SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT CASE PAYMENT RATES ‐ EFFECTIVE 4/1/2011 ‐ 9/30/2011
NYSDOH
(1)
(2)
(3)
(4)
(5)
(6)
(7)
DISCHARGE RATES
STATEWIDE PRICE ‐
MA HMO
ISAF
HIGH COST CC's
IME %'s
DME RATE
CAPITAL RATE ‐ PER DISCH
"DEFAULT & CAPITAL PER *Informational *Informational INSTITUTION "DEFAULT & CONTRACT" Only* DISCHARGE Only* HIGH COST SPECIFIC DISCHARGE CASE CONTRACT" (EXCLUDING DIRECT INDIRECT PAYMENT RATE STATEWIDE BASE ADJUSTMENT CHARGE NON‐
MEDICAL MEDICAL (INCLUDING PHL PRICE (INCLUDING FACTOR CONVERTOR
COMPARABLE EDUCATION EDUCATION (ISAF)
§ 2807‐c(33) ‐ PHL § 2807‐c(33))
ADD‐ONS)
(DME) ADD‐ON
(IME) %
Excluding IME)
OPCERT
1623001
0101000
0101000
1624000
0701000
0501000
3801000
7002001
5501000
1427000
7001041
7002002
3535001
7000001
7001002
5123000
7001003
0601000
4429000
2238001
5263000
5401001
0901001
0824000
4401000
3421000
4720001
1001000
3301000
2625000
7001009
5001000
1101000
HOSPITAL NAME
ADIRONDACK MEDICAL CENTER
ALBANY MEDICAL CTR SO CLINICAL
ALBANY MEDICAL CTR 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
BON SECOURS COMMUNITY HOSP
BRONX‐LEBANON HOSPITAL CTR
BROOKDALE HOSPITAL MED CTR
BROOKHAVEN MEMORIAL HOSP
BROOKLYN HOSPITAL
BROOKS MEMORIAL HOSPITAL
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
COMM‐GEN / GREATER SYRACUSE
COMMUNITY MEMORIAL HOSPITAL
CONEY ISLAND HOSPITAL
CORNING HOSPITAL
CORTLAND REGIONAL MED CTR
$5,284.05
$5,584.74
$5,584.74
$5,203.14
$5,203.37
$5,536.07
$5,097.94
$6,588.45
$5,609.09
$4,453.32
$7,541.51
$7,279.48
$5,840.38
$6,878.52
$6,771.51
$6,531.07
$6,653.82
$4,741.74
$4,986.37
$4,675.48
$5,875.64
$5,687.31
$5,412.95
$4,944.78
$5,006.52
$4,490.16
$4,860.15
$5,313.18
$6,021.25
$5,183.79
$6,522.42
$5,583.66
$5,138.18
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
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
0.7934
0.7348
0.9149
0.8812
0.8403
0.7620
0.7692
0.6948
0.7604
0.8205
0.9264
0.8044
1.0110
0.8778
0.8030
0.633439
0.392209
0.392209
0.573986
0.468437
0.491137
0.668487
0.790023
0.312028
0.602722
0.185338
0.335516
0.309085
0.730071
0.584224
0.209413
0.543652
0.697443
0.600233
0.440857
0.436770
0.759452
0.439962
0.501189
0.665019
0.583462
0.920860
0.462135
0.534457
0.533932
0.680783
0.567279
0.684025
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%
1.73%
0.00%
16.91%
0.00%
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
$26.15
$0.00
$1,173.02
$0.00
$0.00
1 of 12
**(PER DISCH)**
$395.76
$731.72
$731.72
$300.11
$406.35
$446.28
$214.58
$803.88
$829.97
$143.11
$159.85
$688.90
$290.46
$448.35
$383.94
$322.74
$403.96
$222.37
$342.20
$142.22
$351.55
$387.13
$604.61
$198.45
$215.81
$230.81
$471.14
$339.23
$314.39
$204.89
$712.11
$133.26
$409.37
(8)
(9)
(10)
TEACHING SCHOOL OF ELECTION AMBULANCE AMENDMENT NURSING ADD‐ON
ADD‐ON
PHYSICIANS ADD‐ON
$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
(12)
CAPITAL RATE ‐ PER DIEM
STERILIZATION
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
(11)
$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
$0.00
CAPITAL PER DIEM
**(PER DAY**)
$86.11
$130.18
$130.18
$74.13
$88.49
$105.38
$52.68
$151.24
$148.19
$41.97
$26.88
$158.53
$67.67
$82.76
$69.99
$61.18
$78.35
$53.34
$106.73
$34.26
$90.54
$99.72
$103.69
$47.01
$52.08
$40.56
$55.70
$78.91
$67.53
$53.30
$128.48
$42.49
$53.96
(13)
(14)
ALC
HCRA SURCHARGE
STERILIZATION DURING REGIONAL DELIVERY (MANAGED ALC PRICE BAD DEBT PER DAY
PERCENT CARE ADD‐ON
ENROLLEES OF FIDELIS CARE ONLY)
(2290)
$736.87
$778.80
$778.80
$725.59
$725.62
$772.02
$710.92
$918.77
$782.20
$621.03
$1,051.68
$1,015.14
$814.45
$959.23
$944.30
$910.77
$927.89
$661.25
$695.36
$652.01
$819.37
$793.11
$754.85
$689.56
$698.17
$626.16
$677.76
$740.94
$839.68
$722.89
$909.57
$778.65
$716.53
$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
$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%
7.04%
pub_ip_april2011_mmc(initial_XX_XX_12).xls
Ref 040
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT CASE PAYMENT RATES ‐ EFFECTIVE 4/1/2011 ‐ 9/30/2011
NYSDOH
(1)
(2)
(3)
(4)
(5)
(6)
(7)
DISCHARGE RATES
STATEWIDE PRICE ‐
MA HMO
ISAF
HIGH COST CC's
IME %'s
DME RATE
CAPITAL RATE ‐ PER DISCH
"DEFAULT & CAPITAL PER *Informational *Informational INSTITUTION "DEFAULT & CONTRACT" Only* DISCHARGE Only* HIGH COST SPECIFIC DISCHARGE CASE CONTRACT" (EXCLUDING DIRECT INDIRECT PAYMENT RATE STATEWIDE BASE ADJUSTMENT CHARGE NON‐
MEDICAL MEDICAL (INCLUDING PHL PRICE (INCLUDING FACTOR CONVERTOR
COMPARABLE EDUCATION EDUCATION (ISAF)
§ 2807‐c(33) ‐ PHL § 2807‐c(33))
ADD‐ONS)
(DME) ADD‐ON
(IME) %
Excluding IME)
OPCERT
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
1404000
7001016
HOSPITAL NAME
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
KENMORE MERCY HOSPITAL
KINGS COUNTY HOSPITAL CENTER
$6,150.42
$4,456.98
$6,446.90
$5,209.98
$5,426.98
$6,983.64
$5,975.16
$4,591.07
$5,365.28
$6,683.80
$7,295.95
$6,287.39
$4,695.28
$7,333.84
$5,268.31
$6,651.63
$6,565.44
$6,773.68
$5,537.53
$7,686.94
$6,145.27
