
5907002
3522000
2801001
4102003
0101004
7001037
7004003
2701005
4353000
4601004
2754001
0427000
1227001
0303001
1801000
5151001
3301007
3301007
1302001
5957001
0632000
5902001
5902002
2908000
0602001
7001045
7001035
(13)
CRITICAL ACCESS HOSPITAL
CRITICAL
ACCESS
HOSPITAL
ALC PER
DIEM
(14)
(15)
(16)
MEDICAL REHABILITATION
(17)
(18)
DETOX
(19)
HCRA SURCHARGE
MEDICAL *Informational
DETOXDETOX REHAB
Only*
MEDICAL
MEDICALLY
MEDICALLY
INDIGENT CARE
BILLING
MEDICAL
REHAB
MANAGED
SUPERVISED AND HEALTH CARE
RATE (w/out REHAB DME ALC PER WITHDRAWAL WITHDRAWAL
INITIATIVE
DME)
Add-on
DIEM
BILLING RATE BILLING RATE
SURCHARGE
HOSPITAL NAME
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
RIVER HOSPITAL
ROCHESTER GENERAL HOSPITAL
ROCKEFELLER UNIVERSITY
ROME HOSPITAL AND MURPHY
ROSWELL PARK CANCER INSTITUTE
SAMARITAN HOSPITAL OF TROY
SAMARITAN MEDICAL CENTER
SARATOGA HOSPITAL
SCHUYLER HOSPITAL
SISTERS OF CHARITY HOSPITAL
SOLDIERS AND SAILORS MEM HOSP
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 / ROSLYN
ST JAMES MERCY HOSPITAL
ST JOHNS EPISCOPAL SO SHORE
ST JOHNS RIVERSIDE HOSPITAL
ST JOSEPH HOSPITAL
ST JOSEPHS HOSP / ELMIRA
ST JOSEPHS HOSP HLTH CTR
ST JOSEPHS HOSPITAL YONKERS
ST LUKES CORNWALL HOSPITAL
ST MARYS HOSP / AMSTERDAM
ST MARYS HOSPITAL
ST PETERS HOSPITAL
STATE UNIV HOSP / DOWNSTATE
STATEN ISLAND UNIV HOSP
STRONG MEMORIAL HOSPITAL
SUMMIT PARK HOSPITAL
SUNNYVIEW HOSP AND REHAB
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
WESTCHESTER MEDICAL CENTER
WESTFIELD MEMORIAL HOSP
WHITE PLAINS HOSPITAL
WINIFRED MASTERSON BURKE REHAB HOSPITAL
WINTHROP UNIVERSITY HOSPITAL
WOMANS CHRISTIAN ASSOC
WOODHULL MEDICAL
WYCKOFF HEIGHTS HOSPITAL
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$2,218.80
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$2,622.37
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$36.96
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$254.96
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$254.96
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$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$639.96
$650.96
$0.00
$0.00
$642.66
$0.00
$659.18
$732.50
$642.53
$0.00
$545.68
$0.00
$495.30
$0.00
$510.98
$667.96
$534.82
$0.00
$0.00
$530.32
$619.01
$0.00
$672.74
$0.00
$659.82
$679.87
$0.00
$539.26
$0.00
$0.00
$767.14
$0.00
$0.00
$477.43
$567.85
$658.41
$0.00
$597.72
$0.00
$0.00
$701.08
$654.10
$578.14
$0.00
$0.00
$498.19
$539.81
$0.00
$545.23
$0.00
$659.18
$590.22
$595.36
$0.00
$732.18
$0.00
$0.00
$0.00
$0.00
$586.64
$653.91
$0.00
$0.00
$150.22
$52.05
$0.00
$0.00
$77.99
$0.00
$61.61
$65.66
$19.64
$0.00
$59.70
$0.00
$14.88
$0.00
$21.21
$42.57
$65.00
$0.00
$0.00
$56.51
$120.63
$0.00
$53.25
$0.00
$74.61
$58.48
$0.00
$27.40
$0.00
$0.00
$45.38
$0.00
$0.00
$10.95
$59.31
$26.63
$0.00
$20.80
$0.00
$0.00
$109.45
$67.12
$75.33
$0.00
$0.00
$56.04
$41.03
$0.00
$39.91
$0.00
$46.99
$36.33
$36.33
$0.00
$78.06
$0.00
$0.00
$0.00
$0.00
$28.82
$37.10
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$215.88
$8.99
$0.00
$1.17
$0.00
$0.00
$0.00
$0.00
$0.29
$0.00
$0.00
$0.00
$0.00
$0.66
$0.00
$0.07
$0.00
$23.69
$0.00
$0.00
$0.15
$0.00
$0.00
$85.53
$0.00
$0.00
$0.00
$0.23
$29.74
$0.00
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Page 7 of 8
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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%
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%
NYS DEPARTMENT OF HEALTH
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT EXEMPT UNIT RATES - EFFECTIVE 1/1/2015 - 12/31/2015
(1)
(2)
(3)
(4)
(5)
SPECIALTY HOSPITAL
(6)
(7)
(8)
PSYCHIATRIC
(9)
(10)
(11)
(12)
CHEMICAL DEPENDENCY REHAB
(13)
SPECIALTY
SPECIALTY
ACUTE, LONG*Informational
ACUTE, LONGTERM CARE Only* SPECIALTY TERM CARE
*Informational
AND
ACUTE, LONGAND
PSYCHIATRIC
CHEMICAL
Only*
CRITICAL
CHILDREN'S
TERM CARE AND CHILDREN'S
NON*Informational
DEPENDENCY
CHEMICAL
CHEMICAL
ACCESS
HOSPITAL
CHILDREN'S
HOSPITAL
PSYCHIATRIC OPERATING
Only*
PSYCHIATRIC
REHAB
DEPENDENCY DEPENDENCY
HOSPITAL
BILLING RATE HOSPITAL DME ALC PER DIEM
OPERATING BILLING RATE PSYCHIATRIC
ECT
PSYCHIATRIC BILLING RATE
REHAB
REHAB
BILLING RATE
(w/out DME)
Add-on
(w/out DME)
BILLING RATE (w/out DME)
DME Add-on
PAYMENT
ALC PER DIEM (w/out DME)
DME Add-on ALC PER DIEM (w/out DME)
OPCERT
(14)
CRITICAL ACCESS HOSPITAL
CRITICAL
ACCESS
HOSPITAL
ALC PER
DIEM
(15)
(16)
MEDICAL REHABILITATION
(17)
(18)
DETOX
(19)
HCRA SURCHARGE
MEDICAL *Informational
DETOXDETOX REHAB
Only*
MEDICAL
MEDICALLY
MEDICALLY
INDIGENT CARE
BILLING
MEDICAL
REHAB
MANAGED
SUPERVISED AND HEALTH CARE
RATE (w/out REHAB DME ALC PER WITHDRAWAL WITHDRAWAL
INITIATIVE
DME)
Add-on
DIEM
BILLING RATE BILLING RATE
SURCHARGE
HOSPITAL NAME
6027000 WYOMING CO COMMUNITY HOSP
$0.00
$0.00
$0.00
$613.78
$48.50
$0.00
$218.03
Page 8 of 8
$187.52
$0.00
$0.00
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7.04%