NYS DEPARTMENT OF HEALTH
SCHEDULE OF MEDICAID FEE-FOR-SERVICE (MA FFS)
INPATIENT CASE PAYMENT RATES - EFFECTIVE 1/1/2015 - 3/31/2015
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
ADMISSION RATE
DISCHARGE
RATE
STATEWIDE
PRICE
ISAF
HIGH COST CC's
IME %'s
DME RATE
CAPITAL RATE - PER
DISCH
CAPITAL RATE PER DIEM
ALC
HCRA
SURCHARGE
DISCHARGE
ADMISSION CASE CASE PAYMENT STATEWIDE BASE INSTITUTIONPAYMENT RATE
RATE
PRICE
SPECIFIC
(INCLUDING PHL § (INCLUDING PHL (INCLUDING PHL § ADJUSTMENT
2807-c(33))
§ 2807-c(33))
2807-c(33))
FACTOR (ISAF)
HIGH COST
CHARGE
CONVERTOR
(2011)
INDIRECT
MEDICAL
EDUCATION
(IME) %
DIRECT
MEDICAL
EDUCATION
(DME) ADDON
CAPITAL PER DISCHARGE
PLUS NONINDIGENT
COMPARABLES:
AMBULANCE, SCHOOL OF
CARE AND
NURSING, TEACHING
HEALTH CARE
ELECTION AMENDMENT
ALC PRICE
INITIATIVE
PHYS
CAPITAL PER DIEM PER DAY
SURCHARGE
**(PER DISCH)**
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
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
(2960)
$5,474.80
$13,222.73
$13,222.73
$5,335.35
$3,326.28
$4,194.10
$3,523.59
$3,324.52
$13,811.31
$3,263.52
$4,666.25
$11,416.85
$11,998.66
$7,090.17
$9,552.04
$2,385.28
$2,165.09
$3,783.38
$5,548.29
$4,916.03
$4,209.67
$2,466.93
$3,388.94
$6,752.55
$4,052.85
$4,269.43
(2946)
$5,706.48
$6,865.18
$6,865.18
$5,450.91
$5,565.13
$5,569.11
$5,956.04
$5,462.57
$10,112.17
$4,886.24
$6,441.54
$9,196.80
$8,777.18
$7,084.49
$8,742.95
$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%
(2589)
$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
$8,703.35
$3,456.57
$4,285.59
$8,252.69
$7,993.96
$3,249.45
$4,992.99
$10,397.58
$12,313.77
$3,043.82
$4,243.13
$9,045.08
$6,320.66
$8,453.20
$6,071.62
$5,520.54
$6,542.09
$7,011.01
$5,520.64
$6,187.26
$9,580.91
$7,354.12
$4,922.88
$5,749.46
$8,440.87
$8,251.77
$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
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
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%
$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
Page 1 of 9
(2990)
**(PER DAY**)
$451.65
$1,358.97
$1,358.97
$668.22
$220.99
$417.82
$270.30
$428.55
$2,000.85
$180.74
$562.89
$563.47
$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
(2991)
$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
(2950,2951)
$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%
$3,512.22
$583.88
$572.65
$589.14
$471.60
$237.08
$478.55
$2,169.56
$948.36
$471.59
$569.70
$661.13
$357.12
$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
$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
7.04%
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 FEE-FOR-SERVICE (MA FFS)
INPATIENT CASE PAYMENT RATES - EFFECTIVE 1/1/2015 - 3/31/2015
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
ADMISSION RATE
DISCHARGE
RATE
STATEWIDE
PRICE
ISAF
HIGH COST CC's
IME %'s
DME RATE
CAPITAL RATE - PER
DISCH
CAPITAL RATE PER DIEM
ALC
HCRA
SURCHARGE
DISCHARGE
ADMISSION CASE CASE PAYMENT STATEWIDE BASE INSTITUTIONPAYMENT RATE
RATE
PRICE
SPECIFIC
(INCLUDING PHL § (INCLUDING PHL (INCLUDING PHL § ADJUSTMENT
2807-c(33))
§ 2807-c(33))
2807-c(33))
FACTOR (ISAF)
HIGH COST
CHARGE
CONVERTOR
(2011)
INDIRECT
MEDICAL
EDUCATION
(IME) %
DIRECT
MEDICAL
EDUCATION
(DME) ADDON
0.86%
0.00%
4.08%
0.00%
0.00%
6.56%
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%
22.03%
28.56%
11.01%
11.38%
(2589)
$52.16
$0.00
$119.55
$0.00
$0.00
$210.30
$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
$2,018.94
$3,092.37
$1,113.04
$957.05
CAPITAL PER DISCHARGE
PLUS NONINDIGENT
COMPARABLES:
AMBULANCE, SCHOOL OF
CARE AND
NURSING, TEACHING
HEALTH CARE
ELECTION AMENDMENT
ALC PRICE
INITIATIVE
PHYS
CAPITAL PER DIEM PER DAY
SURCHARGE
**(PER DISCH)**
OPCERT
2910000
3402000
2901000
5601000
4329000
5154001
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
5957001
7000006
5903001
5904001
HOSPITAL NAME
FRANKLIN HOSPITAL
GENEVA GENERAL HOSPITAL
GLEN COVE HOSPITAL
GLENS FALLS HOSPITAL
GOOD SAMARITAN / SUFFERN
GOOD SAMARITAN / WEST ISLIP
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
MID-HUDSON VALLEY DIV OF WESTCHESTER MED CTR
MONTEFIORE MEDICAL CENTER
MONTEFIORE MOUNT VERNON HOSP
MONTEFIORE NEW ROCHELLE HOSP
(2960)
$7,216.30
$2,850.27
$8,746.94
$4,626.62
$8,020.13
$8,197.86
$10,804.89
$5,967.18
$7,109.83
$5,704.30
$16,853.16
$7,080.27
$9,429.76
$3,442.29
$13,176.06
$9,163.68
$7,723.18
$3,063.48
$10,030.77
$10,030.77
$11,724.40
$6,331.63
$12,220.44
