SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT CASE PAYMENT RATES ‐ EFFECTIVE 1/1/2012 ‐ 3/31/2012
INPATIENT CASE PAYMENT RATES EFFECTIVE 1/1/2012 ‐ 3/31/2012 (MA HMO ONLY)
OPCERT
1623001
0101000
0101000
1624000
0701000
0501000
3801000
7002001
5501000
1427000
7001041
7002002
3535001
7000001
7001002
5123000
7001003
0601000
4102004
4429000
2238001
5263000
5401001
0901001
0824000
4401000
3421000
4720001
1001000
2625000
7001009
5001000
HOSPITAL NAME
ADIRONDACK MEDICAL CENTER
ALBANY MEDICAL CTR SO CLINICAL
ALBANY MEDICAL CTR HOSP
ALICE HYDE MEDICAL CENTER
ARNOT OGDEN MEDICAL CTR
AUBURN COMMUNITY HOSPITAL
AURELIA OSBORN FOX MEM HOSP
BELLEVUE HOSPITAL CENTER
BENEDICTINE HOSPITAL
BERTRAND CHAFFEE HOSPITAL
BETH ISRAEL / KINGS HIGHWAY
BETH ISRAEL MEDICAL CENTER
BON SECOURS COMMUNITY HOSP
BRONX‐LEBANON HOSPITAL CTR
BROOKDALE HOSPITAL MED CTR
BROOKHAVEN MEMORIAL HOSP
BROOKLYN HOSPITAL
BROOKS MEMORIAL HOSPITAL
BURDETT CARE CENTER
CANTON‐POTSDAM HOSPITAL
CARTHAGE AREA HOSPITAL INC
CATSKILL REGIONAL MED CTR
CAYUGA MEDICAL CENTER
CHAMPLAIN VALLEY PHYS
CHENANGO MEMORIAL HOSP
CLAXTON‐HEPBURN MED CTR
CLIFTON SPRINGS HOSPITAL
COBLESKILL REGIONAL HOSP
COLUMBIA MEMORIAL HOSPITAL
COMMUNITY MEMORIAL HOSPITAL
CONEY ISLAND HOSPITAL
CORNING HOSPITAL
(1)
(2)
(3)
(4)
(5)
(6)
(7)
DISCHARGE RATES
"DEFAULT & CONTRACT" DISCHARGE CASE PAYMENT RATE (INCLUDING PHL § 2807‐c(33) ‐
Excluding IME)
STATEWIDE PRICE ‐
MA HMO
ISAF
HIGH COST CC's
IME %'s
DME RATE
CAPITAL RATE ‐
PER DISCH
$5,294.08
$5,595.36
$5,595.36
$5,213.02
$5,213.26
$5,546.59
$5,107.63
$6,600.98
$5,619.75
$4,461.79
$7,555.83
$7,293.32
$5,851.47
$6,891.59
$6,784.37
$6,543.49
$6,666.45
$4,750.75
$5,185.45
$4,995.84
$4,684.37
$5,886.81
$5,698.12
$5,423.24
$4,954.17
$5,016.04
$4,498.69
$4,869.39
$5,323.27
$5,193.64
$6,534.82
$5,594.27
CAPITAL PER *Informational *Informational Only* DISCHARGE Only* "DEFAULT & INSTITUTION (EXCLUDING DIRECT INDIRECT CONTRACT" SPECIFIC HIGH COST NON‐
MEDICAL MEDICAL STATEWIDE BASE ADJUSTMENT CHARGE COMPARABLE EDUCATION PRICE (INCLUDING FACTOR CONVERTOR EDUCATION ADD‐ONS)
(DME) ADD‐ON
(IME) %
PHL § 2807‐c(33))
(ISAF)
(2010)
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
0.8232
0.8689
0.8689
0.8048
0.8033
0.8622
0.7930
1.0233
0.8726
0.6991
1.1652
1.1304
0.9175
1.0648
1.0476
1.0183
1.0296
0.7324
0.7951
0.7934
0.7348
0.9149
0.8812
0.8403
0.7620
0.7692
0.6948
0.7604
0.8205
0.8044
1.0110
0.8778
0.575033
0.346200
0.346200
0.484968
0.435913
0.444344
0.624273
0.775616
0.305369
0.598639
0.193985
0.332162
0.259890
0.780359
0.510942
0.197953
0.474947
0.676698
0.426210
0.547829
0.424012
0.354614
0.752763
0.425675
0.498288
0.644252
0.562005
0.937064
0.438110
0.526406
0.707615
0.468393
0.00%
19.41%
19.41%
0.00%
0.00%
0.00%
0.00%
26.17%
2.09%
0.00%
0.20%
24.35%
0.00%
27.13%
20.83%
1.87%
20.55%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
16.91%
0.00%
$0.00
$590.34
$590.34
$0.00
$0.00
$0.00
$0.00
$2,419.99
$82.07
$0.00
$605.62
$1,137.48
$0.00
$2,025.89
$1,315.63
$0.00
$612.89
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,173.02
$0.00
Page 1 of 11
**(PER DISCH)**
$474.60
$756.99
$756.99
$193.45
$320.00
$324.11
$219.66
$765.72
$662.72
$186.12
$203.33
$772.75
$446.35
$481.41
$409.98
$444.78
$503.02
$246.72
$156.70
$517.23
$207.18
$236.19
$402.03
$743.66
$262.48
$411.16
$220.17
$306.75
$301.08
$231.87
$749.57
$112.47
(8)
(9)
(10)
(11)
(12)
(13)
(14)
CAPITAL RATE ‐
HCRA PER DIEM
STERILIZATION
ALC
SURCHARGE
STERILIZATION DURING DELIVERY TEACHING (MANAGED ELECTION REGIONAL CARE AMENDMENT SCHOOL OF ENROLLEES OF BAD DEBT AMBULANCE PHYSICIANS NURSING CAPITAL PER FIDELIS CARE ALC PRICE PERCENT ADD‐ON
ADD‐ON
ADD‐ON
DIEM
ONLY)
PER DAY
ADD‐ON
NON‐COMPARABLE ADD‐ONS
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$11.26
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$57.25
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$455.62
$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
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$39.88
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$78.74
$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
**(PER DAY**)
$118.49
$142.50
$142.50
$52.77
$57.02
$38.36
$52.48
$138.66
$132.74
$42.44
$33.61
$178.52
$108.19
$90.85
$74.53
$77.80
$93.61
$59.34
$67.58
$162.42
$59.37
$62.41
$105.66
$146.60
$60.41
$80.95
$49.00
$33.79
$72.56
$65.41
$132.23
$35.28
(2290)
$725.65
$766.95
$766.95
$714.54
$714.57
$760.26
$700.10
$904.79
$770.29
$611.57
$1,035.67
$999.68
$802.05
$944.62
$929.92
$896.91
$913.76
$651.18
$710.76
$684.77
$642.08
$806.90
$781.03
$743.36
$679.06
$687.54
$616.63
$667.44
$729.65
$711.88
$895.72
$766.80
$171.74
$171.74
$171.74
$171.74
$171.74
$171.74
$171.74
$261.20
$171.74
$171.74
$261.20
$261.20
$171.74
$261.20
$261.20
$261.20
$261.20
$171.74
$171.74
$171.74
$171.74
$171.74
$171.74
$171.74
$171.74
$171.74
$171.74
$171.74
$171.74
$171.74
$261.20
$171.74
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT CASE PAYMENT RATES ‐ EFFECTIVE 1/1/2012 ‐ 3/31/2012
INPATIENT CASE PAYMENT RATES EFFECTIVE 1/1/2012 ‐ 3/31/2012 (MA HMO ONLY)
OPCERT
1101000
3301008
4423000
5127000
3101000
4601001
7003000
1401005
3429000
3202003
7003001
7003013
2910000
3402000
2901000
5601000
4329000
5154001
7002009
2701001
7002012
5901000
5153000
7001046
5022000
7000002
7003003
5149000
0228000
1401014
1401014
1401002
HOSPITAL NAME
CORTLAND REGIONAL MED CTR
CROUSE HOSPITAL
E J NOBLE HOSP / GOUVERNEUR
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
HARLEM HOSPITAL CENTER
HIGHLAND HOSP OF ROCHESTER
HOSPITAL FOR SPECIAL SURGERY
HUDSON VALLEY HOSPITAL CTR
HUNTINGTON HOSPITAL
INTERFAITH MEDICAL CENTER
IRA DAVENPORT MEMORIAL HOSP
JACOBI MEDICAL CENTER
JAMAICA HOSPITAL
JOHN T MATHER MEMORIAL HOSP
JONES MEMORIAL HOSPITAL
KALEIDA HEALTH
KALEIDA HEALTH (MILLARD)
KALEIDA HLTH/WOMAN&CHILDRENS
(1)
(2)
(3)
(4)
(5)
(6)
(7)
DISCHARGE RATES
"DEFAULT & CONTRACT" DISCHARGE CASE PAYMENT RATE (INCLUDING PHL § 2807‐c(33) ‐
Excluding IME)
STATEWIDE PRICE ‐
MA HMO
ISAF
HIGH COST CC's
IME %'s
DME RATE
CAPITAL RATE ‐
PER DISCH
$5,147.94
$6,162.11
$4,465.45
$6,459.15
$5,219.88
$5,437.29
$6,996.91
$5,986.51
$4,599.80
$5,375.48
$6,696.50
$7,309.82
$6,299.34
$4,704.20
$7,347.77
$5,278.33
$6,664.27
$6,577.91
$6,786.55
$5,548.05
$7,701.55
$6,156.95
$6,920.41
$6,760.61
$4,880.75
$7,173.82
$7,272.46
$6,661.32
$4,761.52
$6,004.13
$6,004.13
$5,923.69
CAPITAL PER *Informational *Informational Only* DISCHARGE Only* "DEFAULT & INSTITUTION (EXCLUDING DIRECT INDIRECT CONTRACT" SPECIFIC HIGH COST NON‐
MEDICAL MEDICAL STATEWIDE BASE ADJUSTMENT CHARGE COMPARABLE EDUCATION PRICE (INCLUDING FACTOR CONVERTOR EDUCATION ADD‐ONS)
(DME) ADD‐ON
