SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT CASE PAYMENT RATES ‐ EFFECTIVE 10/1/2011 ‐ 12/31/2011
NYSDOH
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
1101000
3301008
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
BURDETT CARE CENTER
CANTON‐POTSDAM HOSPITAL
CARTHAGE AREA HOSPITAL INC
CATSKILL REGIONAL MED CTR
CAYUGA MEDICAL CENTER
CHAMPLAIN VALLEY PHYS
CHENANGO MEMORIAL HOSP
CLAXTON‐HEPBURN MED CTR
CLIFTON SPRINGS HOSPITAL
COBLESKILL REGIONAL HOSP
COLUMBIA MEMORIAL HOSPITAL
COMMUNITY MEMORIAL HOSPITAL
CONEY ISLAND HOSPITAL
CORNING HOSPITAL
CORTLAND REGIONAL MED CTR
CROUSE HOSPITAL
(1)
(2)
(3)
DISCHARGE RATES
"DEFAULT & CONTRACT" DISCHARGE CASE PAYMENT RATE (INCLUDING PHL § 2807‐c(33) ‐ Excluding IME)
STATEWIDE PRICE ‐
MA HMO
ISAF
$5,210.26
$5,506.76
$5,506.76
$5,130.47
$5,130.71
$5,458.76
$5,026.75
$6,496.45
$5,530.76
$4,391.14
$7,436.19
$7,177.83
$5,758.81
$6,782.47
$6,676.94
$6,439.87
$6,560.90
$4,675.52
$5,103.34
$4,916.74
$4,610.19
$5,793.59
$5,607.89
$5,337.37
$4,875.73
$4,936.61
$4,427.46
$4,792.28
$5,238.98
$5,111.40
$6,431.34
$5,505.69
$5,066.43
$6,064.54
(4)
(5)
HIGH COST CC's
IME %'s
(6)
(7)
(9)
(10)
(11)
(12)
(13)
(14)
CAPITAL RATE ‐ PER DIEM
STERILIZATION
ALC
HCRA SURCHARGE
STERILIZATION *Informational *Informational CAPITAL PER DURING TEACHING INSTITUTION "DEFAULT & Only* DISCHARGE Only* INDIGENT CARE DELIVERY SCHOOL OF ELECTION HIGH COST SPECIFIC CONTRACT" CAPITAL PER (EXCLUDING AMBULANCE DIRECT INDIRECT (MANAGED ALC PRICE AND HEALTH CARE AMENDMENT NURSING STATEWIDE BASE ADJUSTMENT CHARGE DIEM
ADD‐ON
NON‐
MEDICAL MEDICAL PER DAY
INITIATIVE CARE ADD‐ON
PHYSICIANS PRICE (INCLUDING FACTOR CONVERTOR
COMPARABLE EDUCATION EDUCATION SURCHARGE
ENROLLEES OF ADD‐ON
(ISAF)
PHL § 2807‐c(33))
ADD‐ONS)
(DME) ADD‐ON
(IME) %
FIDELIS CARE ONLY)
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
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
0.8030
0.9458
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
0.443743
0.600233
0.440857
0.436770
0.759452
0.439962
0.501189
0.665019
0.583462
0.920860
0.462135
0.533932
0.680783
0.567279
0.684025
0.556811
DME RATE
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%
5.23%
$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
$0.00
$129.71
1 of 6
CAPITAL RATE ‐ PER DISCH
(8)
**(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
$211.64
$342.20
$142.22
$351.55
$387.13
$604.61
$198.45
$215.81
$230.81
$471.14
$339.23
$204.89
$712.11
$133.26
$409.37
$479.57
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
$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
$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
$86.78
**(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
$89.96
$106.73
$34.26
$90.54
$99.72
$103.69
$47.01
$52.08
$40.56
$55.70
$78.91
$53.30
$128.48
$42.49
$53.96
$102.41
(2290)
$726.58
$767.93
$767.93
$715.46
$715.49
$761.24
$700.99
$905.94
$771.28
$612.35
$1,036.99
$1,000.96
$803.08
$945.83
$931.11
$898.05
$914.93
$652.01
$711.67
$685.65
$642.90
$807.93
$782.03
$744.31
$679.93
$688.42
$617.42
$668.29
$730.59
$712.80
$896.87
$767.78
$706.53
$845.71
$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