$11,301.24
$10,591.66
$2,702.22
$9,838.44
$15,994.37
$10,172.73
$16,255.55
$6,366.75
$3,067.87
$3,269.11
$6,222.34
$7,456.77
$10,292.38
$20,104.54
$16,143.87
$8,896.05
$5,694.28
(2946)
$7,159.84
$5,205.98
$8,247.19
$5,651.18
$7,245.58
$7,427.52
$9,864.96
$6,479.33
$6,063.57
$6,419.07
$9,823.15
$7,328.91
$9,052.12
$5,160.86
$9,891.70
$8,945.49
$7,632.37
$5,153.91
$7,232.11
$7,232.11
$8,035.72
$5,982.84
$9,171.43
$9,513.90
$8,632.68
$5,622.60
$9,547.79
$9,848.73
$9,372.96
$10,220.52
$5,942.02
$5,539.67
$4,431.49
$6,161.00
$7,044.60
$10,174.80
$9,502.23
$9,889.00
$8,164.29
$7,225.79
$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
1.0325
0.7594
1.1263
0.8031
1.0583
1.0250
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
1.1410
1.1300
1.0154
1.0106
Page 2 of 9
0.279524
0.568222
0.303907
0.456191
0.220855
0.225889
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
0.303204
0.272430
0.539888
0.528855
(2990)
$456.80
$546.30
$592.28
$614.64
$427.30
$410.65
$3,926.73
$288.29
$926.56
$446.71
$2,059.75
$574.83
$818.84
$427.35
$3,395.16
$675.67
$655.27
$210.51
$921.53
$921.53
$390.62
$491.27
$3,095.69
$441.11
$1,481.55
$465.66
$2,518.99
$845.06
$412.84
$1,009.03
$538.12
$405.25
$165.61
$462.16
$444.33
$682.73
$2,499.44
$778.03
$326.30
$486.07
**(PER DAY**)
(2991)
$90.60
$97.19
$122.82
$132.13
$107.84
$82.98
$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
$310.83
$145.22
$58.34
$91.99
(2950,2951)
$254.96
$187.52
$254.96
$187.52
$254.96
$254.96
$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
$254.96
$254.96
$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%
7.04%
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 FEE-FOR-SERVICE (MA FFS)
INPATIENT CASE PAYMENT RATES - EFFECTIVE 1/1/2015 - 3/31/2015
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
ADMISSION RATE
DISCHARGE
RATE
STATEWIDE
PRICE
ISAF
HIGH COST CC's
IME %'s
DME RATE
CAPITAL RATE - PER
DISCH
CAPITAL RATE PER DIEM
ALC
HCRA
SURCHARGE
DISCHARGE
ADMISSION CASE CASE PAYMENT STATEWIDE BASE INSTITUTIONPAYMENT RATE
RATE
PRICE
SPECIFIC
(INCLUDING PHL § (INCLUDING PHL (INCLUDING PHL § ADJUSTMENT
2807-c(33))
§ 2807-c(33))
2807-c(33))
FACTOR (ISAF)
HIGH COST
CHARGE
CONVERTOR
(2011)
INDIRECT
MEDICAL
EDUCATION
(IME) %
DIRECT
MEDICAL
EDUCATION
(DME) ADDON
CAPITAL PER DISCHARGE
PLUS NONINDIGENT
COMPARABLES:
AMBULANCE, SCHOOL OF
CARE AND
NURSING, TEACHING
HEALTH CARE
ELECTION AMENDMENT
ALC PRICE
INITIATIVE
PHYS
CAPITAL PER DIEM PER DAY
SURCHARGE
**(PER DISCH)**
OPCERT
7002002
7001041
7002024
7002024
7002032
3121001
2950002
1701000
7002054
7002026
HOSPITAL NAME
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
NEW YORK EYE AND EAR INFIRMARY OF MOUNT SINAI
5901000 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
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
(2960)
$10,999.18
$9,118.39
$15,702.39
$15,702.39
$13,116.05
$4,249.08
$9,374.13
$3,289.67
$16,722.67
$10,081.41
(2946)
$10,218.30
$9,030.79
$9,222.57
$9,222.57
$10,609.63
$5,919.59
$8,993.55
$5,363.89
$9,763.96
$9,932.63
$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
1.1082
1.1310
1.0801
1.0801
1.1643
0.8399
1.1122
0.7562
1.1302
0.9806
0.308539
0.183347
0.384940
0.384940
0.340470
0.587047
0.501971
0.439216
0.364115
0.444781
26.62%
0.38%
25.76%
25.76%
25.10%
0.00%
25.88%
0.00%
26.54%
31.64%
(2589)
$681.76
$0.00
$1,430.47
$1,430.47
$1,079.42
$0.00
$1,620.79
$0.00
$1,549.47
$744.74
$5,250.33
$5,690.04
$3,799.71
$4,323.35
$2,923.00
$7,198.47
$16,218.97
$4,991.00
$5,761.28
$6,214.01
$9,751.36
$9,225.77
$16,722.67
$16,722.67
$16,722.67
$5,539.35
$16,864.16
$16,864.16
$3,122.08
$2,785.25
$5,672.63
$3,459.48
$4,446.02
$6,284.47
$4,635.00
$7,966.70
$9,053.27
$8,733.83
$8,991.19
$6,591.75
$6,960.30
$5,610.08
$5,480.92
$5,064.10
$8,344.50
$9,412.22
$6,617.61
$6,977.45
$7,799.69
$8,722.49
$8,532.59
$9,763.96
$9,763.96
$9,763.96
$6,697.31
$8,910.47
$8,910.47
$5,191.43
$5,167.43
$6,885.93
$5,683.39
$5,801.75
$7,181.63
$7,439.35
$7,927.19
$7,051.38
$9,314.06
$7,722.06
$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
0.282930
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
0.00%
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%
$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
Page 3 of 9
(2990)
**(PER DAY**)
$877.92
$181.01
$796.61
$796.61
$932.16
$332.26
$494.98
$216.70
$1,463.98
$689.21
(2991)
$181.32
$30.84
$152.82
$152.82
$179.34
$80.16