$6,878.67
$6,747.79
$4,871.49
$7,160.21
$7,258.67
$6,648.69
$4,752.49
$5,992.74
$5,992.74
$5,912.46
$5,309.67
$6,573.40
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
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
1.0580
1.0538
0.7532
1.1093
1.1241
1.0286
0.7428
0.9274
0.9274
0.9147
0.8193
1.0145
0.556811
0.595681
0.416567
0.599802
0.293822
0.574950
0.483063
0.573882
0.481342
0.529894
0.397327
0.288633
0.610428
0.348526
0.516468
0.198706
0.250920
1.002754
0.610190
0.380113
0.297442
0.319587
0.311264
0.571873
0.786295
0.600097
0.355978
0.590215
0.432257
0.432257
0.423450
0.435233
0.723330
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%
33.45%
$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
$0.00
$2,405.63
2 of 12
**(PER DISCH)**
$479.57
$195.07
$960.42
$183.21
$405.53
$586.68
$619.63
$345.38
$301.79
$270.86
$447.10
$327.66
$258.48
$546.97
$449.28
$467.18
$300.82
$558.31
$296.07
$1,530.79
$421.37
$477.25
$894.37
$116.09
$936.94
$215.00
$351.83
$419.53
$706.61
$706.61
$367.52
$406.90
$1,123.95
(8)
(9)
(10)
TEACHING SCHOOL OF ELECTION AMBULANCE AMENDMENT NURSING ADD‐ON
ADD‐ON
PHYSICIANS ADD‐ON
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$337.31
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$460.14
(12)
CAPITAL RATE ‐ PER DIEM
STERILIZATION
NON‐COMPARABLE ADD‐ONS
$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
$90.05
$0.00
(11)
$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
$0.00
$0.00
CAPITAL PER DIEM
**(PER DAY**)
$102.41
$39.32
$213.24
$41.29
$91.29
$136.68
$96.39
$87.52
$63.67
$51.38
$92.93
$59.08
$59.63
$96.33
$99.67
$111.30
$60.32
$107.24
$69.85
$384.55
$89.01
$105.20
$126.15
$30.38
$192.62
$52.30
$63.21
$119.09
$149.32
$149.32
$83.61
$84.85
$223.23
(13)
(14)
ALC
HCRA SURCHARGE
STERILIZATION DURING REGIONAL DELIVERY (MANAGED ALC PRICE BAD DEBT PER DAY
PERCENT CARE ADD‐ON
ENROLLEES OF FIDELIS CARE ONLY)
(2290)
$857.69
$621.54
$899.04
$726.54
$756.80
$973.88
$833.25
$640.24
$748.20
$932.07
$1,017.44
$876.79
$654.77
$1,022.72
$734.68
$927.59
$915.57
$944.61
$772.22
$1,071.96
$856.97
$959.25
$940.99
$679.34
$998.51
$1,012.24
$927.18
$662.75
$835.70
$835.70
$824.51
$740.45
$916.68
$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
$171.74
$261.20
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
pub_ip_april2011_mmc(initial_XX_XX_12).xls
Ref 040
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT CASE PAYMENT RATES ‐ EFFECTIVE 4/1/2011 ‐ 9/30/2011
NYSDOH
(1)
(2)
(3)
(4)
(5)
(6)
(7)
DISCHARGE RATES
STATEWIDE PRICE ‐
MA HMO
ISAF
HIGH COST CC's
IME %'s
DME RATE
CAPITAL RATE ‐ PER DISCH
"DEFAULT & CAPITAL PER *Informational *Informational INSTITUTION "DEFAULT & CONTRACT" Only* DISCHARGE Only* HIGH COST SPECIFIC DISCHARGE CASE CONTRACT" (EXCLUDING DIRECT INDIRECT PAYMENT RATE STATEWIDE BASE ADJUSTMENT CHARGE NON‐
MEDICAL MEDICAL (INCLUDING PHL PRICE (INCLUDING FACTOR CONVERTOR
COMPARABLE EDUCATION EDUCATION (ISAF)
§ 2807‐c(33) ‐ PHL § 2807‐c(33))
ADD‐ONS)
(DME) ADD‐ON
(IME) %
Excluding IME)
OPCERT
7001033
5501001
2728001
5922000
7002017
2424000
7000008
2902000
7001017
7003004
7001019
7001020
3824000
4402000
3622000
0101003
1401008
2909000
7002021
7000006
7003015
7002024
3121001
5903000
2950002
1701000
7002000
3102000
2527000
7000024
2951001
1327000
5920000
HOSPITAL NAME
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 COLLEGE HOSPITAL*
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
NORTHERN DUTCHESS HOSPITAL
NORTHERN WESTCHESTER HOSP
$7,385.14
$5,594.34
$4,667.66
$6,414.56
$6,701.83
$5,313.62
$6,622.94
$5,847.53
$6,642.75
$7,004.89
$6,594.86
$7,713.91
$4,872.43
$5,138.30
$4,201.66
$5,236.85
$5,726.68
$6,602.22
$6,585.59
$7,230.45
$7,203.97
$7,203.97
$5,502.63
$6,668.26
$7,287.20
$5,060.40
$6,903.78
$5,005.93
$4,824.11
$7,366.50
$7,474.24
$6,106.98
$6,544.07
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
1.1482
0.8734
0.7271
0.9974
1.0407
0.8163
1.0321
0.9032
1.0333
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
0.9546
1.0116
0.336873
0.462225
0.424993
0.381174
0.212152
0.701273
0.868774
0.305201
0.409851
0.318139
0.579842
0.313754
0.496744
0.632200
0.865467
0.530937
0.461137
0.316249
0.781170
0.277820
0.388988
0.423808
0.550469
0.560216
0.628195
0.534222
0.540329
0.490218
0.464593
0.755691
0.293430
0.411690
0.535071
14.58%
5.30%
0.00%
0.00%
15.32%
0.00%
24.42%
11.04%
22.80%
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%
0.00%
$1,083.42
$216.69
$0.00
$0.00
$1,069.66
$0.00
$1,159.24
$423.80
$990.97
$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
$0.00
$0.00
3 of 12
**(PER DISCH)**
$410.43
$232.56
$118.86
$448.41
$757.69
$373.44
$369.29
$422.58
$888.08
$685.72
$274.88
$718.64
$325.12
$284.47
$0.00
$447.26
$462.10
$488.88
$502.82
$671.55
$396.65
$819.15
$233.47
$211.30
$405.26
$289.40
$571.89
$428.11
$275.53
$431.36
$810.94
$331.32
$517.97
(8)
(9)
(10)
NON‐COMPARABLE ADD‐ONS
TEACHING SCHOOL OF ELECTION AMBULANCE AMENDMENT NURSING ADD‐ON
ADD‐ON
PHYSICIANS ADD‐ON