(IME) %
PHL § 2807‐c(33))
(ISAF)
(2010)
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
0.8030
0.9458
0.6847
0.9904
0.8083
0.8401
1.0763
0.9218
0.7053
0.8308
1.0332
1.1309
0.9829
0.7297
1.1288
0.8148
1.0239
1.0148
1.0509
0.8599
1.1809
0.9564
1.0624
1.0538
0.7532
1.1093
1.1241
1.0286
0.7428
0.9274
0.9274
0.9147
0.685718
0.497413
0.593789
0.210035
0.598057
0.290752
0.684265
0.516966
0.569360
0.443433
0.508284
0.327173
0.291336
0.580946
0.301352
0.469395
0.225130
0.236398
0.963172
0.591559
0.380157
0.288537
0.326841
0.346073
0.545552
0.841429
0.493138
0.287634
0.627985
0.419224
0.419224
0.412907
0.00%
5.23%
0.00%
0.00%
0.00%
5.19%
22.43%
21.68%
0.00%
0.66%
17.85%
7.13%
1.40%
0.00%
4.10%
0.00%
0.00%
5.49%
31.20%
10.42%
20.75%
0.00%
0.76%
31.03%
0.00%
27.30%
16.18%
0.00%
0.00%
12.35%
12.35%
26.52%
$0.00
$129.71
$0.00
$0.00
$0.00
$153.22
$1,220.96
$555.38
$0.00
$0.13
$658.23
$123.60
$202.76
$0.00
$130.41
$0.00
$0.00
$213.86
$2,720.28
$102.37
$1,558.96
$0.00
$12.34
$866.42
$0.00
$1,976.32
$692.02
$0.00
$0.00
$302.87
$302.87
$359.82
Page 2 of 11
**(PER DISCH)**
$393.96
$466.61
$463.94
$771.60
$166.92
$375.34
$539.23
$418.48
$362.45
$422.51
$309.58
$394.54
$359.59
$237.70
$708.93
$355.17
$446.88
$331.50
$514.43
$375.65
$1,811.42
$782.89
$476.33
$779.60
$184.44
$807.69
$213.22
$308.08
$321.86
$987.69
$987.69
$401.20
(8)
(9)
(10)
(11)
(12)
(13)
(14)
CAPITAL RATE ‐
HCRA PER DIEM
STERILIZATION
ALC
SURCHARGE
STERILIZATION DURING DELIVERY TEACHING (MANAGED ELECTION REGIONAL CARE AMENDMENT SCHOOL OF ENROLLEES OF BAD DEBT AMBULANCE PHYSICIANS NURSING CAPITAL PER FIDELIS CARE ALC PRICE PERCENT ADD‐ON
ADD‐ON
ADD‐ON
DIEM
ONLY)
PER DAY
ADD‐ON
NON‐COMPARABLE ADD‐ONS
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$307.95
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$328.28
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$337.31
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$86.78
$0.00
$0.00
$0.00
$28.70
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$44.70
$0.00
$0.00
$0.00
$0.00
$16.06
$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
**(PER DAY**)
$53.50
$96.06
$77.27
$217.69
$34.59
$86.72
$124.08
$71.29
$94.76
$87.87
$60.99
$83.91
$66.05
$59.22
$130.20
$78.59
$114.06
$68.90
$107.48
$95.01
$440.46
$163.76
$107.37
$134.95
$46.54
$160.45
$47.50
$54.42
$99.61
$194.15
$194.15
$87.45
(2290)
$705.62
$844.63
$612.07
$885.35
$715.48
$745.28
$959.06
$820.56
$630.49
$736.81
$917.88
$1,001.95
$863.44
$644.80
$1,007.15
$723.49
$913.46
$901.62
$930.22
$760.46
$1,055.64
$843.92
$948.57
$926.67
$669.00
$983.30
$996.83
$913.06
$652.65
$822.98
$822.98
$811.95
$171.74
$171.74
$171.74
$261.20
$171.74
$171.74
$261.20
$171.74
$171.74
$171.74
$261.20
$261.20
$261.20
$171.74
$261.20
$171.74
$261.20
$261.20
$261.20
$171.74
$261.20
$261.20
$261.20
$261.20
$171.74
$261.20
$261.20
$261.20
$171.74
$171.74
$171.74
$171.74
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT CASE PAYMENT RATES ‐ EFFECTIVE 1/1/2012 ‐ 3/31/2012
INPATIENT CASE PAYMENT RATES EFFECTIVE 1/1/2012 ‐ 3/31/2012 (MA HMO ONLY)
OPCERT
1404000
7001016
7001033
5501001
2728001
5922000
7002017
2424000
7000008
2902000
7003004
7001019
7001020
3824000
4402000
3622000
0101003
1401008
2909000
7002021
7000006
7003015
7002024
3121001
5903000
2950002
1701000
7002000
3102000
2527000
7000024
2951001
HOSPITAL NAME
KENMORE MERCY HOSPITAL
KINGS COUNTY HOSPITAL CENTER
KINGSBROOK JEWISH MED CTR
KINGSTON HOSPITAL
LAKESIDE MEMORIAL HOSPITAL
LAWRENCE HOSPITAL
LENOX HILL HOSPITAL
LEWIS COUNTY GENERAL HOSP
LINCOLN MEDICAL
LONG BEACH MEDICAL CENTER
LONG ISLAND JEWISH
LUTHERAN MEDICAL CENTER
MAIMONIDES MEDICAL CENTER
MARY IMOGENE BASSETT HOSP
MASSENA MEMORIAL HOSPITAL
MEDINA MEMORIAL HOSPITAL
MEMORIAL HOSP OF ALBANY
MERCY HOSPITAL OF BUFFALO
MERCY MEDICAL CENTER
METROPOLITAN HOSPITAL CENTER
MONTEFIORE MEDICAL CENTER
MOUNT SINAI HOSP OF QUEENS
MOUNT SINAI HOSPITAL
MOUNT ST MARYS HOSPITAL
MOUNT VERNON HOSPITAL
NASSAU UNIV MED CTR
NATHAN LITTAUER HOSPITAL
NEW YORK DOWNTOWN HOSP
NIAGARA FALLS MEMORIAL
NICHOLAS H NOYES MEMORIAL
NORTH CENTRAL BRONX HOSPITAL
NORTH SHORE UNIVERSITY HOSP
(1)
(2)
(3)
(4)
(5)
(6)
(7)
DISCHARGE RATES
"DEFAULT & CONTRACT" DISCHARGE CASE PAYMENT RATE (INCLUDING PHL § 2807‐c(33) ‐
Excluding IME)
STATEWIDE PRICE ‐
MA HMO
ISAF
HIGH COST CC's
IME %'s
DME RATE
CAPITAL RATE ‐
PER DISCH
$5,319.77
$6,585.89
$7,399.17
$5,604.97
$4,676.53
$6,426.74
$6,714.58
$5,323.71
$6,635.53
$5,858.64
$7,018.20
$6,607.39
$7,728.56
$4,881.69
$5,148.07
$4,209.65
$5,246.80
$5,737.57
$6,614.76
$6,598.10
$7,244.19
$7,217.66
$7,217.66
$5,513.09
$6,680.93
$7,301.05
$5,070.02
$6,916.90
$5,015.44
$4,833.28
$7,380.50
$7,488.44
CAPITAL PER *Informational *Informational Only* DISCHARGE Only* "DEFAULT & INSTITUTION (EXCLUDING DIRECT INDIRECT CONTRACT" SPECIFIC HIGH COST NON‐
MEDICAL MEDICAL STATEWIDE BASE ADJUSTMENT CHARGE COMPARABLE EDUCATION PRICE (INCLUDING FACTOR CONVERTOR EDUCATION ADD‐ONS)
(DME) ADD‐ON
(IME) %
PHL § 2807‐c(33))
(ISAF)
(2010)
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
0.8193
1.0145
1.1482
0.8734
0.7271
0.9974
1.0407
0.8163
1.0321
0.9032
1.0882
1.0172
1.1904
0.7538
0.8040
0.6469
0.8062
0.8840
1.0167
1.0211
1.1229
1.1206
1.1206
0.8495
1.0550
1.1324
0.7774
1.0608
0.7768
0.7411
1.1408
1.1617
0.451844
1.009056
0.270908
0.294304
0.484337
0.369849
0.210513
0.785835
0.990930
0.316918
0.285177
0.623073
0.312137
0.490102
0.736774
0.746700
0.507216
0.453288
0.297327
0.883399
0.273569
0.407427
0.388724
0.602028
0.522190
0.608237
0.450400
0.509796
0.522479
0.406857
0.783790
0.258738
0.00%
33.45%
14.58%
5.30%
0.00%
0.00%
15.32%
0.00%
24.42%
11.04%
29.02%
24.00%
23.15%
12.95%
0.00%
0.00%
0.00%
3.01%
0.30%
27.91%
28.96%
32.88%
32.88%
0.00%
9.54%
21.68%
0.00%
18.06%
4.15%
0.00%
12.87%
16.19%
$0.00
$2,405.63
$1,083.42
$216.69
$0.00
$0.00
$1,069.66
$0.00
$1,159.24
$423.80
$1,033.16
$961.59
$1,006.36
$354.81
$0.00
$0.00
$0.00
$45.44
$56.39
$1,903.69
$2,361.54
$1,245.41
$1,245.41
$0.00
$961.22
$839.25
$0.00
$676.97
$79.24
$0.00
$1,275.43
$1,198.15
Page 3 of 11
**(PER DISCH)**
$399.00
$944.03
$339.44
$235.36
$322.92
$441.58
$760.30
$449.51
$390.71
$328.28
$574.81
$276.42
$757.45
$524.02
$340.66
$180.43
$410.14
$418.94
$456.42
$346.89
$846.43
$443.19
$863.49
$194.26
$317.98
$413.87
$264.89
$566.42
$476.00
$296.93
$381.19
$888.96
(8)
(9)
(10)
(11)
(12)
(13)
(14)
CAPITAL RATE ‐
HCRA PER DIEM
STERILIZATION
ALC
SURCHARGE
STERILIZATION DURING DELIVERY TEACHING (MANAGED ELECTION REGIONAL CARE AMENDMENT SCHOOL OF ENROLLEES OF BAD DEBT AMBULANCE PHYSICIANS NURSING CAPITAL PER FIDELIS CARE ALC PRICE PERCENT ADD‐ON
ADD‐ON
ADD‐ON
DIEM
ONLY)
PER DAY
ADD‐ON