$89.53
$57.72
$207.84
$291.92
(2950,2951)
$254.96
$254.96
$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%
$1,296.00
$558.30
$263.30
$522.44
$404.51
$2,080.36
$1,274.83
$323.69
$614.71
$374.53
$1,053.74
$291.92
$1,463.98
$1,463.98
$1,463.98
$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
$2,031.38
$701.51
$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
$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
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
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 FEE-FOR-SERVICE (MA FFS)
INPATIENT CASE PAYMENT RATES - EFFECTIVE 1/1/2015 - 3/31/2015
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
ADMISSION RATE
DISCHARGE
RATE
STATEWIDE
PRICE
ISAF
HIGH COST CC's
IME %'s
DME RATE
CAPITAL RATE - PER
DISCH
CAPITAL RATE PER DIEM
ALC
HCRA
SURCHARGE
DISCHARGE
ADMISSION CASE CASE PAYMENT STATEWIDE BASE INSTITUTIONPAYMENT RATE
RATE
PRICE
SPECIFIC
(INCLUDING PHL § (INCLUDING PHL (INCLUDING PHL § ADJUSTMENT
2807-c(33))
§ 2807-c(33))
2807-c(33))
FACTOR (ISAF)
HIGH COST
CHARGE
CONVERTOR
(2011)
INDIRECT
MEDICAL
EDUCATION
(IME) %
DIRECT
MEDICAL
EDUCATION
(DME) ADDON
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%
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%
(2589)
$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
$1,058.92
$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
CAPITAL PER DISCHARGE
PLUS NONINDIGENT
COMPARABLES:
AMBULANCE, SCHOOL OF
CARE AND
NURSING, TEACHING
HEALTH CARE
ELECTION AMENDMENT
ALC PRICE
INITIATIVE
PHYS
CAPITAL PER DIEM PER DAY
SURCHARGE
**(PER DISCH)**
OPCERT
2701003
3201002
4102002
2201000
4501000
7000014
1401013
2950001
5126000
5154000
3529000
5157003
5149001
3202002
2953000
5002001
7001024
5907001
2952006
0701001
3301003
5907002
3522000
2801001
4102003
0101004
7001037
7004003
2701005
2754001
0427000
1227001
0303001
1801000
5151001
3301007
3301007
1302001
5957001
0632000
HOSPITAL NAME
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
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
(2960)
$7,163.22
$4,720.50
$4,242.30
$3,763.75
$3,898.69
$9,629.64
$6,456.09
$6,919.76
$6,600.83
$6,787.13
$4,252.33
$6,651.35
$5,454.85
$8,570.09
$17,293.18
$2,144.48
$10,587.24
$5,051.09
$7,734.99
$4,014.56
$6,340.32
$6,829.78
$5,915.50
$4,365.53
$4,766.77
$7,201.79
$12,857.98
$9,108.70
$14,750.25
$4,747.21
$4,891.88
$5,978.78
$7,544.15
$3,249.92
$13,790.60
$11,231.67
$11,231.67
$7,698.65
$20,104.54
$3,038.00
(2946)
$6,308.08
$5,516.53
$5,444.43
$5,812.63
$5,763.88
$9,086.39
$6,115.84
$6,890.61
$7,005.39
$7,638.34
$6,252.50
$7,207.79
$6,872.68
$5,984.31
$7,511.84
$4,492.00
$9,798.77
$6,784.54
$7,042.88
$5,107.58
$6,345.21
$7,766.61
$6,551.66
$5,204.49
$5,385.57
$6,059.13
$8,324.71
$8,324.61
$7,878.51
$5,674.30
$4,814.37
$5,978.78
$6,234.40
$5,279.27
$8,793.09
$7,983.23
$7,983.23
$6,814.77
$9,502.23
$4,721.06
$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
0.8156
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
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
Page 4 of 9
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
0.388042
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
(2990)
$645.64
$184.93
$411.34
$482.54
$518.86
$548.28
$313.73
$757.34
$720.43
$543.96
$437.76
$597.46
$492.78
$681.52
$1,361.99
$188.88
$411.31
$521.08
$498.63
$754.35
$931.76
$626.52
$667.52
$207.25
$630.71
$909.94
$1,139.40
$495.83
$837.53
$833.31
$482.13
$233.34
$452.36
$316.77
$751.69
$852.40
$852.40
$464.71
$2,499.44
$2,795.58
**(PER DAY**)
(2991)
$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
$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
(2950,2951)
$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
$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
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
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 FEE-FOR-SERVICE (MA FFS)
INPATIENT CASE PAYMENT RATES - EFFECTIVE 1/1/2015 - 3/31/2015
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
ADMISSION RATE
DISCHARGE
RATE
STATEWIDE
PRICE
ISAF
HIGH COST CC's
IME %'s
DME RATE
CAPITAL RATE - PER
DISCH
CAPITAL RATE PER DIEM
ALC
HCRA
SURCHARGE
DISCHARGE
ADMISSION CASE CASE PAYMENT STATEWIDE BASE INSTITUTIONPAYMENT RATE
RATE
PRICE
SPECIFIC
(INCLUDING PHL § (INCLUDING PHL (INCLUDING PHL § ADJUSTMENT
2807-c(33))
§ 2807-c(33))
2807-c(33))
FACTOR (ISAF)
HIGH COST
CHARGE
CONVERTOR