$0.00
$0.00
$0.00
$0.00
$211.27
$0.00
$0.00
$0.00
$148.37
$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
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$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
$62.62
$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
$0.00
$0.00
(11)
(12)
CAPITAL RATE ‐ PER DIEM
STERILIZATION
CAPITAL PER DIEM
**(PER DAY**)
$68.13
$54.88
$34.82
$100.84
$167.38
$98.45
$103.24
$63.54
$200.24
$146.82
$56.24
$148.36
$72.44
$78.22
$0.00
$88.04
$99.87
$97.31
$147.10
$128.78
$72.78
$166.36
$57.04
$38.71
$92.47
$73.42
$142.61
$95.65
$73.88
$111.13
$155.65
$90.58
$130.50
(13)
(14)
ALC
HCRA SURCHARGE
STERILIZATION DURING REGIONAL DELIVERY (MANAGED ALC PRICE BAD DEBT PER DAY
PERCENT CARE ADD‐ON
ENROLLEES OF FIDELIS CARE ONLY)
(2290)
$1,029.87
$780.14
$650.92
$894.53
$934.59
$741.00
$923.58
$815.45
$926.35
$976.85
$919.67
$1,075.72
$679.47
$716.55
$585.93
$730.29
$798.60
$920.69
$918.38
$1,008.30
$1,004.61
$1,004.61
$767.35
$929.90
$1,016.22
$705.68
$962.75
$698.09
$672.73
$1,027.28
$1,042.30
$851.63
$912.59
$261.20
$171.74
$171.74
$261.20
$261.20
$171.74
$261.20
$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
$171.74
$261.20
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
pub_ip_april2011_mmc(initial_XX_XX_12).xls
Ref 040
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT CASE PAYMENT RATES ‐ EFFECTIVE 4/1/2011 ‐ 9/30/2011
NYSDOH
(1)
(2)
(3)
(4)
(5)
(6)
(7)
DISCHARGE RATES
STATEWIDE PRICE ‐
MA HMO
ISAF
HIGH COST CC's
IME %'s
DME RATE
CAPITAL RATE ‐ PER DISCH
"DEFAULT & CAPITAL PER *Informational *Informational INSTITUTION "DEFAULT & CONTRACT" Only* DISCHARGE Only* HIGH COST SPECIFIC DISCHARGE CASE CONTRACT" (EXCLUDING DIRECT INDIRECT PAYMENT RATE STATEWIDE BASE ADJUSTMENT CHARGE NON‐
MEDICAL MEDICAL (INCLUDING PHL PRICE (INCLUDING FACTOR CONVERTOR
COMPARABLE EDUCATION EDUCATION (ISAF)
§ 2807‐c(33) ‐ PHL § 2807‐c(33))
ADD‐ONS)
(DME) ADD‐ON
(IME) %
Excluding IME)
OPCERT
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
1401006
1401013
5904000
HOSPITAL NAME
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
SHEEHAN MEMORIAL EMERGENCY
SISTERS OF CHARITY HOSPITAL
SOUND SHORE MEDICAL CENTER
(8)
(9)
(10)
(11)
(12)
CAPITAL RATE ‐ PER DIEM
STERILIZATION
NON‐COMPARABLE ADD‐ONS
TEACHING SCHOOL OF ELECTION AMBULANCE AMENDMENT NURSING ADD‐ON
ADD‐ON
PHYSICIANS ADD‐ON
CAPITAL PER DIEM
(13)
(14)
ALC
HCRA SURCHARGE
STERILIZATION DURING REGIONAL DELIVERY (MANAGED ALC PRICE BAD DEBT PER DAY
PERCENT CARE ADD‐ON
ENROLLEES OF FIDELIS CARE ONLY)
$7,119.78
$6,628.03
$7,116.62
$6,879.57
$7,236.42
$7,236.42
$7,236.42
$6,469.08
$6,346.66
$6,894.65
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
1.1128
1.0217
1.0990
1.0683
1.1184
1.1184
1.1184
0.9987
0.9750
1.0701
0.421484
0.420274
0.379023
0.471205
0.385719
0.385719
0.385719
0.400254
0.274764
0.393229
0.00%
16.08%
16.54%
16.78%
27.06%
27.06%
27.06%
0.00%
0.00%
19.78%
$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)**
$272.22
$333.57
$748.00
$342.64
$1,493.61
$1,493.61
$1,493.61
$198.03
$239.51
$1,437.81
$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
**(PER DAY**)
$43.88
$155.14
$149.38
$72.72
$257.30
$257.30
$257.30
$29.16
$57.38
$306.04
(2290)
$992.87
$924.29
$992.43
$959.37
$1,009.14
$1,009.14
$1,009.14
$902.13
$885.06
$961.47
$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%
$6,894.65
$4,889.36
$4,689.59
$6,441.86
$5,327.12
$5,177.35
$6,483.35
$6,049.52
$6,502.88
$7,099.18
$6,612.58
$7,374.88
$6,451.47
$5,474.06
$4,983.68
$5,053.99
$5,480.04
$5,348.85
$5,197.90
$4,770.73
$5,367.64
$6,669.28
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
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
0.7329
0.8265
1.0294
0.393229
0.513318
0.503143
0.260719
0.567339
0.532027
0.240950
0.374040
0.372063
0.342136
0.322529
0.807393
0.279179
0.485187
0.478620
0.443743
0.535569
0.388246
0.355218
0.695993
0.475144
0.538128
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%
0.00%
4.24%
10.85%
$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
$0.00
$134.37
$631.35
$1,437.81
$377.16
$509.71
$623.67
$568.59
$239.28
$845.68
$171.70
$714.00
$351.80
$502.13
$610.36
$263.15
$511.26
$279.85
$401.21
$376.59
$515.80
$273.75
$0.00
$361.35
$281.14
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$319.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$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
$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
$0.00
$0.00
$0.00
$22.05
$6.23
$0.00
$48.91
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$306.04
$83.37
$126.98
$144.92
$118.58
$60.75
$204.31
$23.81
$160.28
$69.05
$108.50
$148.33
$58.15
$103.10
$68.10
$81.77
$77.24
$99.35
$61.66
$0.00
$75.22
$60.54
$961.47
$681.83
$653.97
$898.33
$742.88
$721.99
$904.12
$843.62
$906.84
$990.00
$922.14
$1,028.44
$899.67
$763.37
$694.99
$704.79
$764.20
$745.91
$724.86
$665.29
$748.53
$930.05
$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
$171.74