NON‐COMPARABLE ADD‐ONS
$90.05
$0.00
$0.00
$0.00
$0.00
$0.00
$211.27
$0.00
$0.00
$0.00
$0.00
$204.40
$115.92
$0.00
$0.00
$0.00
$0.00
$22.19
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$109.69
$0.00
$169.51
$0.00
$0.00
$0.00
$409.88
$0.00
$460.14
$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
$271.18
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$147.58
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$336.44
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
**(PER DAY**)
$91.34
$183.98
$57.93
$53.04
$62.99
$95.46
$166.85
$132.08
$109.31
$49.68
$123.81
$63.02
$162.02
$120.94
$89.55
$34.35
$84.36
$93.03
$91.61
$97.32
$172.18
$79.85
$172.41
$46.25
$57.84
$105.44
$63.61
$134.02
$119.43
$84.67
$96.51
$170.03
(2290)
$729.17
$902.72
$1,014.19
$768.26
$641.00
$880.90
$920.36
$729.71
$909.52
$803.03
$961.97
$905.67
$1,059.34
$669.13
$705.64
$577.01
$719.17
$786.44
$906.68
$904.39
$992.95
$989.31
$989.31
$755.67
$915.75
$1,000.74
$694.94
$948.09
$687.46
$662.49
$1,011.63
$1,026.43
$171.74
$261.20
$261.20
$171.74
$171.74
$261.20
$261.20
$171.74
$261.20
$261.20
$261.20
$261.20
$261.20
$171.74
$171.74
$171.74
$171.74
$171.74
$261.20
$261.20
$261.20
$261.20
$261.20
$171.74
$261.20
$261.20
$171.74
$261.20
$171.74
$171.74
$261.20
$261.20
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT CASE PAYMENT RATES ‐ EFFECTIVE 1/1/2012 ‐ 3/31/2012
INPATIENT CASE PAYMENT RATES EFFECTIVE 1/1/2012 ‐ 3/31/2012 (MA HMO ONLY)
OPCERT
1327000
5920000
7001008
7002026
7003010
7001021
7002054
7002054
7002054
7000025
4324000
7002053
7002053
0401001
2601001
3523000
3702000
0301001
5155000
7003006
5932000
2952005
3950000
7003007
7004010
2701003
3201002
4102002
2201000
4501000
4102003
HOSPITAL NAME
NORTHERN DUTCHESS HOSPITAL
NORTHERN WESTCHESTER HOSP
NY COMMUNITY / BROOKLYN
NY EYE AND EAR INFIRMARY
NY MED CTR OF QUEENS
NY METHODIST HOSP / BROOKLYN
NY PRESBYTERIAN HOSPITAL
NY PRESBYTERIAN HOSPITAL (ALLEN)
NY PRESBYTERIAN HOSPITAL (PRESBY)
NY WESTCHESTER SQUARE MED CTR
NYACK HOSPITAL
NYU HOSPITALS CENTER
NYU HOSPITALS CENTER/HOSP FOR JOINT DIS
OLEAN GENERAL HOSPITAL
ONEIDA HEALTHCARE CENTER
ORANGE REGIONAL MED CTR
OSWEGO HOSPITAL
OUR LADY OF LOURDES MEMORIAL
PECONIC BAY MED CTR
PENINSULA HOSPITAL CENTER
PHELPS MEMORIAL HOSP
PLAINVIEW HOSPITAL
PUTNAM COMMUNITY HOSPITAL
QUEENS HOSPITAL CENTER
RICHMOND UNIV MED CTR
ROCHESTER GENERAL HOSPITAL
ROME HOSPITAL AND MURPHY
SAMARITAN HOSPITAL OF TROY
SAMARITAN MEDICAL CENTER
SARATOGA HOSPITAL
SETON HEALTH SYSTEMS
(1)
(2)
(3)
(4)
(5)
(6)
(7)
DISCHARGE RATES
"DEFAULT & CONTRACT" DISCHARGE CASE PAYMENT RATE (INCLUDING PHL § 2807‐c(33) ‐
Excluding IME)
STATEWIDE PRICE ‐
MA HMO
ISAF
HIGH COST CC's
IME %'s
DME RATE
CAPITAL RATE ‐
PER DISCH
CAPITAL PER *Informational *Informational Only* DISCHARGE Only* "DEFAULT & INSTITUTION (EXCLUDING DIRECT INDIRECT CONTRACT" SPECIFIC HIGH COST NON‐
MEDICAL MEDICAL STATEWIDE BASE ADJUSTMENT CHARGE COMPARABLE EDUCATION PRICE (INCLUDING FACTOR CONVERTOR EDUCATION ADD‐ONS)
(DME) ADD‐ON
(IME) %
PHL § 2807‐c(33))
(ISAF)
(2010)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
CAPITAL RATE ‐
HCRA PER DIEM
STERILIZATION
ALC
SURCHARGE
STERILIZATION DURING DELIVERY TEACHING (MANAGED ELECTION REGIONAL CARE AMENDMENT SCHOOL OF ENROLLEES OF BAD DEBT AMBULANCE PHYSICIANS NURSING CAPITAL PER FIDELIS CARE ALC PRICE PERCENT ADD‐ON
ADD‐ON
ADD‐ON
DIEM
ONLY)
PER DAY
ADD‐ON
NON‐COMPARABLE ADD‐ONS
$6,118.59
$6,556.51
$7,133.31
$6,640.62
$7,130.14
$6,892.65
$7,250.18
$7,250.18
$7,250.18
$6,481.36
$6,358.72
$6,907.75
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
0.9546
1.0116
1.1128
1.0217
1.0990
1.0683
1.1184
1.1184
1.1184
0.9987
0.9750
1.0701
0.370558
0.512740
0.470160
0.397784
0.404734
0.436643
0.361704
0.361704
0.361704
0.418130
0.225634
0.325725
0.00%
0.00%
0.00%
16.08%
16.54%
16.78%
27.06%
27.06%
27.06%
0.00%
0.00%
19.78%
$0.00
$0.00
$0.00
$2,251.44
$744.93
$781.00
$1,344.21
$1,344.21
$1,344.21
$0.00
$0.00
$1,814.25
**(PER DISCH)**
$353.07
$580.52
$333.95
$328.68
$779.01
$333.70
$1,359.07
$1,359.07
$1,359.07
$161.30
$254.99
$1,142.97
$0.00
$0.00
$0.00
$0.00
$173.37
$0.00
$258.15
$258.15
$258.15
$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
$0.00
$0.00
$0.00
$0.00
$0.00
**(PER DAY**)
$95.40
$139.05
$53.57
$157.47
$155.68
$70.95
$232.43
$232.43
$232.43
$24.86
$60.11
$247.30
(2290)
$838.67
$898.69
$977.75
$910.22
$977.32
$944.77
$993.77
$993.77
$993.77
$888.39
$871.58
$946.83
$171.74
$261.20
$261.20
$261.20
$261.20
$261.20
$261.20
$261.20
$261.20
$261.20
$261.20
$261.20
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
$6,907.75
$4,898.65
$4,698.50
$6,454.10
$5,337.24
$5,187.18
$6,495.66
$6,061.02
$6,515.24
$7,112.68
$6,625.15
$7,388.90
$6,463.73
$5,484.47
$4,993.15
$5,063.59
$5,490.45
$5,359.02
$5,207.77
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
1.0701
0.7681
0.7242
0.9958
0.8229
0.8047
1.0002
0.9395
1.0000
1.1043
1.0257
1.1398
0.9998
0.8491
0.7707
0.7951
0.8444
0.8322
0.8048
0.325725
0.572045
0.501680
0.262200
0.554691
0.493525
0.244537
0.350192
0.356045
0.317635
0.335775
0.853551
0.298097
0.433957
0.441550
0.426210
0.520684
0.399622
0.362212
19.78%
0.00%
0.00%
0.00%
0.00%
2.17%
0.00%
11.07%
0.00%
4.08%
0.00%
17.94%
15.31%
10.08%
0.00%
0.00%
0.96%
0.00%
0.00%
$1,814.25
$0.00
$0.00
$0.00
$0.00
$5.13
$0.00
$380.09
$0.00
$149.83
$0.00
$1,021.41
$454.19
$210.34
$0.00
$0.00
$24.52
$0.00
$0.00
$1,142.97
$322.26
$413.44
$837.22
$595.94
$284.53
$928.79
$150.67
$522.04
$339.98
$605.58
$534.34
$307.31
$510.91
$330.77
$319.91
$423.53
$315.32
$239.44
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$319.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$244.27
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$22.05
$6.23
$0.00
$48.91
$0.00
$0.00
$0.00
$247.30
$71.31
$103.23
$188.45
$150.73
$73.02
$220.77
$24.33
$116.94
$66.02
$130.14
$122.60
$68.19
$105.73
$80.86
$67.23
$100.33
$66.28
$57.10
$946.83
$671.45
$644.02
$884.65
$731.57
$711.00
$890.35
$830.77
$893.03
$974.92
$908.10
$1,012.79
$885.97
$751.75
$684.40
$694.06
$752.57
$734.55
$713.82
$261.20
$171.74
$171.74
$171.74
$171.74
$171.74
$261.20
$261.20
$261.20
$261.20
$171.74
$261.20
$261.20
$171.74
$171.74
$171.74
$171.74
$171.74
$171.74
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
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 4 of 11
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT CASE PAYMENT RATES ‐ EFFECTIVE 1/1/2012 ‐ 3/31/2012
INPATIENT CASE PAYMENT RATES EFFECTIVE 1/1/2012 ‐ 3/31/2012 (MA HMO ONLY)
OPCERT
1401006
1401013
5904000
2950001
5126000
5154000
3529000
7000014
5157003
5149001
3202002
1302000
2953000
5002001
7001024
5907001
2952006