$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%
7.04%
~5049794.xls
Ref 050
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT CASE PAYMENT RATES ‐ EFFECTIVE 10/1/2011 ‐ 12/31/2011
NYSDOH
OPCERT
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
7001033
5501001
HOSPITAL NAME
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
KINGSBROOK JEWISH MED CTR
KINGSTON HOSPITAL
(1)
(2)
(3)
DISCHARGE RATES
"DEFAULT & CONTRACT" DISCHARGE CASE PAYMENT RATE (INCLUDING PHL § 2807‐c(33) ‐ Excluding IME)
STATEWIDE PRICE ‐
MA HMO
ISAF
$4,394.74
$6,356.87
$5,137.23
$5,351.19
$6,886.11
$5,891.71
$4,526.96
$5,290.35
$6,590.46
$7,194.07
$6,199.59
$4,629.71
$7,231.42
$5,194.75
$6,558.75
$6,473.75
$6,679.09
$5,460.20
$7,579.59
$6,059.45
$6,782.61
$6,653.55
$4,803.47
$7,060.22
$7,157.30
$6,555.85
$4,686.12
$5,909.06
$5,909.06
$5,829.89
$5,235.53
$6,481.61
$7,282.01
$5,516.22
(4)
(5)
HIGH COST CC's
IME %'s
(6)
(7)
(9)
(10)
(11)
(12)
(13)
(14)
CAPITAL RATE ‐ PER DIEM
STERILIZATION
ALC
HCRA SURCHARGE
STERILIZATION *Informational *Informational CAPITAL PER DURING TEACHING INSTITUTION "DEFAULT & Only* DISCHARGE Only* INDIGENT CARE DELIVERY SCHOOL OF ELECTION HIGH COST SPECIFIC CONTRACT" CAPITAL PER (EXCLUDING AMBULANCE DIRECT INDIRECT (MANAGED ALC PRICE AND HEALTH CARE AMENDMENT NURSING STATEWIDE BASE ADJUSTMENT CHARGE DIEM
ADD‐ON
NON‐
MEDICAL MEDICAL PER DAY
INITIATIVE CARE ADD‐ON
PHYSICIANS PRICE (INCLUDING FACTOR CONVERTOR
COMPARABLE EDUCATION EDUCATION SURCHARGE
ENROLLEES OF ADD‐ON
(ISAF)
PHL § 2807‐c(33))
ADD‐ONS)
(DME) ADD‐ON
(IME) %
FIDELIS CARE ONLY)
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
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
1.1482
0.8734
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
0.336873
0.462225
DME RATE
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%
14.58%
5.30%
$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
$1,083.42
$216.69
2 of 6
CAPITAL RATE ‐ PER DISCH
(8)
**(PER DISCH)**
$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
$410.43
$232.56
NON‐COMPARABLE ADD‐ONS
$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
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$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
$0.00
$0.00
$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
$0.00
$0.00
**(PER DAY**)
$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
$68.13
$54.88
(2290)
$612.86
$886.48
$716.40
$746.24
$960.28
$821.61
$631.29
$737.75
$919.05
$1,003.23
$864.55
$645.62
$1,008.44
$724.42
$914.63
$902.78
$931.41
$761.44
$1,056.99
$845.00
$945.85
$927.85
$669.85
$984.56
$998.10
$914.23
$653.49
$824.03
$824.03
$812.99
$730.11
$903.88
$1,015.49
$769.25
$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
$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%
7.04%
7.04%
~5049794.xls
Ref 050
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT CASE PAYMENT RATES ‐ EFFECTIVE 10/1/2011 ‐ 12/31/2011
NYSDOH
OPCERT
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
1327000
5920000
7001008
7002026
7003010
7001021
HOSPITAL NAME
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