$171.74
$261.20
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
4 of 12
pub_ip_april2011_mmc(initial_XX_XX_12).xls
Ref 040
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT CASE PAYMENT RATES ‐ EFFECTIVE 4/1/2011 ‐ 9/30/2011
NYSDOH
(1)
(2)
(3)
(4)
(5)
(6)
(7)
DISCHARGE RATES
STATEWIDE PRICE ‐
MA HMO
ISAF
HIGH COST CC's
IME %'s
DME RATE
CAPITAL RATE ‐ PER DISCH
"DEFAULT & CAPITAL PER *Informational *Informational INSTITUTION "DEFAULT & CONTRACT" Only* DISCHARGE Only* HIGH COST SPECIFIC DISCHARGE CASE CONTRACT" (EXCLUDING DIRECT INDIRECT PAYMENT RATE STATEWIDE BASE ADJUSTMENT CHARGE NON‐
MEDICAL MEDICAL (INCLUDING PHL PRICE (INCLUDING FACTOR CONVERTOR
COMPARABLE EDUCATION EDUCATION (ISAF)
§ 2807‐c(33) ‐ PHL § 2807‐c(33))
ADD‐ONS)
(DME) ADD‐ON
(IME) %
Excluding IME)
OPCERT
2950001
5126000
5154000
3529000
7000014
5157003
5149001
3202002
1302000
2953000
5002001
7001024
5907001
2952006
0701001
3301003
5907002
7002032
3522000
2801001
0101004
7001037
7004003
2701005
2754001
0427000
1227001
0303001
1801000
5151001
3301007
1302001
HOSPITAL NAME
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
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
(8)
(9)
(10)
NON‐COMPARABLE ADD‐ONS
TEACHING SCHOOL OF ELECTION AMBULANCE AMENDMENT NURSING ADD‐ON
ADD‐ON
PHYSICIANS ADD‐ON
(11)
(12)
CAPITAL RATE ‐ PER DIEM
STERILIZATION
CAPITAL PER DIEM
(13)
(14)
ALC
HCRA SURCHARGE
STERILIZATION DURING REGIONAL DELIVERY (MANAGED ALC PRICE BAD DEBT PER DAY
PERCENT CARE ADD‐ON
ENROLLEES OF FIDELIS CARE ONLY)
$6,224.70
$6,489.34
$6,799.04
$6,224.93
$6,596.98
$6,867.69
$6,210.59
$5,443.46
$5,584.74
$6,921.15
$4,245.48
$7,714.31
$6,317.36
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
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
0.288378
0.412366
0.337697
0.262404
0.262966
0.266765
0.313916
0.481391
0.318707
0.332146
0.501685
0.504795
0.423654
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%
$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
**(PER DISCH)**
$529.58
$583.88
$543.78
$412.06
$540.85
$295.16
$279.60
$416.09
$866.74
$1,041.21
$298.85
$245.72
$247.71
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$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
**(PER DAY**)
$100.02
$170.38
$126.79
$101.73
$124.67
$56.21
$67.96
$89.06
$188.47
$181.50
$90.03
$40.54
$47.75
(2290)
$868.05
$904.95
$948.14
$868.08
$919.96
$957.72
$866.08
$759.10
$778.80
$965.17
$592.04
$1,075.78
$880.97
$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
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
$6,537.72
$4,791.34
$5,724.09
$6,222.58
$7,807.77
$5,849.40
$4,904.24
$5,622.76
$7,022.27
$6,589.48
$5,796.12
$5,020.85
$4,438.01
$6,509.39
$5,502.14
$4,937.91
$6,635.95
$5,942.95
$6,390.80
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
$6,509.39
1.0095
0.7429
0.8836
0.9703
1.2181
0.9024
0.7556
0.8670
1.0909
1.0178
0.8996
0.7752
0.6824
1.0000
0.8484
0.7647
1.0257
0.9184
0.9923
0.341489
0.479156
0.459105
0.582145
0.331090
0.241413
0.518524
0.349021
0.743965
0.350479
0.571813
0.563002
0.594185
1.000000
0.529650
0.513022
0.433128
0.577036
0.307627
0.00%
0.00%
5.47%
8.01%
24.50%
0.00%
0.00%
2.24%
25.55%
17.29%
29.02%
7.65%
0.00%
0.00%
7.53%
0.00%
28.73%
29.03%
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
$46.51
$0.00
$0.00
$201.14
$0.00
$1,059.23
$1,013.90
$0.00
$302.47
$205.18
$368.25
$613.49
$916.10
$466.21
$194.19
$619.02
$889.10
$301.52
$704.80
$471.94
$175.76
$415.00
$328.34
$425.46
$936.86
$739.65
$452.40
$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
$268.38
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$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
$0.00
$0.00
$0.00
$57.21
$37.92
$71.38
$113.35
$220.74
$104.10
$46.67
$132.94
$159.21
$49.13
$122.76
$100.76
$39.19
$207.50
$65.81
$101.39
$176.98
$127.05
$98.68
$911.70
$668.16
$798.24
$867.75
$1,088.81
$815.71
$683.91
$784.11
$979.27
$918.92
$808.28
$700.17
$618.89
$907.75
$767.29
$688.60
$925.40
$828.76
$891.21
$261.20
$171.74
$171.74
$261.20
$261.20
$171.74
$171.74
$171.74
$261.20
$261.20
$171.74
$171.74
$171.74
$171.74
$171.74
$171.74
$261.20
$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%
5 of 12
pub_ip_april2011_mmc(initial_XX_XX_12).xls
Ref 040
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT CASE PAYMENT RATES ‐ EFFECTIVE 4/1/2011 ‐ 9/30/2011
NYSDOH
(1)
(2)
(3)
(4)
(5)
(6)
(7)
DISCHARGE RATES
STATEWIDE PRICE ‐
MA HMO
ISAF
HIGH COST CC's
IME %'s
DME RATE
CAPITAL RATE ‐ PER DISCH
"DEFAULT & CAPITAL PER *Informational *Informational INSTITUTION "DEFAULT & CONTRACT" Only* DISCHARGE Only* HIGH COST SPECIFIC DISCHARGE CASE CONTRACT" (EXCLUDING DIRECT INDIRECT PAYMENT RATE STATEWIDE BASE ADJUSTMENT CHARGE NON‐
MEDICAL MEDICAL (INCLUDING PHL PRICE (INCLUDING FACTOR CONVERTOR
COMPARABLE EDUCATION EDUCATION (ISAF)
§ 2807‐c(33) ‐ PHL § 2807‐c(33))
ADD‐ONS)
(DME) ADD‐ON
(IME) %
Excluding IME)
OPCERT
5820000
5957001
0632000
5902001
2908000
0602001
7001045
7001035