(2011)
INDIRECT
MEDICAL
EDUCATION
(IME) %
DIRECT
MEDICAL
EDUCATION
(DME) ADDON
0.00%
16.78%
0.00%
19.40%
20.13%
0.00%
(2589)
$0.00
$947.46
$0.00
$1,987.71
$684.51
$0.00
CAPITAL PER DISCHARGE
PLUS NONINDIGENT
COMPARABLES:
AMBULANCE, SCHOOL OF
CARE AND
NURSING, TEACHING
HEALTH CARE
ELECTION AMENDMENT
ALC PRICE
INITIATIVE
PHYS
CAPITAL PER DIEM PER DAY
SURCHARGE
**(PER DISCH)**
OPCERT
5902001
2908000
0602001
7001045
7001035
6027000
HOSPITAL NAME
WHITE PLAINS HOSPITAL
WINTHROP UNIVERSITY HOSPITAL
WOMANS CHRISTIAN ASSOC
WOODHULL MEDICAL
WYCKOFF HEIGHTS HOSPITAL
WYOMING CO COMMUNITY HOSP
(2960)
$5,884.25
$9,995.52
$3,829.62
$8,566.88
$8,440.86
$2,697.66
(2946)
$7,116.89
$8,291.84
$5,116.40
$8,055.79
$8,598.10
$5,392.08
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
$6,931.12
0.9862
1.0394
0.7224
1.0415
1.0022
0.7890
Page 5 of 9
0.419909
0.303881
0.471825
0.908330
0.407080
0.954952
(2990)
$562.08
$717.51
$402.78
$3,910.48
$670.01
$527.52
**(PER DAY**)
(2991)
$123.01
$143.98
$106.65
$99.26
$108.81
$126.98
(2950,2951)
$254.96
$254.96
$187.52
$254.96
$254.96
$187.52
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
NYS DEPARTMENT OF HEALTH
SCHEDULE OF MEDICAID FEE-FOR-SERVICE (MA FFS)
INPATIENT EXEMPT UNIT RATES - EFFECTIVE 1/1/2015 - 12/31/2015
(1)
(2)
SPECIALTY HOSPITAL
OPCERT
1623001
0101000
0101000
0101003
1624000
0701000
0501000
3801000
7002001
1427000
5957000
3535001
7000001
7001002
5123000
7001003
0601000
7000011
4429000
2238700
5263700
5263000
5401001
0901001
0824000
4401000
3421000
4458701
4720001
7002051
1001000
2625700
7001009
5001000
1101000
3301008
0226700
1229700
5127000
3101000
1552701
5526700
4601001
7003000
1401005
3429000
3202003
7003001
7003013
2910000
3402000
2901000
5601000
4329000
HOSPITAL NAME
ADIRONDACK MEDICAL CENTER
ALB MED CTR SO CLINICAL CAMP
ALBANY MEDICAL CTR HOSP
ALBANY MEMORIAL HOSPITAL
ALICE HYDE MEDICAL CENTER
ARNOT OGDEN MEDICAL CTR
AUBURN MEMORIAL HOSPITAL
AURELIA OSBORN FOX MEM HOSP
BELLEVUE HOSPITAL CENTER
BERTRAND CHAFFEE HOSPITAL
BLYTHEDALE CHILDRENS HOSP
BON SECOURS COMMUNITY HOSP
BRONX-LEBANON HOSPITAL CTR
BROOKDALE HOSPITAL MED CTR
BROOKHAVEN MEMORIAL HOSP
BROOKLYN HOSPITAL CENTER
BROOKS MEMORIAL HOSPITAL
CALVARY HOSPITAL
CANTON-POTSDAM HOSPITAL
CARTHAGE AREA HOSPITAL INC
CATSKILL REGIONAL / G HERMANN
CATSKILL REGIONAL MED CTR
CAYUGA MEDICAL CENTER
CHAMPLAIN VALLEY PHYS
CHENANGO MEMORIAL HOSP
CLAXTON-HEPBURN MED CTR
CLIFTON SPRINGS HOSPITAL
CLIFTON-FINE HOSPITAL
COBLESKILL REGIONAL HOSP
COLER MEMORIAL HOSP
COLUMBIA MEMORIAL HOSPITAL
COMMUNITY MEMORIAL HOSPITAL
CONEY ISLAND HOSPITAL
CORNING HOSPITAL
CORTLAND REGIONAL MED CTR
CROUSE HOSPITAL
CUBA MEMORIAL HOSPITAL
DELAWARE VALLEY HOSPITAL
EASTERN LONG ISLAND HOSPITAL
EASTERN NIAGARA HOSPITAL
ELIZABETHTOWN COMMUNITY HOSP
ELLENVILLE REGIONAL 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
(3)
(4)
(5)
(6)
PSYCHIATRIC
(7)
(8)
CHEMICAL DEPENDENCY REHAB
(9)
(10)
CRITICAL ACCESS HOSPITAL
(11)
(12)
MEDICAL REHABILITATION
(13)
(14)
DETOX
(15)
HCRA SURCHARGE
SPECIALTY
SPECIALTY
DETOX DETOX ACUTE, LONGACUTE, LONGINDIGENT CARE
MEDICALLY
MEDICALLY
CRITICAL
CRITICAL
CHEMICAL
CHEMICAL
PSYCHIATRIC
TERM CARE AND TERM CARE AND
SUPERVISED AND HEALTH CARE
MANAGED
MEDICAL
MEDICAL
ACCESS
ACCESS
DEPENDENCY
DEPENDENCY
PSYCHIATRIC
NONPSYCHIATRIC
CHILDREN'S
CHILDREN'S
INITIATIVE
REHAB ALC WITHDRAWAL WITHDRAWAL
REHAB
HOSPITAL
HOSPITAL
REHAB
REHAB
ECT
PSYCHIATRIC
OPERATING
OPERATING
HOSPITAL
HOSPITAL
SURCHARGE
BILLING RATE BILLING RATE
ALC PER DIEM BILLING RATE ALC PER DIEM BILLING RATE PER DIEM
PAYMENT
ALC PER DIEM BILLING RATE
ALC PER DIEM BILLING RATE BILLING RATE
BILLING RATE
(2947,2948)
(2966,2967)
(2968,2969)
(2949,2959)
(2954,2955)
(2852)
(2571)
(2570)
(2962,2963)
(2957, 2993)
(3118,3119)
(2999)
(2853,2948)
(2970,2971)
(4800)
(4801)
Published Separately
$0.00
$0.00
$651.19
$41.79
$231.32
$187.52
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$558.41
$103.40
$244.16
$187.52
$0.00
$0.00
$0.00
$0.00
$1,059.67
$187.52
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$682.04
$29.34
$242.28
$187.52
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$657.63
$167.23
$287.55
$254.96
$0.00
$0.00
$0.00
$0.00
$1,156.20
$254.96
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$1,629.26
$254.96
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$589.64
$34.22
$257.82
$187.52
$548.29
$187.52
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$684.30