NORTHERN DUTCHESS HOSPITAL
NORTHERN WESTCHESTER HOSP
NY COMMUNITY / BROOKLYN
NY EYE AND EAR INFIRMARY
NY MED CTR OF QUEENS
NY METHODIST HOSP / BROOKLYN
(1)
(2)
(3)
DISCHARGE RATES
"DEFAULT & CONTRACT" DISCHARGE CASE PAYMENT RATE (INCLUDING PHL § 2807‐c(33) ‐ Excluding IME)
STATEWIDE PRICE ‐
MA HMO
ISAF
$4,602.48
$6,324.98
$6,608.25
$5,239.41
$6,530.45
$5,765.88
$6,907.07
$6,502.77
$7,606.19
$4,804.39
$5,066.55
$4,142.99
$5,163.72
$5,646.72
$6,510.02
$6,493.62
$7,129.48
$7,103.37
$7,103.37
$5,425.79
$6,575.14
$7,185.44
$4,989.73
$6,807.37
$4,936.02
$4,756.74
$7,263.63
$7,369.87
$6,021.70
$6,452.68
$7,020.36
$6,535.47
$7,017.24
$6,783.50
(4)
(5)
HIGH COST CC's
IME %'s
(6)
(7)
(9)
(10)
(11)
(12)
(13)
(14)
CAPITAL RATE ‐ PER DIEM
STERILIZATION
ALC
HCRA SURCHARGE
STERILIZATION *Informational *Informational CAPITAL PER DURING TEACHING INSTITUTION "DEFAULT & Only* DISCHARGE Only* INDIGENT CARE DELIVERY SCHOOL OF ELECTION HIGH COST SPECIFIC CONTRACT" CAPITAL PER (EXCLUDING AMBULANCE DIRECT INDIRECT (MANAGED ALC PRICE AND HEALTH CARE AMENDMENT NURSING STATEWIDE BASE ADJUSTMENT CHARGE DIEM
ADD‐ON
NON‐
MEDICAL MEDICAL PER DAY
INITIATIVE CARE ADD‐ON
PHYSICIANS PRICE (INCLUDING FACTOR CONVERTOR
COMPARABLE EDUCATION EDUCATION SURCHARGE
ENROLLEES OF ADD‐ON
(ISAF)
PHL § 2807‐c(33))
ADD‐ONS)
(DME) ADD‐ON
(IME) %
FIDELIS CARE ONLY)
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
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
0.9546
1.0116
1.1128
1.0217
1.0990
1.0683
0.424993
0.381174
0.212152
0.701273
0.868774
0.305201
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
0.421484
0.420274
0.379023
0.471205
DME RATE
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%
0.00%
0.00%
16.08%
16.54%
16.78%
$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
$0.00
$0.00
$0.00
$2,251.44
$744.93
$781.00
3 of 6
CAPITAL RATE ‐ PER DISCH
(8)
**(PER DISCH)**
$118.86
$448.41
$757.69
$373.44
$369.29
$422.58
$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
$272.22
$333.57
$748.00
$342.64
NON‐COMPARABLE ADD‐ONS
$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
$0.00
$0.00
$0.00
$173.37
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$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
$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
$0.00
$0.00
$0.00
$0.00
**(PER DAY**)
$34.82
$100.84
$167.38
$98.45
$103.24
$63.54
$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
$43.88
$155.14
$149.38
$72.72
(2290)
$641.83
$882.03
$921.54
$730.65
$910.69
$804.07
$963.21
$906.83
$1,060.70
$669.98
$706.54
$577.75
$720.09
$787.45
$907.84
$905.55
$994.22
$990.58
$990.58
$756.64
$916.92
$1,002.03
$695.83
$949.30
$688.34
$663.34
$1,012.93
$1,027.75
$839.74
$899.84
$979.01
$911.39
$978.57
$945.97
$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
$171.74
$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%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
~5049794.xls
Ref 050
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT CASE PAYMENT RATES ‐ EFFECTIVE 10/1/2011 ‐ 12/31/2011
NYSDOH
OPCERT
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
2950001
5126000
5154000
3529000