6027000
HOSPITAL NAME
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
**(PER DISCH)**
$6,509.39
0.7734
0.485046
0.00%
$0.00
$310.32
$4,993.58
$7,364.24
$6,509.39
1.1393
0.342782
18.54%
$1,845.43
$1,797.23
$6,509.39
0.7195
0.884032
0.00%
$0.00
$150.45
$4,589.37
$6,611.81
$6,509.39
1.0231
0.460502
0.00%
$0.00
$419.56
$6,620.50
$6,509.39
1.0188
0.300934
16.50%
$691.02
$730.86
$4,795.50
$6,509.39
0.7416
0.469819
0.00%
$0.00
$228.65
$6,560.38
$6,509.39
1.0175
0.933577
20.72%
$1,664.32
$628.87
$6,863.20
$6,509.39
1.0677
0.509478
15.91%
$950.14
$453.54
$6,509.39
0.7759
0.942083
0.00%
$0.00
$194.95
$4,990.54
Note: Effective 1/1/2011, Maimonides Capital per Discharge rate no longer includes a High Cost Outlier add‐on.
*See "Rate changes with special dates" tab for this facility.
6 of 12
(8)
(9)
(10)
TEACHING SCHOOL OF ELECTION AMBULANCE AMENDMENT NURSING ADD‐ON
ADD‐ON
PHYSICIANS ADD‐ON
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$366.78
$0.00
$0.00
(12)
CAPITAL RATE ‐ PER DIEM
STERILIZATION
NON‐COMPARABLE ADD‐ONS
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$18.37
$0.00
(11)
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
CAPITAL PER DIEM
**(PER DAY**)
$76.99
$245.38
$50.15
$81.89
$154.09
$51.26
$134.30
$98.20
$40.11
(13)
(14)
ALC
HCRA SURCHARGE
STERILIZATION DURING REGIONAL DELIVERY (MANAGED ALC PRICE BAD DEBT PER DAY
PERCENT CARE ADD‐ON
ENROLLEES OF FIDELIS CARE ONLY)
(2290)
$696.37
$1,026.96
$640.00
$922.03
$923.24
$668.74
$914.86
$957.09
$695.94
$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%
pub_ip_april2011_mmc(initial_XX_XX_12).xls
Ref 040
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT EXEMPT UNIT RATES - EFFECTIVE 4/1/2011 - 9/30/2011
NYSDOH
(1)
(2)
(3)
SPECIALTY HOSPITAL
SPECIALTY ACUTE, LONG‐
TERM CARE AND CHILDREN'S HOSPITAL BILLING RATE (w/out DME)
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
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
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,598.64
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,052.45
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$562.28
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
*Informational Only* SPECIALTY ACUTE, LONG‐TERM CARE AND CHILDREN'S HOSPITAL DME Add‐on
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$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
(4)
(5)
PSYCHIATRIC
(6)
(7)
(8)
(9)
CHEMICAL DEPENDENCY REHAB
(10)
(11)
CRITICAL ACCESS HOSPITAL
(12)
(13)
(14)
MEDICAL REHABILITATION
SPECIALTY *Informational *Informational CRITICAL ACUTE, LONG‐
CHEMICAL Only* *Informational CRITICAL MEDICAL CHEMICAL Only* ACCESS MEDICAL TERM CARE AND PSYCHIATRIC DEPENDENCY CHEMICAL Only* ACCESS REHAB DEPENDENCY PSYCHIATRIC MEDICAL REHAB ALC HOSPITAL CHILDREN'S BILLING RATE REHAB BILLING DEPENDENCY PSYCHIATRIC ALC PER DIEM
HOSPITAL BILLING RATE REHAB REHAB DME PER DIEM
BILLING RATE HOSPITAL (w/out DME)
RATE (w/out REHAB ALC PER DIEM
DME Add‐on
ALC PER DIEM (w/out DME)
Add‐on
(w/out DME)
ALC PER DIEM DME)
DME Add‐on
(w/out DME)
$0.00
$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
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
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Requires DOB Approval
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Requires DOB Approval
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Requires DOB Approval
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Requires DOB Approval
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Requires DOB Approval
Requires DOB Approval
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Requires DOB Approval
Requires DOB Approval
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Requires DOB Approval
Requires DOB Approval
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$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$316.80
$0.00
$0.00
$674.29
$0.00
$531.55
$367.21
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$415.21
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$289.13
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$440.39
$0.00
$1,076.40
$0.00
$646.15
Page 7 of 12
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.59
$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
$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
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$2,424.82
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$2,299.02
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$2,319.03
$1,076.40
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$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
$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
$0.00
$917.87
$0.00
$0.00
$0.00
$0.00
$0.00
$1,048.65
$972.33
$0.00
$0.00
$1,412.95
$0.00
$0.00
$0.00
$0.00
$0.00
$1,305.31
$0.00
$1,122.76
$0.00
$0.00
$1,033.31
$0.00
$0.00
$968.81
$0.00
$0.00
$869.78
$0.00
$0.00
$0.00
$0.00
$0.00
$924.91
$0.00
$1,045.22
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$91.89