$252.93
$299.21
$254.96
$675.32
$254.96
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$673.25
$127.86
$294.38
$254.96
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$654.42
$35.14
$286.14
$254.96
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,314.82
$254.96
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$1,064.14
$254.96
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$459.42
$187.52
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$2,329.82
$187.52
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$2,375.42
$187.52
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$723.73
$22.41
$257.09
$187.52
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$697.07
$39.82
$247.62
$187.52
$0.00
$0.00
$0.00
$0.00
$986.78
$187.52
7.04%
Published Separately
$0.00
$0.00
$664.72
$63.36
$236.12
$187.52
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published
Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$608.48
$45.34
$216.15
$187.52
$0.00
$0.00
$0.00
$0.00
$887.20
$187.52
7.04%
Published Separately
$0.00
$0.00
$446.52
$18.93
$195.24
$187.52
$281.65
$187.52
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$2,310.80
$187.52
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$619.72
$254.96
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$649.06
$23.17
$230.56
$187.52
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$2,345.81
$187.52
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$649.73
$171.32
$284.09
$254.96
$0.00
$0.00
$0.00
$0.00
$1,121.07
$254.96
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$635.21
$107.55
$225.64
$187.52
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$392.68
$187.52
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$2,295.40
$187.52
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,085.19
$187.52
$1,085.19
$187.52
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$636.49
$37.47
$278.30
$254.96
$620.86
$254.96
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$519.46
$8.46
$227.13
$187.52
$296.28
$187.52
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,956.96
$187.52
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,789.11
$187.52
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$539.90
$46.89
$236.07
$187.52
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$691.69
$307.74
$302.44
$254.96
$0.00
$0.00
$0.00
$0.00
$1,452.35
$254.96
7.04%
Published Separately
$0.00
$0.00
$592.40
$73.20
$259.03
$187.52
$292.75
$187.52
$0.00
$0.00
$1,076.03
$187.52
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$657.20
$60.69
$233.45
$187.52
$0.00
$0.00
$0.00
$0.00
$948.91
$187.52
7.04%
Published Separately
$0.00
$0.00
$664.00
$163.01
$290.33
$254.96
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published
Separately
$0.00
$0.00
$631.67
$41.57
$276.19
$254.96
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,205.38
$187.52
7.04%
Published Separately
$0.00
$0.00
$725.43
$47.43
$317.19
$254.96
$0.00
$0.00
$0.00
$0.00
$1,074.92
$254.96
7.04%
Published Separately
$0.00
$0.00
$644.55
$67.73
$228.96
$187.52
$0.00
$0.00
$0.00
$0.00
$1,069.38
$187.52
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$583.65
$254.96
$0.00
$0.00
$0.00
$0.00
7.04%
Page 6 of 9
NYS DEPARTMENT OF HEALTH
SCHEDULE OF MEDICAID FEE-FOR-SERVICE (MA FFS)
INPATIENT EXEMPT UNIT RATES - EFFECTIVE 1/1/2015 - 12/31/2015
(1)
(2)
(3)
(4)
SPECIALTY HOSPITAL
OPCERT
5154001
4423701
7002009
5501001
5501000
4322000
7002050
2701001
7002012
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
HOSPITAL NAME
GOOD SAMARITAN / WEST ISLIP
GOUVERNEUR HOSPITAL (formerly EJ Noble)
HARLEM HOSPITAL CENTER
HEALTHALLIANCE HOSP BROADWAY CAMPUS
HEALTHALLIANCE HOSP MARYS AVE CAMPUS
HELEN HAYES HOSPITAL
HENRY J CARTER SPECIALTY HOSPITAL
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 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
5957001
2701006
7000006
5903001
5904001
1564701
7002002
7001041
7003015
7002024
7002032
3121001
2950002
1701000
7002000
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 BROOKLYN
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
5901000
NEW YORK-PRESBYTERIAN HUDSON VALLEY HOSPITAL
(5)
(6)
(7)
PSYCHIATRIC
(8)
(9)
CHEMICAL DEPENDENCY REHAB
(10)
(11)
CRITICAL ACCESS HOSPITAL
(12)
MEDICAL REHABILITATION
(13)
(14)
DETOX
(15)
HCRA SURCHARGE
SPECIALTY
SPECIALTY