0701001
3301003
5907002
7002032
3522000
2801001
0101004
7001037
7004003
2701005
7001037
2754001
0427000
1227001
0303001
HOSPITAL NAME
SHEEHAN MEMORIAL EMERGENCY
SISTERS OF CHARITY HOSPITAL
SOUND SHORE MEDICAL CENTER
SOUTH NASSAU COMMUNITIES
SOUTHAMPTON HOSPITAL
SOUTHSIDE HOSPITAL
ST ANTHONY COMMUNITY HOSP
ST BARNABAS HOSPITAL
ST CATHERINE OF SIENA
ST CHARLES HOSPITAL
ST ELIZABETH MEDICAL CENTER
ST FRANCIS HOSP / POUGH
ST FRANCIS HOSP / ROSLYN
ST JAMES MERCY HOSPITAL
ST JOHNS EPISCOPAL SO SHORE
ST JOHNS RIVERSIDE HOSPITAL
ST JOSEPH HOSPITAL
ST JOSEPHS HOSP / ELMIRA
ST JOSEPHS HOSP HLTH CTR
ST JOSEPHS MEDICAL CENTER
ST LUKES / ROOSEVELT HOSP
ST LUKES CORNWALL
ST MARYS HEALTHCARE
ST PETERS HOSPITAL
STATE UNIV HOSP / DOWNSTATE
STATEN ISLAND UNIV HOSP
STRONG MEMORIAL HOSPITAL
SUNY DOWNSTATE MED CTRAT LICH
THE UNITY HOSPITAL
TLC HEALTH NETWORK
TRI‐TOWN REGIONAL HEALTHCARE
UNITED HEALTH SERVICES INC
(1)
(2)
(3)
(4)
(5)
(6)
(7)
DISCHARGE RATES
"DEFAULT & CONTRACT" DISCHARGE CASE PAYMENT RATE (INCLUDING PHL § 2807‐c(33) ‐
Excluding IME)
STATEWIDE PRICE ‐
MA HMO
ISAF
HIGH COST CC's
IME %'s
DME RATE
CAPITAL RATE ‐
PER DISCH
$4,779.80
$5,377.83
$6,681.95
$6,236.53
$6,501.67
$6,811.96
$6,236.76
$6,609.51
$6,880.74
$6,222.40
$5,453.80
$5,595.36
$6,934.30
$4,253.55
$7,728.97
$6,329.37
$6,550.14
$4,800.45
$5,734.97
$6,234.40
$7,822.61
$5,860.52
$4,913.55
$5,633.45
$7,035.62
$6,602.01
$5,807.14
$7,035.62
$5,030.39
$4,446.44
$6,521.76
$5,512.59
CAPITAL PER *Informational *Informational Only* DISCHARGE Only* "DEFAULT & INSTITUTION (EXCLUDING DIRECT INDIRECT CONTRACT" SPECIFIC HIGH COST NON‐
MEDICAL MEDICAL STATEWIDE BASE ADJUSTMENT CHARGE COMPARABLE EDUCATION PRICE (INCLUDING FACTOR CONVERTOR EDUCATION ADD‐ONS)
(DME) ADD‐ON
(IME) %
PHL § 2807‐c(33))
(ISAF)
(2010)
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
$6,521.76
0.7329
0.8265
1.0294
0.9632
1.0076
1.0468
0.9563
1.0267
1.0579
0.9651
0.8391
0.8640
1.0656
0.6610
1.1937
0.9705
1.0095
0.7429
0.8836
0.9703
1.2181
0.9024
0.7556
0.8670
1.0909
1.0178
0.8996
1.0909
0.7752
0.6824
1.0000
0.8484
0.705839
0.464375
0.498011
0.286358
0.354301
0.315522
0.263654
0.295769
0.252010
0.302427
0.445100
0.285995
0.274505
0.487220
0.455537
0.343670
0.314170
0.425164
0.440473
0.545533
0.345893
0.291237
0.488571
0.315153
0.750147
0.338481
0.545115
0.750147
0.523484
0.580598
0.000000
0.482716
0.00%
4.24%
10.85%
3.42%
4.35%
4.78%
0.00%
26.30%
0.00%
0.92%
5.73%
0.00%
0.52%
0.00%
25.33%
0.00%
0.00%
0.00%
5.47%
8.01%
24.50%
0.00%
0.00%
2.24%
25.55%
17.29%
29.02%
25.55%
7.65%
0.00%
0.00%
7.53%
$0.00
$134.37
$631.35
$106.23
$0.00
$147.45
$0.00
$1,045.95
$0.00
$76.53
$117.99
$0.00
$189.36
$0.00
$742.17
$0.00
$15.05
$0.00
$47.68
$560.84
$1,282.72
$0.00
$0.00
$57.16
$1,882.99
$509.59
$709.84
$1,882.99
$46.51
$0.00
$0.00
$201.14
Page 5 of 11
**(PER DISCH)**
$0.00
$358.96
$417.47
$465.50
$579.81
$565.34
$401.17
$390.16
$400.55
$410.83
$415.15
$931.57
$226.58
$381.12
$367.93
$269.39
$337.38
$171.66
$584.03
$732.32
$966.76
$504.25
$173.45
$658.36
$997.28
$257.91
$770.52
$997.28
$488.64
$175.00
$197.50
$311.60
(8)
(9)
(10)
(11)
(12)
(13)
(14)
CAPITAL RATE ‐
HCRA PER DIEM
STERILIZATION
ALC
SURCHARGE
STERILIZATION DURING DELIVERY TEACHING (MANAGED ELECTION REGIONAL CARE AMENDMENT SCHOOL OF ENROLLEES OF BAD DEBT AMBULANCE PHYSICIANS NURSING CAPITAL PER FIDELIS CARE ALC PRICE PERCENT ADD‐ON
ADD‐ON
ADD‐ON
DIEM
ONLY)
PER DAY
ADD‐ON
NON‐COMPARABLE ADD‐ONS
$0.00
$36.90
$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
$179.54
$0.00
$0.00
$0.00
$0.00
$120.03
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$162.86
$0.00
$0.00
$0.00
$0.00
$95.79
$0.00
$0.00
$105.66
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
**(PER DAY**)
$0.00
$77.24
$81.21
$91.07
$168.94
$133.86
$96.04
$93.93
$74.55
$103.53
$90.77
$205.69
$37.14
$72.65
$61.54
$51.03
$64.30
$33.36
$117.16
$117.90
$213.44
$120.97
$43.06
$132.62
$211.43
$61.21
$127.46
$211.43
$104.33
$40.47
$98.75
$61.29
(2290)
$655.16
$737.13
$915.88
$854.83
$891.17
$933.71
$854.86
$905.96
$943.13
$852.90
$747.54
$766.95
$950.47
$583.03
$1,059.40
$867.56
$897.82
$657.99
$786.08
$854.54
$1,072.23
$803.29
$673.49
$772.17
$964.36
$904.93
$795.98
$964.36
$689.51
$609.47
$893.93
$755.60
$171.74
$171.74
$261.20
$261.20
$261.20
$261.20
$171.74
$261.20
$261.20
$261.20
$171.74
$171.74
$261.20
$171.74
$261.20
$261.20
$261.20
$171.74
$171.74
$261.20
$261.20
$171.74
$171.74
$171.74
$261.20
$261.20
$171.74
$261.20
$171.74
$171.74
$171.74
$171.74
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT CASE PAYMENT RATES ‐ EFFECTIVE 1/1/2012 ‐ 3/31/2012
INPATIENT CASE PAYMENT RATES EFFECTIVE 1/1/2012 ‐ 3/31/2012 (MA HMO ONLY)
OPCERT
1801000
5151001
3301007
3301007
1302001
5820000
5957001
0632000
5902001
2908000
0602001
7001045
7001035
6027000
HOSPITAL NAME
UNITED MEMORIAL MED CTR
UNIV HOSP AT STONY BROOK
UNIV HOSP SUNY HLTH SCI CTR
UPSTATE UNIV HOSPITAL AT COMM GEN
VASSAR BROTHERS MED CTR
WAYNE HEALTH CARE
WESTCHESTER MEDICAL CENTER
WESTFIELD MEMORIAL HOSP
WHITE PLAINS HOSPITAL
WINTHROP UNIVERSITY HOSPITAL
WOMANS CHRISTIAN ASSOC
WOODHULL MEDICAL
WYCKOFF HEIGHTS HOSPITAL
WYOMING CO COMMUNITY HOSP
(1)
(2)
(3)
(4)
(5)
(6)
(7)
DISCHARGE RATES
"DEFAULT & CONTRACT" DISCHARGE CASE PAYMENT RATE (INCLUDING PHL § 2807‐c(33) ‐
Excluding IME)
STATEWIDE PRICE ‐
MA HMO
ISAF
HIGH COST CC's
IME %'s
DME RATE
CAPITAL RATE ‐
PER DISCH
CAPITAL PER *Informational *Informational Only* DISCHARGE Only* "DEFAULT & INSTITUTION (EXCLUDING DIRECT INDIRECT CONTRACT" SPECIFIC HIGH COST NON‐
MEDICAL MEDICAL STATEWIDE BASE ADJUSTMENT CHARGE COMPARABLE EDUCATION PRICE (INCLUDING FACTOR CONVERTOR EDUCATION ADD‐ONS)
(DME) ADD‐ON
(IME) %
PHL § 2807‐c(33))
(ISAF)
(2010)
**(PER DISCH)**
0.7647
0.506741
0.00%
$0.00
$430.60
$6,521.76
$4,947.29
$6,648.56
$6,521.76
1.0257
0.370460
28.73%
$1,059.23
$782.28
$5,954.24
$6,521.76
0.9184
0.495110
29.03%
$1,013.90
$804.12
$5,954.24
$6,521.76
0.9184
0.495110
29.03%
$1,013.90
$804.12
$6,402.94
$6,521.76
0.9923
0.320949
0.00%
$0.00
$489.53
$6,521.76
0.7734
0.443292
0.00%
$0.00
$433.58
$5,003.07
$7,378.23
$6,521.76
1.1393
0.320525
18.54%
$1,845.43
$1,925.99
0.7195
0.636786
0.00%
$0.00
$204.25
$6,521.76
$4,598.09
$6,624.37
$6,521.76
1.0231
0.422305
0.00%
$0.00
$356.83
$6,633.07
$6,521.76
1.0188
0.288464
16.50%
$691.02
$699.28
$4,804.62
$6,521.76
0.7416
0.464471
0.00%
$0.00
$319.15
$6,572.85
$6,521.76
1.0175
0.867083
20.72%
$1,664.32
$687.02
$6,876.24
$6,521.76
1.0677
0.418698
15.91%
$950.14
$493.37
0.7759
0.966555
0.00%
$0.00
$138.18
$6,521.76
$5,000.01
*Note: Effective 1/1/2011, Maimonides Capital per Discharge rate no longer includes a High Cost Outlier add‐on.