$0.00
$0.00
$0.00
$0.00
$0.00
$120.71
$0.00
$0.00
$0.00
$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
$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
(15)
(16)
DETOX
DETOX‐ MEDICALLY MANAGED WITHDRAWAL BILLING RATE
(17)
HCRA SURCHARGE
DETOX ‐ MEDICALLY SUPERVISED WITHDRAWAL BILLING RATE
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
INDIGENT CARE AND HEALTH CARE INITIATIVE SURCHARGE
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
pub_ip_april2011_mmc(initial_XX_XX_12).xls
Ref 040
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT EXEMPT UNIT RATES - EFFECTIVE 4/1/2011 - 9/30/2011
NYSDOH
(1)
(2)
(3)
SPECIALTY HOSPITAL
SPECIALTY ACUTE, LONG‐
TERM CARE AND CHILDREN'S HOSPITAL BILLING RATE (w/out DME)
OPCERT
3101000
1552701
5526700
4601001
7003000
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
HOSPITAL NAME
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
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
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$639.80
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
*Informational Only* SPECIALTY ACUTE, LONG‐TERM CARE AND CHILDREN'S HOSPITAL DME Add‐on
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$56.88
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
(4)
(5)
PSYCHIATRIC
(6)
(7)
(8)
(9)
CHEMICAL DEPENDENCY REHAB
(10)
(11)
CRITICAL ACCESS HOSPITAL
(12)
(13)
(14)
MEDICAL REHABILITATION
SPECIALTY *Informational *Informational CRITICAL ACUTE, LONG‐
CHEMICAL Only* *Informational CRITICAL MEDICAL CHEMICAL Only* ACCESS MEDICAL TERM CARE AND PSYCHIATRIC DEPENDENCY CHEMICAL Only* ACCESS REHAB DEPENDENCY PSYCHIATRIC MEDICAL REHAB ALC HOSPITAL CHILDREN'S BILLING RATE REHAB BILLING DEPENDENCY PSYCHIATRIC ALC PER DIEM
HOSPITAL BILLING RATE REHAB REHAB DME PER DIEM
BILLING RATE HOSPITAL (w/out DME)
RATE (w/out REHAB ALC PER DIEM
DME Add‐on
ALC PER DIEM (w/out DME)
Add‐on
(w/out DME)
ALC PER DIEM DME)
DME Add‐on
(w/out DME)
$0.00
$0.00
$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
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
$296.23
$0.00
$0.00
$0.00
$0.00
$269.90
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$557.92
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$533.20
$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
Page 8 of 12
$0.00
$0.00
$0.00
$0.00
$0.00
$1.45
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.30
$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
$171.74
$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
$1,993.09
$1,771.56
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,451.73
$0.00
$0.00
$0.00
$0.00
$0.00
$171.74
$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
$171.74
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,189.72
$982.23
$0.00
$910.70
$0.00
$0.00
$0.00
$1,158.27
$1,089.11
$1,082.48
$0.00
$0.00
$0.00
$1,463.14
$1,298.43
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,269.35
$1,204.27
$0.00
$0.00
$806.13
$0.00
$727.15
$1,770.14
$883.22
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$661.70
$1,493.86
$0.00
$778.80
$0.00
$0.00
$0.00
$0.00
$257.66
$70.64
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$6.82
$0.00
$0.00
$0.00
$0.00
$456.19
$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
$261.20
$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
(15)
(16)
DETOX
DETOX‐ MEDICALLY MANAGED WITHDRAWAL BILLING RATE
(17)
HCRA SURCHARGE
DETOX ‐ MEDICALLY SUPERVISED WITHDRAWAL BILLING RATE
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
INDIGENT CARE AND HEALTH CARE INITIATIVE SURCHARGE
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
pub_ip_april2011_mmc(initial_XX_XX_12).xls
Ref 040
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT EXEMPT UNIT RATES - EFFECTIVE 4/1/2011 - 9/30/2011
NYSDOH
(1)
(2)
(3)
SPECIALTY HOSPITAL
SPECIALTY ACUTE, LONG‐
TERM CARE AND CHILDREN'S HOSPITAL BILLING RATE (w/out DME)
OPCERT
7001020
1226701
3824000
4402000
3622000
7002020
0101003
1401008
2909000
7002021
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
HOSPITAL NAME
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
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 JOI
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
$0.00
$0.00
$0.00
$0.00
$0.00
$2,794.80
$0.00
$0.00
$0.00
$0.00
$2,415.95
$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
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
*Informational Only* SPECIALTY ACUTE, LONG‐TERM CARE AND CHILDREN'S HOSPITAL DME Add‐on
$0.00
$0.00
$0.00
$0.00
$0.00
$236.79
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
(4)
(5)
PSYCHIATRIC
(6)
(7)
(8)
(9)
CHEMICAL DEPENDENCY REHAB
(10)
(11)
CRITICAL ACCESS HOSPITAL
(12)
(13)
(14)
MEDICAL REHABILITATION
SPECIALTY *Informational *Informational CRITICAL ACUTE, LONG‐
CHEMICAL Only* *Informational CRITICAL MEDICAL CHEMICAL Only* ACCESS MEDICAL TERM CARE AND PSYCHIATRIC DEPENDENCY CHEMICAL Only* ACCESS REHAB DEPENDENCY PSYCHIATRIC MEDICAL REHAB ALC HOSPITAL CHILDREN'S BILLING RATE REHAB BILLING DEPENDENCY PSYCHIATRIC ALC PER DIEM