DETOX DETOX ACUTE, LONGACUTE, LONGINDIGENT CARE
MEDICALLY
MEDICALLY
CRITICAL
CRITICAL
CHEMICAL
CHEMICAL
PSYCHIATRIC
TERM CARE AND TERM CARE AND
SUPERVISED AND HEALTH CARE
MANAGED
MEDICAL
MEDICAL
ACCESS
ACCESS
DEPENDENCY
DEPENDENCY
PSYCHIATRIC
NONPSYCHIATRIC
CHILDREN'S
CHILDREN'S
INITIATIVE
REHAB ALC WITHDRAWAL WITHDRAWAL
REHAB
HOSPITAL
HOSPITAL
REHAB
REHAB
ECT
PSYCHIATRIC
OPERATING
OPERATING
HOSPITAL
HOSPITAL
SURCHARGE
BILLING RATE BILLING RATE
ALC PER DIEM BILLING RATE ALC PER DIEM BILLING RATE PER DIEM
PAYMENT
ALC PER DIEM BILLING RATE
ALC PER DIEM BILLING RATE BILLING RATE
BILLING RATE
(2947,2948)
(2966,2967)
(2968,2969)
(2949,2959)
(2954,2955)
(2852)
(2571)
(2570)
(2962,2963)
(2957, 2993)
(3118,3119)
(2999)
(2853,2948)
(2970,2971)
(4800)
(4801)
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$2,115.43
$187.52
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$675.37
$328.69
$295.30
$254.96
$0.00
$0.00
$0.00
$0.00
$2,214.66
$254.96
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$690.27
$30.72
$245.20
$187.52
$323.09
$187.52
$0.00
$0.00
$987.31
$187.52
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,273.37
$254.96
7.04%
Published Separately
$918.62
$254.96
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$679.93
$62.50
$297.30
$254.96
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$677.24
$68.38
$296.12
$254.96
$515.20
$254.96
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$712.90
$254.89
$311.71
$254.96
$0.00
$0.00
$0.00
$0.00
$1,392.66
$254.96
7.04%
Published
Separately
$0.00
$0.00
$722.41
$237.28
$315.87
$254.96
$0.00
$0.00
$0.00
$0.00
$1,310.38
$254.96
7.04%
Published Separately
$0.00
$0.00
$661.04
$66.97
$289.04
$254.96
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$903.33
$187.52
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$729.54
$187.52
7.04%
Published Separately
$0.00
$0.00
$651.98
$329.42
$285.07
$254.96
$0.00
$0.00
$0.00
$0.00
$1,859.84
$254.96
7.04%
Published Separately
$0.00
$0.00
$737.90
$48.91
$322.64
$254.96
$0.00
$0.00
$0.00
$0.00
$1,057.38
$254.96
7.04%
Published Separately
$0.00
$0.00
$668.82
$248.98
$292.44
$254.96
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$663.29
$288.11
$290.02
$254.96
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,510.81
$187.52
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$699.34
$135.86
$305.78
$254.96
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$653.71
$102.12
$285.83
$254.96
$0.00
$0.00
$0.00
$0.00
$813.25
$254.96
7.04%
Published Separately
$0.00
$0.00
$765.02
$100.46
$334.50
$254.96
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$2,071.02
$187.52
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
$0.00
$0.00
$596.29
$52.24
$211.82
$187.52
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$772.03
$187.52
7.04%
Published Separately
$3,150.29
$254.96
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$935.60
$187.52
7.04%
Published Separately
$0.00
$0.00
$653.39
$37.80
$285.69
$254.96
$0.00
$0.00
$0.00
$0.00
$894.53
$254.96
7.04%
Published Separately
$0.00
$0.00
$656.22
$292.80
$286.93
$254.96
$0.00
$0.00
$0.00
$0.00
$1,107.42
$254.96
7.04%
$0.00
$2,162.78
$0.00
$0.00
$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
$0.00
$0.00
$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
$78.06
$0.00
$596.08
$28.69
$0.00
$0.00
$305.38
$0.00
$0.00
$224.94
$121.57
$0.00
$55.38
$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
$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
$317.27
$0.00
$0.00
$0.00
$0.00
$0.00
$671.13
$0.00
$0.00
$0.00
$608.83
$339.47
$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
$254.96
$187.52
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$2,356.94
$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
$187.52
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,192.07
$0.00
$1,847.04
$0.00
$0.00
$0.00
$1,447.49
$0.00
$0.00
$1,439.26
$1,387.26
$0.00
$1,285.63
$0.00
$0.00
$187.52
$0.00
$254.96
$0.00
$0.00
$0.00
$254.96
$0.00
$0.00
$254.96
$254.96
$0.00
$254.96
$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
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Published Separately
7.04%
Page 7 of 9
NYS DEPARTMENT OF HEALTH
SCHEDULE OF MEDICAID FEE-FOR-SERVICE (MA FFS)
INPATIENT EXEMPT UNIT RATES - EFFECTIVE 1/1/2015 - 12/31/2015
(1)
(2)
SPECIALTY HOSPITAL
OPCERT
5922000
5820000
3102000
2527000
7000024
2951001
1327000
5920000