7000014
5157003
HOSPITAL NAME
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
SOUTH NASSAU COMMUNITIES
SOUTHAMPTON HOSPITAL
SOUTHSIDE HOSPITAL
ST ANTHONY COMMUNITY HOSP
ST BARNABAS HOSPITAL
ST CATHERINE OF SIENA
(1)
(2)
(3)
DISCHARGE RATES
"DEFAULT & CONTRACT" DISCHARGE CASE PAYMENT RATE (INCLUDING PHL § 2807‐c(33) ‐ Excluding IME)
STATEWIDE PRICE ‐
MA HMO
ISAF
$7,135.37
$7,135.37
$7,135.37
$6,378.74
$6,258.03
$6,798.37
$6,798.37
$4,821.09
$4,624.10
$6,351.90
$5,252.73
$5,105.05
$6,392.81
$5,965.04
$6,412.07
$7,000.05
$6,520.25
$7,271.90
$6,361.38
$5,397.62
$4,914.08
$4,983.41
$5,403.51
$5,274.17
$5,125.31
$4,704.11
$5,292.68
$6,576.14
$6,137.78
$6,398.72
$6,704.10
$6,138.00
$6,504.85
$6,771.79
(4)
(5)
HIGH COST CC's
IME %'s
(6)
(7)
(9)
(10)
(11)
(12)
(13)
(14)
CAPITAL RATE ‐ PER DIEM
STERILIZATION
ALC
HCRA SURCHARGE
STERILIZATION *Informational *Informational CAPITAL PER DURING TEACHING INSTITUTION "DEFAULT & Only* DISCHARGE Only* INDIGENT CARE DELIVERY SCHOOL OF ELECTION HIGH COST SPECIFIC CONTRACT" CAPITAL PER (EXCLUDING AMBULANCE DIRECT INDIRECT (MANAGED ALC PRICE AND HEALTH CARE AMENDMENT NURSING STATEWIDE BASE ADJUSTMENT CHARGE DIEM
ADD‐ON
NON‐
MEDICAL MEDICAL PER DAY
INITIATIVE CARE ADD‐ON
PHYSICIANS PRICE (INCLUDING FACTOR CONVERTOR
COMPARABLE EDUCATION EDUCATION SURCHARGE
ENROLLEES OF ADD‐ON
(ISAF)
PHL § 2807‐c(33))
ADD‐ONS)
(DME) ADD‐ON
(IME) %
FIDELIS CARE ONLY)
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
1.1184
1.1184
1.1184
0.9987
0.9750
1.0701
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
0.9632
1.0076
1.0468
0.9563
1.0267
1.0579
0.385719
0.385719
0.385719
0.400254
0.274764
0.393229
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
0.288378
0.412366
0.337697
0.262404
0.262966
0.266765
DME RATE
27.06%
27.06%
27.06%
0.00%
0.00%
19.78%
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%
3.42%
4.35%
4.78%
0.00%
26.30%
0.00%
$1,344.21
$1,344.21
$1,344.21
$0.00
$0.00
$1,814.25
$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
$106.23
$0.00
$147.45
$0.00
$1,045.95
$0.00
4 of 6
CAPITAL RATE ‐ PER DISCH
(8)
**(PER DISCH)**
$1,493.61
$1,493.61
$1,493.61
$198.03
$239.51
$1,437.81
$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
$529.58
$583.88
$543.78
$412.06
$540.85
$295.16
NON‐COMPARABLE ADD‐ONS
$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
$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
$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
$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
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
**(PER DAY**)
$257.30
$257.30
$257.30
$29.16
$57.38
$306.04
$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
$100.02
$170.38
$126.79
$101.73
$124.67
$56.21
(2290)
$995.04
$995.04
$995.04
$889.53
$872.70
$948.05
$948.05
$672.31
$644.84
$885.79
$732.51
$711.91
$891.49
$831.84
$894.18
$976.17
$909.26
$1,014.08
$887.11
$752.71
$685.28
$694.95
$753.53
$735.50
$714.74
$656.00
$738.08
$917.06
$855.93
$892.32
$934.90
$855.96
$907.12
$944.34
$261.20
$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
$171.74
$261.20
$261.20
$171.74
$171.74
$171.74
$171.74
$171.74
$171.74
$171.74