Page 6 of 11
(8)
(9)
(10)
(11)
(12)
(13)
(14)
CAPITAL RATE ‐
HCRA PER DIEM
STERILIZATION
ALC
SURCHARGE
STERILIZATION DURING DELIVERY TEACHING (MANAGED ELECTION REGIONAL CARE AMENDMENT SCHOOL OF ENROLLEES OF BAD DEBT AMBULANCE PHYSICIANS NURSING CAPITAL PER FIDELIS CARE ALC PRICE PERCENT ADD‐ON
ADD‐ON
ADD‐ON
DIEM
ONLY)
PER DAY
ADD‐ON
NON‐COMPARABLE ADD‐ONS
$0.00
$268.38
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$18.37
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$366.78
$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
$0.00
$0.00
**(PER DAY**)
$88.90
$146.97
$148.94
$148.94
$102.05
$96.51
$245.86
$68.08
$70.26
$146.24
$72.02
$168.44
$107.46
$29.81
(2290)
$678.12
$911.31
$816.14
$816.14
$877.64
$685.76
$1,011.32
$630.25
$907.99
$909.18
$658.56
$900.93
$942.52
$685.34
$171.74
$261.20
$171.74
$171.74
$171.74
$171.74
$261.20
$171.74
$261.20
$261.20
$171.74
$261.20
$261.20
$171.74
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT EXEMPT UNIT RATES - EFFECTIVE 1/1/2012 - 12/31/2012
(1)
(2)
(3)
(4)
(5)
SPECIALTY HOSPITAL
(6)
(7)
(8)
(9)
(10)
(11)
CHEMICAL DEPENDENCY REHAB
PSYCHIATRIC
(12)
(13)
CRITICAL ACCESS HOSPITAL
(14)
(15)
(16)
MEDICAL REHABILITATION
(17)
(18)
DETOX
SPECIALTY SPECIALTY ACUTE, *Informational Only* ACUTE, LONG‐
*Informational PSYCHIATRIC CHEMICAL LONG‐TERM CARE SPECIALTY ACUTE, TERM CARE AND Only* CRITICAL DETOX‐
*Informational MEDICAL CRITICAL CHILDREN'S NON‐
*Informational DEPENDENCY AND CHILDREN'S LONG‐TERM CARE CHEMICAL CHEMICAL ACCESS Only* MEDICALLY REHAB BILLING MEDICAL ACCESS Only* REHAB BILLING DEPENDENCY DEPENDENCY HOSPITAL PSYCHIATRIC OPERATING HOSPITAL BILLING AND CHILDREN'S HOSPITAL MEDICAL MANAGED RATE (w/out HOSPITAL DME Add‐ ALC PER DIEM OPERATING BILLING RATE PSYCHIATRIC PSYCHIATRIC PSYCHIATRIC RATE (w/out REHAB REHAB BILLING RATE HOSPITAL RATE (w/out REHAB DME REHAB ALC WITHDRAWAL DME)
(w/out DME)
BILLING RATE w/out DME
DME Add‐on ECT PAYMENT ALC PER DIEM
DME)
DME)
DME Add‐on
ALC PER DIEM (w/out DME) ALC PER DIEM
BILLING RATE
Add‐on
PER DIEM
on
OPCERT
1623001
0101005
0101000
3701000
1624000
0701000
0501000
3801000
7002001
5501000
1427000
7001041
7002002
5957000
3535001
7000001
7001002
5123000
7001003
0601000
5902002
7000011
4429000
2238001
5263700
5263000
5401001
0901001
0824000
4401000
3421000
4458700
4720001
7002051
1001000
3301000
2625000
7001009
5001000
1101000
3301008
0226700
1229700
4423000
5127000
3101000
1552701
5526700
4601001
7003000
HOSPITAL NAME
ADIRONDACK MEDICAL CENTER
ALB MED CTR SO CLINICAL CAMP
ALBANY MEDICAL CTR HOSP
ALBERT LINDLEY LEE MEM HOSP
ALICE HYDE MEDICAL CENTER
ARNOT OGDEN MEDICAL CTR
AUBURN MEMORIAL HOSPITAL
AURELIA OSBORN FOX MEM HOSP
BELLEVUE HOSPITAL CENTER
BENEDICTINE HOSPITAL
BERTRAND CHAFFEE HOSPITAL
BETH ISRAEL / KINGS HIGHWAY
BETH ISRAEL MEDICAL CENTER
BLYTHEDALE CHILDRENS HOSP
BON SECOURS COMMUNITY HOSP
BRONX‐LEBANON HOSPITAL CTR
BROOKDALE HOSPITAL MED CTR
BROOKHAVEN MEMORIAL HOSP
BROOKLYN HOSPITAL
BROOKS MEMORIAL HOSPITAL
BURKE REHABILITATION CTR
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
COMM‐GEN / GREATER SYRACUSE
COMMUNITY MEMORIAL HOSPITAL
CONEY ISLAND HOSPITAL
CORNING HOSPITAL
CORTLAND REGIONAL MED CTR
CROUSE HOSPITAL
CUBA MEMORIAL HOSPITAL
DELAWARE VALLEY HOSPITAL
E J NOBLE HOSP / GOUVERNEUR
EASTERN LONG ISLAND HOSPITAL
EASTERN NIAGARA HOSPITAL (1)
ELIZABETHTOWN COMMUNITY HOSP
ELLENVILLE REGIONAL HOSPITAL
ELLIS HOSPITAL
ELMHURST HOSPITAL CTR
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,611.88
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,059.16
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$587.15
$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
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$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
$261.20
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$261.20
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$261.20
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$630.47
$0.00
$540.64
$0.00
$0.00
$0.00
$660.34
$0.00
$636.71
$668.31
$0.00
$0.00
$703.35
$0.00
$570.88
$662.53
$651.83
$633.60
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$700.70
$674.89
$643.57
$0.00
$589.11
$432.31
$0.00
$0.00
$0.00
$628.40
$576.42
$0.00
$629.05
$0.00
$615.00
$0.00
$0.00
$0.00
$0.00
$616.24
$502.93
$0.00
$0.00
$522.72
$669.68
$62.51
$0.00
$45.79
$0.00
$0.00
$0.00
$31.92
$0.00
$51.64
$16.17
$0.00
$0.00
$113.69
$0.00
$30.71
$62.10
$32.50
$45.34
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$18.38
$45.71
$76.13
$0.00
$28.10
$23.13
$0.00
$0.00
$0.00
$24.59
$38.57
$0.00
$47.08
$0.00
$80.31
$0.00
$0.00
$0.00
$0.00
$72.76
$16.12
$0.00
$0.00
$39.68
$58.06
$0.00
$0.00
$29.80
$0.00
$0.00
$0.00
$0.00
$0.00
$129.33
$0.00
$0.00
$0.00
$180.18
$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
$0.00
$0.00
$116.79
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.81
$257.88
$231.32
$0.00
$244.16
$0.00
$0.00
$0.00
$242.28
$0.00
$287.55
$245.20
$0.00
$0.00
$317.64
$0.00
$257.82
$299.21
$294.38
$286.14
$0.00
$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
$260.32
$0.00
$284.09
$0.00
$225.64
$0.00
$0.00
$0.00
$0.00
$278.30
$227.13
$0.00
$0.00
$236.07
$302.44
$171.74
$0.00
$171.74
$0.00
$0.00
$0.00
$171.74
$0.00
$261.20
$171.74
$0.00
$0.00
$261.20
$0.00
$171.74
$261.20
$261.20
$261.20
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$171.74
$171.74
$171.74
$0.00
$171.74
$171.74
$0.00
$0.00
$0.00
$171.74
$171.74
$0.00
$261.20
$0.00
$171.74
$0.00
$0.00
$0.00
$0.00
$261.20
$171.74
$0.00
$0.00
$171.74
$261.20
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$308.36
$0.00
$0.00
$684.12
$0.00
$539.18
$377.26
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$441.93
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$287.02
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$397.09
$0.00
$1,077.85
$0.00
$643.30
$296.91
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.59
$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
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$171.74
$0.00
$0.00
$261.20
$0.00
$171.74
$261.20
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$171.74
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$171.74
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$171.74
$0.00
$171.74
$0.00
$261.20
$171.74
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
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$0.00
$0.00
$0.00
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$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$2,511.62
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$2,290.55
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$2,352.01
$1,077.85
$0.00
$0.00
$0.00
$1,938.96
$1,770.58
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
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$0.00
$0.00
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$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$171.74
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$171.74
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$171.74
$171.74
$0.00
$0.00
$0.00
$171.74
$171.74
$0.00
$0.00
$0.00
$0.00
$915.67
$0.00
$0.00
$0.00
$0.00
$0.00
$1,053.01
$958.76
$0.00
$0.00
$1,456.58
$0.00
$0.00
$0.00
$0.00
$0.00
$1,336.59
$0.00
$1,146.35
$0.00
$0.00
$1,033.31
$0.00
$0.00
$980.22
$0.00
$0.00
$911.76
$0.00
$0.00
$0.00
$0.00
$0.00
$966.51
$0.00
$1,037.36
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,164.41