7001008
7002026
7003010
7001021
7002054
7002054
4324000
7002053
7002053
1254700
0401001
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
HOSPITAL NAME
NEW YORK-PRESBYTERIAN LAWRENCE HOSPITAL
NEWARK WAYNE COMMUNITY 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 (PRESBY)
NYACK HOSPITAL
NYU HOSPITALS CENTER
NYU HOSPITALS CENTER/HOSP FOR JOINT DIS
O'CONNOR HOSPITAL
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
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
(3)
(4)
(5)
(6)
PSYCHIATRIC
(7)
(8)
CHEMICAL DEPENDENCY REHAB
(9)
(10)
CRITICAL ACCESS HOSPITAL
(11)
(12)
MEDICAL REHABILITATION
(13)
(14)
DETOX
(15)
HCRA SURCHARGE
SPECIALTY
SPECIALTY
DETOX DETOX ACUTE, LONGACUTE, LONGINDIGENT CARE
MEDICALLY
MEDICALLY
CRITICAL
CRITICAL
CHEMICAL
CHEMICAL
PSYCHIATRIC
TERM CARE AND TERM CARE AND
SUPERVISED AND HEALTH CARE
MANAGED
MEDICAL
MEDICAL
ACCESS
ACCESS
DEPENDENCY
DEPENDENCY
PSYCHIATRIC
NONPSYCHIATRIC
CHILDREN'S
CHILDREN'S
INITIATIVE
REHAB ALC WITHDRAWAL WITHDRAWAL
REHAB
HOSPITAL
HOSPITAL
REHAB
REHAB
ECT
PSYCHIATRIC
OPERATING
OPERATING
HOSPITAL
HOSPITAL
SURCHARGE
BILLING RATE BILLING RATE
ALC PER DIEM BILLING RATE ALC PER DIEM BILLING RATE PER DIEM
PAYMENT
ALC PER DIEM BILLING RATE
ALC PER DIEM BILLING RATE BILLING RATE
BILLING RATE
(2947,2948)
(2966,2967)
(2968,2969)
(2949,2959)
(2954,2955)
(2852)
(2571)
(2570)
(2962,2963)
(2957, 2993)
(3118,3119)
(2999)
(2853,2948)
(2970,2971)
(4800)
(4801)
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$497.03
$22.02
$217.33
$187.52
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$499.22
$38.07
$218.28
$187.52
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
$0.00
$0.00
$733.15
$139.71
$320.56
$254.96
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$746.58
$520.47
$326.44
$254.96
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,212.91
$187.52
7.04%
Published Separately
$0.00
$0.00
$650.11
$83.26
$284.26
$254.96
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$686.55
$151.44
$300.19
$254.96
$0.00
$0.00
$0.00
$0.00
$880.85
$254.96
7.04%
Published Separately
7.04%
$0.00
$0.00
$718.75
$148.54
$314.27
$254.96
$682.60
$254.96
$0.00
$0.00
$1,572.93
$254.96
Published Separately
$0.00
$0.00
$718.75
$148.54
$314.27
$254.96
$682.60
$254.96
$0.00
$0.00
$1,572.93
$254.96
7.04%
Published Separately
$0.00
$0.00
$626.59
$15.91
$273.98
$254.96
$459.00
$254.96
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$687.71
$578.23
$300.70
$254.96
$0.00
$0.00
$0.00
$0.00
$1,633.20
$254.96
7.04%
Published Separately
$0.00
$0.00
$687.71
$578.23
$300.70
$254.96
$0.00
$0.00
$0.00
$0.00
$1,633.20
$254.96
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$2,323.03
$187.52
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$607.61
$45.36
$215.84
$187.52
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$639.96
$150.22
$279.82
$187.52
$0.00
$0.00
$0.00
$0.00
$1,101.91
$187.52
7.04%
Published Separately
$0.00
$0.00
$650.96
$52.05
$231.23
$187.52
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$564.49
$254.96
$0.00
$0.00
$1,316.84
$254.96
7.04%
$0.00
$0.00
$642.66
$77.99
$281.00
$254.96
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$659.18
$61.61
$288.22
$187.52
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$732.50
$281.54
$320.28
$254.96
$0.00
$0.00
$0.00
$0.00
$1,492.35
$254.96
7.04%
Published Separately
$0.00
$0.00
$642.53
$28.63
$280.94
$254.96
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$2,421.69
$187.52
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$545.68
$60.87
$238.60
$187.52
$0.00
$0.00
$0.00
$0.00
$1,214.55
$187.52
7.04%
Published Separately
$2,255.76
$254.96
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$495.30
$14.88
$216.57
$187.52
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$2,673.47
$187.52
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$510.98
$21.21
$223.42
$187.52
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$667.96
$42.86
$237.28
$187.52
$0.00
$0.00
$0.00
$0.00
$1,116.94
$187.52
7.04%
Published Separately
$0.00
$0.00
$534.82
$65.00
$233.85
$187.52
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,454.46
$187.52
$0.00
$0.00
7.04%
Published
Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$530.32
$56.51
$188.38
$187.52
$0.00
$0.00
$1,717.54
$187.52
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$619.01
$121.29
$270.66
$254.96