$171.74
$261.20
$261.20
$261.20
$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%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
~5049794.xls
Ref 050
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT CASE PAYMENT RATES ‐ EFFECTIVE 10/1/2011 ‐ 12/31/2011
NYSDOH
OPCERT
5149001
3202002
1302000
2953000
5002001
7001024
5907001
2952006
0701001
3301003
5907002
7002032
3522000
2801001
0101004
7001037
7004003
2701005
7001037
2754001
0427000
1227001
0303001
1801000
5151001
3301007
3301000
1302001
5820000
5957001
0632000
5902001
2908000
0602001
HOSPITAL NAME
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 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
SUNY DOWNSTATE MED CTR AT LICH
THE UNITY HOSPITAL
TLC HEALTH NETWORK
TRI‐TOWN REGIONAL HEALTHCARE
UNITED HEALTH SERVICES INC
UNITED MEMORIAL MED CTR
UNIV HOSP AT STONY BROOK
UNIV HOSP SUNY HLTH SCI CTR
UPSTATE UNIV HOSP 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
(1)
(2)
(3)
DISCHARGE RATES
"DEFAULT & CONTRACT" DISCHARGE CASE PAYMENT RATE (INCLUDING PHL § 2807‐c(33) ‐ Excluding IME)
STATEWIDE PRICE ‐
MA HMO
ISAF
$6,123.86
$5,367.44
$5,506.76
$6,824.49
$4,186.19
$7,606.59
$6,229.14
$6,446.42
$4,724.43
$5,644.16
$6,135.69
$7,698.74
$5,767.72
$4,835.75
$5,544.24
$6,924.21
$6,497.46
$5,715.17
$6,924.21
$4,950.73
$4,376.04
$6,418.49
$5,425.30
$4,868.95
$6,543.29
$5,859.96
$5,937.17
$6,301.56
$4,923.85
$7,261.40
$4,525.28
$6,519.48
$6,528.04
$4,728.53
(4)
(5)
HIGH COST CC's
IME %'s
(6)
(7)
(9)
(10)
(11)
(12)
(13)
(14)
CAPITAL RATE ‐ PER DIEM
STERILIZATION
ALC
HCRA SURCHARGE
STERILIZATION *Informational *Informational CAPITAL PER DURING TEACHING INSTITUTION "DEFAULT & Only* DISCHARGE Only* INDIGENT CARE DELIVERY SCHOOL OF ELECTION HIGH COST SPECIFIC CONTRACT" CAPITAL PER (EXCLUDING AMBULANCE DIRECT INDIRECT (MANAGED ALC PRICE AND HEALTH CARE AMENDMENT NURSING STATEWIDE BASE ADJUSTMENT CHARGE DIEM
ADD‐ON
NON‐
MEDICAL MEDICAL PER DAY
INITIATIVE CARE ADD‐ON
PHYSICIANS PRICE (INCLUDING FACTOR CONVERTOR
COMPARABLE EDUCATION EDUCATION SURCHARGE
ENROLLEES OF ADD‐ON
(ISAF)
PHL § 2807‐c(33))
ADD‐ONS)
(DME) ADD‐ON
(IME) %
FIDELIS CARE ONLY)
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
$6,418.49
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
0.7647
1.0257
0.9184
0.9264
0.9923
0.7734
1.1393
0.7195
1.0231
1.0188
0.7416
0.313916
0.481391
0.318707
0.332146
0.501685
0.504795
0.423654
0.341489
0.479156
0.459105
0.582145
0.331090
0.241413
0.518524
0.349021
0.743965
0.350479
0.571813
0.743965
0.563002
0.594185
1.000000
0.529650
0.513022
0.433128
0.577036
0.534457
0.307627
0.485046
0.342782
0.884032
0.460502
0.300934
0.469819
DME RATE
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%
28.73%
29.03%
1.73%
0.00%
0.00%
18.54%
0.00%
0.00%
16.50%
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
$0.00
$1,059.23
$1,013.90
$26.15
$0.00
$0.00
$1,845.43
$0.00
$0.00
$691.02
$0.00
5 of 6
CAPITAL RATE ‐ PER DISCH
(8)
**(PER DISCH)**
$279.60
$416.09
$866.74
$1,041.21
$298.85
$245.72
$247.71
$302.47
$205.18
$368.25
$613.49
$916.10
$466.21
$194.19
$619.02
$889.10
$301.52
$704.80
$889.10
$471.94
$175.76
$415.00
$328.34