$0.00
$0.00
$91.89
$0.00
$0.00
$0.00
$0.00
$0.00
$120.71
$0.00
$0.00
$0.00
$25.98
$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
$0.44
$0.00
$95.78
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$257.66
$0.00
$0.00
$171.74
$0.00
$0.00
$0.00
$0.00
$0.00
$261.20
$171.74
$0.00
$0.00
$261.20
$0.00
$0.00
$0.00
$0.00
$0.00
$261.20
$0.00
$261.20
$0.00
$0.00
$171.74
$0.00
$0.00
$171.74
$0.00
$0.00
$171.74
$0.00
$0.00
$0.00
$0.00
$0.00
$171.74
$0.00
$261.20
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$261.20
(19)
HCRA SURCHARGE
DETOX ‐
MEDICALLY INDIGENT CARE SUPERVISED AND HEALTH CARE WITHDRAWAL INITIATIVE BILLING RATE
SURCHARGE
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%
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT EXEMPT UNIT RATES - EFFECTIVE 1/1/2012 - 12/31/2012
(1)
(2)
(3)
(4)
(5)
SPECIALTY HOSPITAL
(6)
(7)
(8)
PSYCHIATRIC
(9)
(10)
(11)
(12)
(13)
CRITICAL ACCESS HOSPITAL
CHEMICAL DEPENDENCY REHAB
(14)
(15)
(16)
MEDICAL REHABILITATION
(17)
(18)
DETOX
SPECIALTY SPECIALTY ACUTE, *Informational Only* ACUTE, LONG‐
*Informational PSYCHIATRIC CHEMICAL LONG‐TERM CARE SPECIALTY ACUTE, TERM CARE AND Only* CRITICAL DETOX‐
*Informational MEDICAL CRITICAL CHILDREN'S NON‐
*Informational DEPENDENCY AND CHILDREN'S LONG‐TERM CARE CHEMICAL CHEMICAL ACCESS Only* MEDICALLY REHAB BILLING MEDICAL ACCESS Only* REHAB BILLING DEPENDENCY DEPENDENCY HOSPITAL PSYCHIATRIC OPERATING HOSPITAL BILLING AND CHILDREN'S HOSPITAL MEDICAL MANAGED RATE (w/out HOSPITAL DME Add‐ ALC PER DIEM OPERATING BILLING RATE PSYCHIATRIC PSYCHIATRIC PSYCHIATRIC RATE (w/out REHAB REHAB BILLING RATE HOSPITAL RATE (w/out REHAB DME REHAB ALC WITHDRAWAL DME)
(w/out DME)
BILLING RATE w/out DME
DME Add‐on ECT PAYMENT ALC PER DIEM
DME)
DME)
DME Add‐on
ALC PER DIEM (w/out DME) ALC PER DIEM
BILLING RATE
Add‐on
PER DIEM
on
OPCERT
1401005
3429000
3202003
7003001
7003013
2910000
3402000
2901000
5601000
7002050
4329000
5154001
7002009
4322000
2701001
7002012
5901000
5153000
7001046
5022000
7000002
7003003
5149000
0228000
1401014
1401002
1404000
7001016
7001033
5501001
2728001
5922000
7002017
2424000
7000008
2129700
2902000
7001017
7003004
7001019
7001020
1226701
3824000
4402000
3622000
7002020
0101003
1401008
2909000
7002021
HOSPITAL NAME
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
GOLDWATER MEMORIAL HOSP
GOOD SAMARITAN / SUFFERN
GOOD SAMARITAN / WEST ISLIP
HARLEM HOSPITAL CENTER
HELEN HAYES HOSPITAL
HIGHLAND HOSP OF ROCHESTER
HOSPITAL FOR SPECIAL SURGERY
HUDSON VALLEY HOSPITAL CTR
HUNTINGTON HOSPITAL
INTERFAITH MEDICAL CENTER
IRA DAVENPORT MEMORIAL HOSP
JACOBI MEDICAL CENTER
JAMAICA HOSPITAL
JOHN T MATHER MEMORIAL HOSP
JONES MEMORIAL HOSPITAL
KALEIDA HEALTH
KALEIDA HLTH/WOMAN&CHILDRENS
KENMORE MERCY HOSPITAL
KINGS COUNTY HOSPITAL CENTER
KINGSBROOK JEWISH MED CTR
KINGSTON HOSPITAL
LAKESIDE MEMORIAL HOSPITAL
LAWRENCE HOSPITAL
LENOX HILL HOSPITAL
LEWIS COUNTY GENERAL HOSP
LINCOLN MEDICAL
LITTLE FALLS HOSPITAL
LONG BEACH MEDICAL CENTER
LONG ISLAND COLLEGE 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
MEMORIAL HOSP OF ALBANY
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
$644.68
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
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$0.00
$0.00
$0.00
$0.00
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$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$2,824.92
$0.00
$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
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$0.00
$0.00
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$0.00
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$0.00
$0.00
$0.00
$0.00
$0.00
$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
$261.20
$0.00
$0.00
$0.00
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$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$261.20
$0.00
$0.00
$0.00
$0.00
$573.55
$0.00
$636.29
$642.87
$0.00
$611.57
$0.00
$702.35
$624.04
$0.00
$0.00
$0.00
$653.88
$0.00
$0.00
$0.00
$0.00
$658.30
$655.68
$0.00
$690.22
$699.43
$640.01
$0.00
$577.04
$0.00
$0.00
$631.23
$714.42
$0.00
$0.00
$0.00
$647.53
$0.00
$642.18
$0.00
$561.98
$642.93
$677.09
$632.91
$740.68
$0.00
$577.32
$0.00
$495.45
$0.00
$0.00
$0.00
$632.60
$635.34
$22.49
$0.00
$56.21
$34.36
$0.00
$40.16
$0.00
$53.81
$38.71
$0.00
$0.00
$0.00
$30.95
$0.00
$0.00
$0.00
$0.00
$61.53
$67.28
$0.00
$115.62
$26.69
$40.63
$0.00
$59.26
$0.00
$0.00
$155.52
$21.87
$0.00
$0.00
$0.00
$79.32
$0.00
$41.62
$0.00
$53.01
$97.12
$47.27
$32.25
$57.24
$0.00
$35.50
$0.00
$24.90
$0.00
$0.00
$0.00
$37.74
$28.98
$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
$0.05
$0.73
$0.00
$98.71
$215.50
$0.00
$0.00
$27.79
$0.00
$0.00
$159.72
$23.66
$0.00
$0.00
$0.00
$88.11
$0.00
$236.99
$0.00
$0.20
$89.63
$73.43
$65.98
$39.56
$0.00
$6.41
$0.00
$0.00
$0.00
$0.00
$0.00
$2.31
$267.98
$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
$0.00
$0.00
$0.00
$297.30
$296.12
$0.00
$311.71
$315.87
$289.04
$0.00
$260.60
$0.00
$0.00
$285.07
$322.64
$0.00
$0.00
$0.00
$292.44
$0.00
$290.02
$0.00
$253.80
$290.36
$305.78
$285.83
$334.50
$0.00
$211.82
$0.00
$181.78
$0.00
$0.00
$0.00
$285.69
$286.93
$171.74
$0.00
$171.74
$261.20
$0.00
$261.20
$0.00
$261.20
$171.74
$0.00
$0.00
$0.00
$261.20
$0.00
$0.00
$0.00
$0.00
$261.20
$261.20
$0.00
$261.20
$261.20
$261.20
$0.00
$171.74
$0.00
$0.00
$261.20
$261.20
$0.00
$0.00
$0.00
$261.20
$0.00
$261.20
$0.00
$261.20
$261.20
$261.20
$261.20
$261.20
$0.00
$171.74
$0.00
$171.74
$0.00
$0.00
$0.00
$261.20
$261.20
$273.38
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$551.88
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$525.91
$0.00
$0.00
$0.00
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$0.00
$0.00
$0.00
$0.00
$1.45
$0.00
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$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
$0.00
$0.00
$0.00
$0.00
$0.00
$171.74
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$261.20
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$261.20
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,469.76
$0.00
$0.00
$0.00
$0.00
$0.00
$1,953.44
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$171.74
$0.00
$0.00
$0.00
$0.00
$0.00
$171.74
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$956.63
$0.00
$921.87
$0.00
$0.00
$0.00
$1,141.75
$1,100.58
$1,049.57
$0.00
$0.00
$0.00
$1,463.64
$1,303.94
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,269.27
$1,182.14
$0.00
$0.00
$848.53
$0.00
$715.14
$1,641.42
$877.57
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$654.91
$1,418.31
$0.00
$787.81
$0.00
$0.00
$0.00
$0.00
$802.99
$0.00
$0.00
$943.91
$881.07
$870.82
$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
$2.16
$0.00
$0.00
$0.00
$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
$0.00
$0.00
$0.13
$237.30
$0.00
$24.28
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1.30
$263.74
$171.74
$0.00
$171.74
$0.00
$0.00
$0.00
$171.74
$261.20
$171.74
$0.00
$0.00
$0.00
$261.20
$261.20
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$261.20
$261.20
$0.00
$0.00
$171.74
$0.00
$171.74
$261.20
$261.20
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$261.20
$261.20
$0.00
$261.20
$0.00
$0.00
$0.00
$0.00
$171.74
$0.00
$0.00
$171.74
$261.20
$261.20
(19)
HCRA SURCHARGE
DETOX ‐
MEDICALLY INDIGENT CARE SUPERVISED AND HEALTH CARE WITHDRAWAL INITIATIVE BILLING RATE
SURCHARGE
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%