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$672.74
$53.32
$294.15
$254.96
$0.00
$0.00
$0.00
$0.00
$1,256.97
$254.96
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$659.82
$98.30
$288.50
$254.96
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$679.87
$58.48
$297.27
$254.96
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$287.31
$254.96
$0.00
$0.00
$857.01
$254.96
7.04%
Published Separately
$0.00
$0.00
$539.26
$27.55
$235.79
$187.52
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$295.68
$187.52
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$767.14
$130.91
$335.43
$254.96
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$472.70
$254.96
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$477.43
$10.95
$208.75
$187.52
$303.58
$187.52
$0.00
$0.00
$757.83
$187.52
7.04%
Page 8 of 9
NYS DEPARTMENT OF HEALTH
SCHEDULE OF MEDICAID FEE-FOR-SERVICE (MA FFS)
INPATIENT EXEMPT UNIT RATES - EFFECTIVE 1/1/2015 - 12/31/2015
(1)
(2)
SPECIALTY HOSPITAL
OPCERT
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
6027000
HOSPITAL NAME
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
WYOMING CO COMMUNITY HOSP
(3)
(4)
(5)
(6)
PSYCHIATRIC
(7)
(8)
CHEMICAL DEPENDENCY REHAB
(9)
(10)
CRITICAL ACCESS HOSPITAL
(11)
(12)
MEDICAL REHABILITATION
(13)
(14)
DETOX
(15)
HCRA SURCHARGE
SPECIALTY
SPECIALTY
DETOX DETOX ACUTE, LONGACUTE, LONGINDIGENT CARE
MEDICALLY
MEDICALLY
CRITICAL
CRITICAL
CHEMICAL
CHEMICAL
PSYCHIATRIC
TERM CARE AND TERM CARE AND
SUPERVISED AND HEALTH CARE
MANAGED
MEDICAL
MEDICAL
ACCESS
ACCESS
DEPENDENCY
DEPENDENCY
PSYCHIATRIC
NONPSYCHIATRIC
CHILDREN'S
CHILDREN'S
INITIATIVE
REHAB ALC WITHDRAWAL WITHDRAWAL
REHAB
HOSPITAL
HOSPITAL
REHAB
REHAB
ECT
PSYCHIATRIC
OPERATING
OPERATING
HOSPITAL
HOSPITAL
SURCHARGE
BILLING RATE BILLING RATE
ALC PER DIEM BILLING RATE ALC PER DIEM BILLING RATE PER DIEM
PAYMENT
ALC PER DIEM BILLING RATE
ALC PER DIEM BILLING RATE BILLING RATE
BILLING RATE
(2947,2948)
(2966,2967)
(2968,2969)
(2949,2959)
(2954,2955)
(2852)
(2571)
(2570)
(2962,2963)
(2957, 2993)
(3118,3119)
(2999)
(2853,2948)
(2970,2971)
(4800)
(4801)
Published Separately
$0.00
$0.00
$567.85
$59.54
$248.29
$187.52
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$658.41
$56.37
$287.88
$254.96
$358.97
$254.96
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$597.72
$20.80
$212.32
$187.52
$381.13
$187.52
$0.00
$0.00
$1,031.25
$187.52
7.04%
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Published Separately
$200.32
$187.52
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$431.73
$187.52
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$701.08
$274.87
$306.54
$254.96
$0.00
$0.00
$0.00
$0.00
$1,749.10
$254.96
7.04%
Published Separately
$0.00
$0.00
$654.10
$128.65
$286.00
$254.96
$547.45
$254.96
$0.00
$0.00
$1,284.18
$254.96
7.04%
Published Separately
$0.00
$0.00
$578.14
$109.54
$252.79
$187.52
$0.00
$0.00
$0.00
$0.00
$1,174.48
$187.52
7.04%
Published Separately
$937.84
$254.96
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$946.17
$187.52
7.04%
Published Separately
$0.00
$0.00
$498.19
$57.05
$217.83
$187.52
$376.42
$187.52
$0.00
$0.00
$1,107.11
$187.52
7.04%
Published Separately
$0.00
$0.00
$539.81
$41.03
$191.75
$187.52
$190.83
$187.52
$0.00
$0.00
$0.00
$0.00
7.04%
Published
Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$545.23
$40.67
$238.40
$187.52
$412.39
$187.52
$0.00
$0.00
$1,029.63
$187.52
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$335.48
$187.52
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$659.18
$159.47
$288.22
$254.96
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$590.22
$158.10
$258.07
$187.52
$0.00
$0.00
$0.00
$0.00
$1,263.15
$187.52
7.04%
Published Separately
$0.00
$0.00
$595.36
$36.33
$260.32
$187.52
$0.00
$0.00
$0.00
$0.00
$971.28
$187.52
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$732.18
$178.00
$320.14
$254.96
$0.00
$0.00
$0.00
$0.00
$1,538.41
$254.96
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,160.09
$254.96
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Published Separately
$0.00
$0.00
$586.64
$28.82
$208.39
$187.52
$348.54
$187.52
$0.00
$0.00
$912.16
$187.52
7.04%
Published Separately
$0.00
$0.00
$653.91
$109.68
$285.92
$254.96
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Published Separately
$0.00
$0.00
$613.78
$48.50
$218.03
$187.52
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7.04%
Page 9 of 9