$425.46
$936.86
$739.65
$314.39
$452.40
$310.32
$1,797.23
$150.45
$419.56
$730.86
$228.65
NON‐COMPARABLE ADD‐ONS
$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
$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
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$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
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
**(PER DAY**)
$67.96
$89.06
$188.47
$181.50
$90.03
$40.54
$47.75
$57.21
$37.92
$71.38
$113.35
$220.74
$104.10
$46.67
$132.94
$159.21
$49.13
$122.76
$159.21
$100.76
$39.19
$207.50
$65.81
$101.39
$176.98
$127.05
$67.53
$98.68
$76.99
$245.38
$50.15
$81.89
$154.09
$51.26
(2290)
$853.99
$748.50
$767.93
$951.69
$583.77
$1,060.76
$868.67
$898.97
$658.83
$787.09
$855.64
$1,073.61
$804.32
$674.36
$773.16
$965.60
$906.09
$796.99
$965.60
$690.39
$610.25
$895.07
$756.57
$678.99
$912.48
$817.18
$827.95
$878.77
$686.64
$1,012.62
$631.06
$909.16
$910.35
$659.40
$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
$171.74
$261.20
$171.74
$171.74
$171.74
$171.74
$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%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
~5049794.xls
Ref 050
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT CASE PAYMENT RATES ‐ EFFECTIVE 10/1/2011 ‐ 12/31/2011
NYSDOH
OPCERT
HOSPITAL NAME
7001045 WOODHULL MEDICAL
7001035 WYCKOFF HEIGHTS HOSPITAL
6027000 WYOMING CO COMMUNITY HOSP
(1)
(2)
(3)
DISCHARGE RATES
"DEFAULT & CONTRACT" DISCHARGE CASE PAYMENT RATE (INCLUDING PHL § 2807‐c(33) ‐ Excluding IME)
STATEWIDE PRICE ‐
MA HMO
ISAF
$6,468.77
$6,767.36
$4,920.85
(4)
(5)
HIGH COST CC's
IME %'s
(6)
(7)
(9)
(10)
(11)
(12)
(13)
(14)
CAPITAL RATE ‐ PER DIEM
STERILIZATION
ALC
HCRA SURCHARGE
STERILIZATION *Informational *Informational CAPITAL PER DURING TEACHING INSTITUTION "DEFAULT & Only* DISCHARGE Only* INDIGENT CARE DELIVERY SCHOOL OF ELECTION HIGH COST SPECIFIC CONTRACT" CAPITAL PER (EXCLUDING AMBULANCE DIRECT INDIRECT (MANAGED ALC PRICE AND HEALTH CARE AMENDMENT NURSING STATEWIDE BASE ADJUSTMENT CHARGE DIEM
ADD‐ON
NON‐
MEDICAL MEDICAL PER DAY
INITIATIVE CARE ADD‐ON
PHYSICIANS PRICE (INCLUDING FACTOR CONVERTOR
COMPARABLE EDUCATION EDUCATION SURCHARGE
ENROLLEES OF ADD‐ON
(ISAF)
PHL § 2807‐c(33))
ADD‐ONS)
(DME) ADD‐ON
(IME) %
FIDELIS CARE ONLY)
$6,418.49
$6,418.49
$6,418.49
1.0175
1.0677
0.7759
0.933577
0.509478
0.942083
DME RATE
20.72%
15.91%
0.00%
$1,664.32
$950.14
$0.00
6 of 6
CAPITAL RATE ‐ PER DISCH
(8)
**(PER DISCH)**
$628.87
$453.54
$194.95
NON‐COMPARABLE ADD‐ONS
$0.00
$18.37
$0.00
$366.78
$0.00
$0.00
$0.00
$0.00
$0.00
**(PER DAY**)
$134.30
$98.20
$40.11
(2290)
$902.08
$943.72
$686.22
$261.20
$261.20
$171.74
7.04%
7.04%
7.04%
~5049794.xls
Ref 050
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT EXEMPT UNIT RATES - EFFECTIVE 10/1/2011 - 12/31/2011
NYSDOH
(1)
(2)
(3)
(4)
(5)
SPECIALTY HOSPITAL
SPECIALTY ACUTE, LONG‐
TERM CARE AND CHILDREN'S HOSPITAL BILLING RATE (w/out DME)
OPCERT
1623001
0101000
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
2625000
7001009
5001000
1101000
3301008
0226700
1229700
4423000
5127000
3101000
1552701
5526700
4601001
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