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT EXEMPT UNIT RATES - EFFECTIVE 1/1/2012 - 12/31/2012
(1)
(2)
(3)
(4)
(5)
SPECIALTY HOSPITAL
(6)
(7)
(8)
PSYCHIATRIC
(9)
(10)
(11)
(12)
(13)
CRITICAL ACCESS HOSPITAL
CHEMICAL DEPENDENCY REHAB
(14)
(15)
(16)
MEDICAL REHABILITATION
(17)
(18)
DETOX
SPECIALTY SPECIALTY ACUTE, *Informational Only* ACUTE, LONG‐
*Informational PSYCHIATRIC CHEMICAL LONG‐TERM CARE SPECIALTY ACUTE, TERM CARE AND Only* CRITICAL DETOX‐
*Informational MEDICAL CRITICAL CHILDREN'S NON‐
*Informational DEPENDENCY AND CHILDREN'S LONG‐TERM CARE CHEMICAL CHEMICAL ACCESS Only* MEDICALLY REHAB BILLING MEDICAL ACCESS Only* REHAB BILLING DEPENDENCY DEPENDENCY HOSPITAL PSYCHIATRIC OPERATING HOSPITAL BILLING AND CHILDREN'S HOSPITAL MEDICAL MANAGED RATE (w/out HOSPITAL DME Add‐ ALC PER DIEM OPERATING BILLING RATE PSYCHIATRIC PSYCHIATRIC PSYCHIATRIC RATE (w/out REHAB REHAB BILLING RATE HOSPITAL RATE (w/out REHAB DME REHAB ALC WITHDRAWAL DME)
(w/out DME)
BILLING RATE w/out DME
DME Add‐on ECT PAYMENT ALC PER DIEM
DME)
DME)
DME Add‐on
ALC PER DIEM (w/out DME) ALC PER DIEM
BILLING RATE
Add‐on
PER DIEM
on
OPCERT
2701006
7000006
1564701
7003015
7002024
3121001
5903000
2950002
1701000
7002000
3102000
2527000
7000024
2951001
1327000
5920000
7001008
7002026
7003010
7001021
7002054
7002054
7000025
4324000
7002053
7002053
1254700
0401001
2601001
3523000
3702000
0301001
5155000
7003006
5932000
2952005
3950000
7003007
7004010
2221700
2701003
7002031
3201002
1401010
4102002
2201000
4501000
4823700
4102003
1401006
HOSPITAL NAME
MONROE COMMUNITY HOSPITAL
MONTEFIORE MEDICAL CENTER
MOSES‐LUDINGTON HOSPITAL
MOUNT SINAI HOSP OF QUEENS
MOUNT SINAI HOSPITAL
MOUNT ST MARYS HOSPITAL
MOUNT VERNON HOSPITAL
NASSAU UNIV MED CTR
NATHAN LITTAUER HOSPITAL
NEW YORK DOWNTOWN HOSP
NIAGARA FALLS MEMORIAL
NICHOLAS H NOYES MEMORIAL
NORTH CENTRAL BRONX HOSPITAL
NORTH SHORE UNIVERSITY HOSP
NORTHERN DUTCHESS HOSPITAL
NORTHERN WESTCHESTER HOSP
NY COMMUNITY / BROOKLYN
NY EYE AND EAR INFIRMARY
NY MED CTR OF QUEENS
NY METHODIST HOSP / BROOKLYN
NY PRESBYTERIAN HOSPITAL
NY PRESBYTERIAN HOSPITAL (PRESBY)
NY WESTCHESTER SQUARE MED CTR
NYACK HOSPITAL
NYU HOSPITALS CENTER
NYU HOSPITALS CENTER/HOSP FOR JOIN
O'CONNOR HOSPITAL
OLEAN GENERAL HOSPITAL
ONEIDA HEALTHCARE CENTER
ORANGE REGIONAL MED CTR
OSWEGO HOSPITAL
OUR LADY OF LOURDES MEMORIAL
PECONIC BAY MED CTR
PENINSULA HOSPITAL CENTER
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 SAMARITAN HOSPITAL OF TROY
SAMARITAN MEDICAL CENTER
SARATOGA HOSPITAL
SCHUYLER HOSPITAL
SETON HEALTH SYSTEMS
SHEEHAN MEMORIAL EMERGENCY
$2,121.67
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$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
$0.00
$2,637.15
$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
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$36.96
$0.00
$51.10
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$171.74
$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
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$261.20
$0.00
$171.74
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$698.68
$0.00
$0.00
$697.25
$0.00
$656.43
$704.59
$0.00
$0.00
$483.33
$0.00
$709.82
$722.82
$0.00
$629.43
$0.00
$0.00
$0.00
$664.71
$695.88
$695.88
$0.00
$0.00
$665.83
$665.83
$0.00
$588.27
$0.00
$619.60
$630.24
$0.00
$0.00
$0.00
$622.21
$0.00
$638.20
$709.19
$0.00
$0.00
$528.32
$0.00
$479.54
$0.00
$494.72
$646.71
$517.80
$0.00
$0.00
$0.00
$0.00
$73.72
$0.00
$0.00
$81.71
$0.00
$18.42
$36.65
$0.00
$0.00
$21.92
$0.00
$32.50
$60.03
$0.00
$107.74
$0.00
$0.00
$0.00
$68.72
$73.08
$73.08
$0.00
$0.00
$84.90
$84.90
$0.00
$42.63
$0.00
$87.14
$56.80
$0.00
$0.00
$0.00
$63.54
$0.00
$45.03
$84.42
$0.00
$0.00
$51.84
$0.00
$30.85
$0.00
$27.79
$35.85
$39.60
$0.00
$0.00
$0.00
$0.00
$538.26
$0.00
$0.00
$78.95
$0.00
$0.06
$22.76
$0.00
$0.00
$1.83
$0.00
$111.34
$469.17
$0.00
$0.00
$0.00
$0.00
$0.00
$81.23
$66.56
$66.56
$0.00
$0.00
$391.91
$391.91
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$215.88
$0.00
$0.00
$1.17
$0.00
$0.00
$0.00
$0.00
$0.29
$0.00
$0.00
$0.00
$0.00
$0.00
$315.53
$0.00
$0.00
$314.89
$0.00
$296.46
$318.20
$0.00
$0.00
$218.28
$0.00
$320.56
$326.44
$0.00
$284.26
$0.00
$0.00
$0.00
$300.19
$314.27
$314.27
$0.00
$0.00
$300.70
$300.70
$0.00
$215.84
$0.00
$279.82
$231.23
$0.00
$0.00
$0.00
$281.00
$0.00
$288.22
$320.28
$0.00
$0.00
$238.60
$0.00
$216.57
$0.00
$223.42
$237.28
$233.85
$0.00
$0.00
$0.00
$0.00
$261.20
$0.00
$0.00
$261.20
$0.00
$261.20
$261.20
$0.00
$0.00
$171.74
$0.00
$261.20
$261.20
$0.00
$261.20
$0.00
$0.00
$0.00
$261.20
$261.20
$261.20
$0.00
$0.00
$261.20
$261.20
$0.00
$171.74
$0.00
$171.74
$171.74
$0.00
$0.00
$0.00
$261.20
$0.00
$171.74
$261.20
$0.00
$0.00
$171.74
$0.00
$171.74
$0.00
$171.74
$171.74
$171.74
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$335.44
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$683.43
$683.43
$0.00
$437.68
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$554.24
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$190.44
$323.16
$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
$2.15
$2.15
$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
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$171.74
$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
$261.20
$261.20
$0.00
$261.20
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$261.20
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$171.74
$171.74
$0.00
$0.00
$2,471.19
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$2,326.93
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$2,293.39
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,396.27
$0.00
$0.00
$0.00
$0.00
$171.74
$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
$171.74
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$171.74
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$171.74
$0.00
$0.00
$0.00
$1,325.37
$0.00
$0.00
$1,319.15
$0.00
$0.00
$1,121.69
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,224.90
$0.00
$0.00
$0.00
$0.00
$886.67
$1,255.76
$1,255.76
$0.00
$0.00
$1,293.50
$1,293.50
$0.00
$0.00
$0.00
$1,059.95
$0.00
$0.00
$0.00
$1,268.57
$1,335.25
$0.00
$0.00
$1,292.68
$0.00
$0.00
$1,060.79
$0.00
$0.00
$0.00
$0.00
$1,166.94
$0.00
$0.00
$0.00
$0.00
$0.00
$558.93
$0.00
$0.00
$50.10
$0.00
$0.00
$183.44
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$2.15
$264.16
$264.16
$0.00
$0.00
$135.52
$135.52
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$59.93
$0.00
$0.00
$0.00
$203.85
$0.00
$0.00
$56.49
$0.00
$0.00
$0.00
$0.00
$0.13
$0.00
$0.00
$0.00
$0.00
$0.00
$261.20
$0.00
$0.00
$261.20
$0.00
$0.00
$261.20
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$171.74
$0.00
$0.00
$0.00
$0.00
$261.20
$261.20
$261.20
$0.00
$0.00
$261.20
$261.20
$0.00
$0.00
$0.00
$171.74
$0.00
$0.00
$0.00
$261.20
$261.20
$0.00
$0.00
$261.20
$0.00
$0.00
$171.74
$0.00
$0.00
$0.00
$0.00
$171.74
$0.00
$0.00
$0.00
$0.00
(19)
HCRA SURCHARGE
DETOX ‐
MEDICALLY INDIGENT CARE SUPERVISED AND HEALTH CARE WITHDRAWAL INITIATIVE BILLING RATE
SURCHARGE
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%
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT EXEMPT UNIT RATES - EFFECTIVE 1/1/2012 - 12/31/2012
(1)
(2)
(3)
(4)
(5)
SPECIALTY HOSPITAL
(6)
(7)
(8)
PSYCHIATRIC
(9)
(10)
(11)
(12)
(13)
CRITICAL ACCESS HOSPITAL
CHEMICAL DEPENDENCY REHAB
(14)
(15)
(16)
MEDICAL REHABILITATION
(17)
(18)
DETOX
SPECIALTY SPECIALTY ACUTE, *Informational Only* ACUTE, LONG‐