HOSPITAL BILLING RATE REHAB REHAB DME PER DIEM
BILLING RATE HOSPITAL (w/out DME)
RATE (w/out REHAB ALC PER DIEM
DME Add‐on
ALC PER DIEM (w/out DME)
Add‐on
(w/out DME)
ALC PER DIEM DME)
DME Add‐on
(w/out DME)
$0.00
$0.00
$0.00
$0.00
$0.00
$261.20
$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
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$338.53
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$677.33
$677.33
$0.00
$428.91
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$568.93
Page 9 of 12
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$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
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$171.74
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$0.00
$0.00
$0.00
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$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
$1,891.85
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
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$0.00
$2,525.69
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$0.00
$0.00
$0.00
$0.00
$2,339.54
$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
$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
$753.38
$0.00
$0.00
$956.30
$868.27
$863.33
$0.00
$1,294.34
$0.00
$0.00
$1,308.33
$0.00
$0.00
$1,103.21
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,225.04
$0.00
$0.00
$0.00
$0.00
$885.33
$1,266.75
$1,266.75
$0.00
$0.00
$1,323.71
$1,323.71
$0.00
$0.00
$0.00
$1,018.79
$0.00
$0.00
$0.00
$1,280.51
$1,410.25
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1.30
$263.74
$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
$0.00
$0.00
$171.74
$0.00
$0.00
$171.74
$261.20
$261.20
$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
(15)
(16)
DETOX
DETOX‐ MEDICALLY MANAGED WITHDRAWAL BILLING RATE
(17)
HCRA SURCHARGE
DETOX ‐ MEDICALLY SUPERVISED WITHDRAWAL BILLING RATE
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
INDIGENT CARE AND HEALTH CARE INITIATIVE SURCHARGE
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
pub_ip_april2011_mmc(initial_XX_XX_12).xls
Ref 040
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT EXEMPT UNIT RATES - EFFECTIVE 4/1/2011 - 9/30/2011
NYSDOH
(1)
(2)
(3)
(4)
SPECIALTY HOSPITAL
SPECIALTY ACUTE, LONG‐
TERM CARE AND CHILDREN'S HOSPITAL BILLING RATE (w/out DME)
OPCERT
2952005
3950000
7003007
7004010
2221700
2701003
7002031
3201002
1401010
4102002
2201000
4501000
4823700
4102003
1401006
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
HOSPITAL NAME
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
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
*Informational Only* SPECIALTY ACUTE, LONG‐TERM CARE AND CHILDREN'S HOSPITAL DME Add‐on
(5)
PSYCHIATRIC
(6)
(7)
(8)
(9)
CHEMICAL DEPENDENCY REHAB
(10)
(11)
CRITICAL ACCESS HOSPITAL
(12)
(13)
(14)
MEDICAL REHABILITATION
SPECIALTY *Informational *Informational CRITICAL ACUTE, LONG‐
CHEMICAL Only* *Informational CRITICAL MEDICAL CHEMICAL Only* ACCESS MEDICAL TERM CARE AND PSYCHIATRIC DEPENDENCY CHEMICAL Only* ACCESS REHAB DEPENDENCY PSYCHIATRIC MEDICAL REHAB ALC HOSPITAL CHILDREN'S BILLING RATE REHAB BILLING DEPENDENCY PSYCHIATRIC ALC PER DIEM
HOSPITAL BILLING RATE REHAB REHAB DME PER DIEM
BILLING RATE HOSPITAL (w/out DME)
RATE (w/out REHAB ALC PER DIEM
DME Add‐on
ALC PER DIEM (w/out DME)
Add‐on
(w/out DME)
ALC PER DIEM DME)
DME Add‐on
(w/out DME)
(15)
(16)
DETOX
DETOX‐ MEDICALLY MANAGED WITHDRAWAL BILLING RATE
(17)
HCRA SURCHARGE
DETOX ‐ MEDICALLY SUPERVISED WITHDRAWAL BILLING RATE
INDIGENT CARE AND HEALTH CARE INITIATIVE SURCHARGE
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$2,218.80
$0.00
$2,573.63
$0.00
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$36.96
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$51.10
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$261.20
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$0.00
$0.00
$0.00
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$0.00
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$194.34
$298.29
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$255.64
$0.00
$324.24
$0.00
$310.22
$0.00
$468.95
$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
$171.74
$171.74
$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
$0.00
$0.00
$0.00
$2,290.69
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,375.49
$0.00
$0.00
$0.00
$1,719.44
$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
$171.74
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$171.74
$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
$1,343.50
$0.00
$0.00
$1,041.15
$0.00
$1,000.53
$0.00
$0.00
$1,158.89
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,103.16
$0.00
$0.00
$0.00
$789.85
$0.00
$1,204.65
$0.00
$0.00
$0.00
$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