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
ELIZABETHTOWN COMMUNITY HOSP
ELLENVILLE REGIONAL HOSPITAL
ELLIS 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
$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
$0.00
$0.00
$0.00
PSYCHIATRIC
SPECIALTY ACUTE, LONG‐
TERM CARE AND PSYCHIATRIC BILLING RATE CHILDREN'S HOSPITAL (w/out DME)
ALC PER DIEM (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
$0.00
$0.00
$0.00
(6)
(7)
(8)
(9)
CHEMICAL DEPENDENCY REHAB
(10)
6/20/2012
(11)
CRITICAL ACCESS HOSPITAL
(12)
(13)
(14)
MEDICAL REHABILITATION
(15)
(16)
DETOX
(17)
HCRA SURCHARGE
*Informational *Informational CRITICAL CRITICAL CHEMICAL Only* MEDICAL DETOX‐ MEDICALLY DETOX ‐ MEDICALLY INDIGENT CARE CHEMICAL Only* ACCESS ACCESS MEDICAL DEPENDENCY CHEMICAL REHAB AND HEALTH CARE MANAGED SUPERVISED DEPENDENCY PSYCHIATRIC MEDICAL REHAB ALC HOSPITAL HOSPITAL REHAB BILLING DEPENDENCY PSYCHIATRIC ALC PER DIEM
BILLING RATE WITHDRAWAL WITHDRAWAL INITIATIVE REHAB REHAB DME PER DIEM
BILLING RATE ALC PER RATE (w/out REHAB ALC PER DIEM
DME Add‐on
(w/out DME)
SURCHARGE
BILLING RATE
BILLING RATE
Add‐on
DIEM
(w/out DME)
DME)
DME Add‐on
*Informational Only* 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
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
$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
$440.39
$0.00
$1,076.40
$0.00
$646.15
$296.23
$0.00
$0.00
$0.00
Page 1 of 5
$0.00
$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
$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
$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
$0.00
$0.00
$0.00
$0.00
$0.00
$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
$2,319.03
$1,076.40
$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
$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
$171.74
$171.74
$0.00
$0.00
$0.00
$171.74
$171.74
$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
$0.00
$1,045.22
$0.00
$0.00
$0.00
$0.00
$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
$0.00
$95.78
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$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
$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
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
~5049794.xls
Ref 050
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT EXEMPT UNIT RATES - EFFECTIVE 10/1/2011 - 12/31/2011
NYSDOH
(1)
(2)
(3)
(4)
(5)
SPECIALTY HOSPITAL
SPECIALTY ACUTE, LONG‐
TERM CARE AND CHILDREN'S HOSPITAL BILLING RATE (w/out DME)
OPCERT
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
7003004
7001019
7001020
1226701
3824000
4402000
3622000
7002020
0101003
1401008
HOSPITAL NAME
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 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
$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
$0.00
$0.00
$0.00
$0.00
$2,794.80
$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
$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
$0.00
$0.00
$0.00
$0.00
$236.79
$0.00
$0.00
PSYCHIATRIC
SPECIALTY ACUTE, LONG‐
TERM CARE AND PSYCHIATRIC BILLING RATE CHILDREN'S HOSPITAL (w/out DME)
ALC PER DIEM (w/out DME)