*Informational PSYCHIATRIC CHEMICAL LONG‐TERM CARE SPECIALTY ACUTE, TERM CARE AND Only* CRITICAL DETOX‐
*Informational MEDICAL CRITICAL CHILDREN'S NON‐
*Informational DEPENDENCY AND CHILDREN'S LONG‐TERM CARE CHEMICAL CHEMICAL ACCESS Only* MEDICALLY REHAB BILLING MEDICAL ACCESS Only* REHAB BILLING DEPENDENCY DEPENDENCY HOSPITAL PSYCHIATRIC OPERATING HOSPITAL BILLING AND CHILDREN'S HOSPITAL MEDICAL MANAGED RATE (w/out HOSPITAL DME Add‐ ALC PER DIEM OPERATING BILLING RATE PSYCHIATRIC PSYCHIATRIC PSYCHIATRIC RATE (w/out REHAB REHAB BILLING RATE HOSPITAL RATE (w/out REHAB DME REHAB ALC WITHDRAWAL DME)
(w/out DME)
BILLING RATE w/out DME
DME Add‐on ECT PAYMENT ALC PER DIEM
DME)
DME)
DME Add‐on
ALC PER DIEM (w/out DME) ALC PER DIEM
BILLING RATE
Add‐on
PER DIEM
on
OPCERT
1401013
6120700
5904000
2950001
5126000
5154000
3529000
7000014
5157003
5149001
3202002
1302000
2953000
5002001
7001024
5907001
2952006
0701001
3301003
5907002
7002032
3522000
2801001
0101004
7001037
7004003
2701005
4353000
4601004
2754001
0427000
1227001
0303001
1801000
5151001
3301007
1302001
5820000
5957001
0632000
5902001
2908000
0602001
7001045
7001035
6027000
HOSPITAL NAME
SISTERS OF CHARITY HOSPITAL
SOLDIERS AND SAILORS MEM HOSP
SOUND SHORE MEDICAL CENTER
SOUTH NASSAU COMMUNITIES
SOUTHAMPTON HOSPITAL
SOUTHSIDE HOSPITAL
ST ANTHONY COMMUNITY HOSP
ST BARNABAS HOSPITAL
ST CATHERINE OF SIENA
ST CHARLES HOSPITAL
ST ELIZABETH MEDICAL CENTER
ST FRANCIS HOSP / POUGH
ST FRANCIS HOSP / ROSLYN
ST JAMES MERCY HOSPITAL
ST JOHNS EPISCOPAL SO SHORE
ST JOHNS RIVERSIDE HOSPITAL
ST JOSEPH HOSPITAL (formerly NEW ISLAND HOSP)
ST JOSEPHS HOSP / ELMIRA
ST JOSEPHS HOSP HLTH CTR
ST JOSEPHS HOSPITAL YONKERS
ST LUKES / ROOSEVELT HOSP
ST LUKES CORNWALL
ST MARYS HOSP / AMSTERDAM
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
VASSAR BROTHERS MED CTR
WAYNE HEALTH CARE
WESTCHESTER MEDICAL CENTER
WESTFIELD MEMORIAL HOSP
WHITE PLAINS HOSPITAL
WINTHROP UNIVERSITY HOSPITAL
WOMANS CHRISTIAN ASSOC
WOODHULL MEDICAL
WYCKOFF HEIGHTS HOSPITAL
WYOMING CO COMMUNITY HOSP
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$513.44
$0.00
$599.31
$0.00
$651.33
$0.00
$638.82
$658.24
$0.00
$522.10
$537.59
$0.00
$506.25
$742.73
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$462.24
$0.00
$0.00
$0.00
$549.78
$0.00
$0.00
$0.00
$637.45
$0.00
$0.00
$0.00
$757.91
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$578.70
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$678.77
$0.00
$0.00
$0.00
$633.29
$0.00
$0.00
$0.00
$559.74
$907.64
$15.18
$261.20
$614.93
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$482.34
$0.00
$0.00
$0.00
$522.64
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$527.88
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$638.20
$0.00
$0.00
$0.00
$571.44
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$481.22
$0.00
$0.00
$0.00
$708.88
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$567.98
$0.00
$0.00
$0.00
$633.10
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$594.24
(1) Note: Eastern Niagara Hospital's Psychiatric rates were effective 10/3/2012
(19)
HCRA SURCHARGE
DETOX ‐
MEDICALLY INDIGENT CARE SUPERVISED AND HEALTH CARE WITHDRAWAL INITIATIVE BILLING RATE
SURCHARGE
$0.00
$34.46
$0.00
$64.27
$0.00
$55.51
$0.00
$51.18
$64.02
$0.00
$30.20
$79.79
$0.00
$30.03
$38.84
$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
$0.00
$85.53
$0.00
$0.00
$188.38
$0.00
$270.66
$0.00
$294.15
$0.00
$288.50
$297.27
$0.00
$235.79
$242.78
$0.00
$185.74
$335.43
$0.00
$0.00
$171.74
$0.00
$261.20
$0.00
$261.20
$0.00
$261.20
$261.20
$0.00
$171.74
$171.74
$0.00
$171.74
$261.20
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$286.79
$0.00
$326.06
$0.00
$306.62
$0.00
$470.43
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$261.20
$0.00
$171.74
$0.00
$171.74
$0.00
$261.20
$0.00
$1,726.07
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$171.74
$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
$1,112.51
$0.00
$0.00
$0.00
$836.83
$0.00
$1,195.85
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$137.01
$0.00
$0.00
$0.00
$26.76
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$261.20
$0.00
$0.00
$0.00
$261.20
$0.00
$171.74
$0.00
$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
7.04%
7.04%
7.04%
7.04%
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
$10.38
$43.51
$15.36
$72.76
$0.00
$19.20
$0.00
$97.12
$56.70
$69.01
$5.07
$0.00
$34.36
$21.07
$0.00
$24.82
$0.00
$69.77
$38.57
$0.00
$42.71
$48.27
$0.00
$0.00
$0.00
$29.77
$50.15
$0.00
$28.36
$0.00
$0.00
$0.23
$29.74
$44.74
$0.00
$0.00
$0.00
$165.42
$61.53
$34.21
$2.36
$0.00
$1.01
$0.00
$0.00
$0.76
$0.00
$112.48
$121.77
$0.00
$0.00
$99.94
$0.00
$0.00
$0.00
$0.00
$72.58
$0.00
$0.00
$0.00
$208.75
$248.29
$287.88
$342.29
$0.00
$212.32
$0.00
$306.54
$286.00
$252.79
$277.71
$0.00
$217.83
$191.75
$0.00
$238.40
$0.00
$288.22
$258.07
$0.00
$217.33
$320.14
$0.00
$0.00
$0.00
$208.39
$285.92
$0.00
$218.03
$0.00
$171.74
$171.74
$261.20
$261.20
$0.00
$171.74
$0.00
$261.20
$261.20
$171.74
$261.20
$0.00
$171.74
$171.74
$0.00
$171.74
$0.00
$261.20
$171.74
$0.00
$171.74
$261.20
$0.00
$0.00
$0.00
$171.74
$261.20
$0.00
$171.74
$0.00
$303.04
$0.00
$402.88
$549.68
$0.00
$375.37
$0.00
$0.00
$536.73
$0.00
$0.00
$0.00
$366.52
$190.83
$0.00
$391.72
$349.29
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$342.53
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.01
$2.76
$0.00
$0.00
$0.00
$0.00
$3.57
$0.00
$0.00
$0.00
$1.72
$0.00
$0.00
$0.03
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$171.74
$0.00
$261.20
$261.20
$0.00
$171.74
$0.00
$0.00
$261.20
$0.00
$0.00
$0.00
$171.74
$171.74
$0.00
$171.74
$171.74
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$171.74
$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
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$765.55
$0.00
$0.00
$1,381.11
$0.00
$1,019.73
$893.08
$1,418.31
$1,241.74
$1,121.88
$0.00
$937.93
$1,043.04
$0.00
$0.00
$1,017.52
$0.00
$0.00
$1,177.39
$0.00
$0.00
$1,342.26
$0.00
$0.00
$0.00
$882.70
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$6.35
$0.00
$0.00
$7.64
$391.72
$26.80
$40.35
$0.00
$0.00
$30.42
$0.00
$0.00
$3.53
$0.00
$0.00
$81.43
$0.00
$0.00
$177.75
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$171.74
$0.00
$0.00
$261.20
$0.00
$171.74
$171.74
$261.20
$261.20
$171.74
$0.00
$171.74
$171.74
$0.00
$0.00
$171.74
$0.00
$0.00
$171.74
$0.00
$0.00
$261.20
$0.00
$0.00
$0.00
$171.74
$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
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
Revised since September 21, 2012 Publication (included in 10/11/13 file version)
Psychiatric per Diem rates in the "MA_HMO_EU" tab were added. These rates were previously labeled as "TBD"
since the Psych reform methodology hadn't been implemented by the Managed Care Plans when the rest of the rates
were released. Psychiatric rates were also added to the public website for January 1, 2011 and April 1, 2011 at the same time
that these 2012 rates were posted.
Revised since September 10, 2012 Publication (included in 9/21/2012 file version)
(4)
HIGH COST CC's
HIGH COST CHARGE CONVERTOR (2010)
OPCERT
0101000
0101000
7000001
3101000
7000002
3622000
0301001
HOSPITAL NAME
ALBANY MEDICAL CTR SO CLINICAL
ALBANY MEDICAL CTR HOSP
BRONX‐LEBANON HOSPITAL CTR
EASTERN NIAGARA HOSPITAL
JACOBI MEDICAL CENTER
MEDINA MEMORIAL HOSPITAL
OUR LADY OF LOURDES MEMORIAL
0.346200
0.346200
0.780359
0.598057
0.841429
0.746700
0.493525