$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
$261.20
$0.00
$0.00
$171.74
$0.00
$171.74
$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
$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
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%
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
$0.00
$305.05
$0.00
$412.66
$532.86
$0.00
$379.62
$0.00
$0.00
$536.67
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.06
$2.76
$0.00
$0.00
$0.00
$0.00
$3.57
$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
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$774.79
$0.00
$0.00
$1,348.45
$0.00
$1,024.83
$1,006.95
$1,377.34
$1,267.05
$1,116.89
$908.65
$934.53
$0.00
$0.00
$0.00
$0.00
$6.35
$0.00
$0.00
$7.64
$391.72
$26.80
$40.35
$15.18
$0.00
$0.00
$171.74
$0.00
$0.00
$261.20
$0.00
$171.74
$171.74
$261.20
$261.20
$171.74
$261.20
$171.74
Published Separately
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Published Separately
Published Separately
Published Separately
Published Separately
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7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
Page 10 of 12
pub_ip_april2011_mmc(initial_XX_XX_12).xls
Ref 040
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT EXEMPT UNIT RATES - EFFECTIVE 4/1/2011 - 9/30/2011
NYSDOH
(1)
(2)
(3)
SPECIALTY HOSPITAL
SPECIALTY ACUTE, LONG‐
TERM CARE AND CHILDREN'S HOSPITAL BILLING RATE (w/out DME)
OPCERT
2754001
0427000
1227001
0303001
1801000
5151001
3301007
1302001
5820000
5957001
0632000
5902001
2908000
0602001
7001045
7001035
6027000
HOSPITAL NAME
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
*Informational Only* SPECIALTY ACUTE, LONG‐TERM CARE AND CHILDREN'S HOSPITAL DME Add‐on
(4)
(5)
PSYCHIATRIC
(6)
(7)
(8)
(9)
CHEMICAL DEPENDENCY REHAB
(10)
(11)
CRITICAL ACCESS HOSPITAL
(12)
(13)
(14)
MEDICAL REHABILITATION
SPECIALTY *Informational *Informational CRITICAL ACUTE, LONG‐
CHEMICAL Only* *Informational CRITICAL MEDICAL CHEMICAL Only* ACCESS MEDICAL TERM CARE AND PSYCHIATRIC DEPENDENCY CHEMICAL Only* ACCESS REHAB DEPENDENCY PSYCHIATRIC MEDICAL REHAB ALC HOSPITAL CHILDREN'S BILLING RATE REHAB BILLING DEPENDENCY PSYCHIATRIC ALC PER DIEM
HOSPITAL BILLING RATE REHAB REHAB DME PER DIEM
BILLING RATE HOSPITAL (w/out DME)
RATE (w/out REHAB ALC PER DIEM
DME Add‐on
ALC PER DIEM (w/out DME)
Add‐on
(w/out DME)
ALC PER DIEM DME)
DME Add‐on
(w/out DME)
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
**See "Rate changes with special dates" tab for this facility.
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
$366.51
$190.83
$0.00
$405.64
$351.46
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$342.12
$0.00
$0.00
$0.00
Page 11 of 12
$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
$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
$1,039.34
$0.00
$0.00
$1,029.02
$0.00
$0.00
$1,180.25
$0.00
$0.00
$1,300.98
$0.00
$0.00
$0.00
$868.40
$0.00
$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
$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
(15)
(16)
DETOX
DETOX‐ MEDICALLY MANAGED WITHDRAWAL BILLING RATE
(17)
HCRA SURCHARGE
DETOX ‐ MEDICALLY SUPERVISED WITHDRAWAL BILLING RATE
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INDIGENT CARE AND HEALTH CARE INITIATIVE SURCHARGE
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
pub_ip_april2011_mmc(initial_XX_XX_12).xls
Ref 040
RATE CHANGES WITH SPECIAL EFFECTIVE DATES ‐ MA HMO
4/1/2011 ‐ 9/30/2011
NYSDOH
RATE CHANGES WITH SPECIAL EFFECTIVE DATES (NOT INCLUDED IN THE "PUB_MA_HMO_Acute" RATE TAB):
OPCERT
HOSPITAL NAME
7001037 SUNY DOWNSTATE MED CTR AT LICH
(1)
(3)
(4)
(5)
(6)
(7)
DISCHARGE RATES
ISAF
HIGH COST CC's
IME %'s
DME RATE
CAPITAL RATE ‐ PER DISCH
"DEFAULT & CONTRACT" INSTITUTION DISCHARGE CASE SPECIFIC PAYMENT RATE ADJUSTMENT (INCLUDING PHL § FACTOR (ISAF)
2807‐c(33) ‐ Excluding IME)
$7,022.27
1.0909
(8)
(9)
(10)
(11)
(12)
CAPITAL RATE ‐
PER DIEM
STERILIZATION
NON‐COMPARABLE ADD‐ONS
STERILIZATION TEACHING *Informational *Informational CAPITAL PER DURING DELIVERY ELECTION SCHOOL OF HIGH COST Only* INDIRECT Only* DISCHARGE AMBULANCE CAPITAL PER (MANAGED CARE AMENDMENT NURSING CHARGE MEDICAL DIRECT MEDICAL (EXCLUDING NON‐
ADD‐ON
DIEM
ENROLLEES OF COMPARABLE PHYSICIANS ADD‐ ADD‐ON
CONVERTOR
EDUCATION EDUCATION FIDELIS CARE ADD‐ONS)
ON
(IME) %
(DME) ADD‐ON
ONLY)
0.743965
25.55%
$1,882.99
**(PER DISCH)**
$889.10
$0.00
$0.00
$0.00
**(PER DAY**)
$159.21
(2290)
$979.27
1) Long Island College Hospital was acquired by State Univ Hosp / Downstate effective 5/29/2011 to become SUNY Downstate Med Ctr at LICH (7001037). The amounts for their
Exempt Unit rates did not change as part of the acquisition, only the acute rates changed effective 5/29/2011.
Other Publication Notes for 4/1/2011, Ref 040:
1) Chemical Dependency Detoxification rates for the period 4/1/2011 ‐ 12/31/2011 were also approved for Ref 040, but issued under a separate publication.
pub_ip_april2011_mmc(initial_XX_XX_12).xls
Ref 040