$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
$0.00
$0.00
$0.00
$0.00
$261.20
$0.00
$0.00
(6)
(7)
(8)
(9)
CHEMICAL DEPENDENCY REHAB
(10)
6/20/2012
(11)
CRITICAL ACCESS HOSPITAL
(12)
(13)
(14)
MEDICAL REHABILITATION
(15)
(16)
DETOX
(17)
HCRA SURCHARGE
*Informational *Informational CRITICAL CRITICAL CHEMICAL Only* MEDICAL DETOX‐ MEDICALLY DETOX ‐ MEDICALLY INDIGENT CARE CHEMICAL Only* ACCESS ACCESS MEDICAL DEPENDENCY CHEMICAL REHAB AND HEALTH CARE MANAGED SUPERVISED DEPENDENCY PSYCHIATRIC MEDICAL REHAB ALC HOSPITAL HOSPITAL REHAB BILLING DEPENDENCY PSYCHIATRIC ALC PER DIEM
BILLING RATE WITHDRAWAL WITHDRAWAL INITIATIVE REHAB REHAB DME PER DIEM
BILLING RATE ALC PER RATE (w/out REHAB ALC PER DIEM
DME Add‐on
(w/out DME)
SURCHARGE
BILLING RATE
BILLING RATE
Add‐on
DIEM
(w/out DME)
DME)
DME Add‐on
*Informational Only* 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
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
$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
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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
Page 2 of 5
$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
$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
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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
$0.00
$0.00
$0.00
$0.00
$0.00
$1,451.73
$0.00
$0.00
$0.00
$0.00
$1,891.85
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$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
$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
$0.00
$778.80
$0.00
$0.00
$0.00
$0.00
$753.38
$0.00
$0.00
$956.30
$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
$0.00
$24.28
$0.00
$0.00
$0.00
$0.00
$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
$0.00
$261.20
$0.00
$0.00
$0.00
$0.00
$171.74
$0.00
$0.00
$171.74
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
~5049794.xls
Ref 050
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT EXEMPT UNIT RATES - EFFECTIVE 10/1/2011 - 12/31/2011
NYSDOH
(1)
(2)
(3)
(4)
(5)
SPECIALTY HOSPITAL
SPECIALTY ACUTE, LONG‐
TERM CARE AND CHILDREN'S HOSPITAL BILLING RATE (w/out DME)
OPCERT
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
2952005
3950000
7003007
7004010
2221700
2701003
7002031
3201002
1401010
4102002
2201000
HOSPITAL NAME
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 JOINT DIS
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
$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
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$2,218.80
$0.00
$2,573.63
$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
$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
PSYCHIATRIC
SPECIALTY ACUTE, LONG‐
TERM CARE AND PSYCHIATRIC BILLING RATE CHILDREN'S HOSPITAL (w/out DME)
ALC PER DIEM (w/out DME)
$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
(6)
(7)
(8)
(9)
CHEMICAL DEPENDENCY REHAB
(10)
6/20/2012
(11)
CRITICAL ACCESS HOSPITAL
(12)
(13)
(14)
MEDICAL REHABILITATION
(15)
(16)
DETOX
(17)
HCRA SURCHARGE
*Informational *Informational CRITICAL CRITICAL CHEMICAL Only* MEDICAL DETOX‐ MEDICALLY DETOX ‐ MEDICALLY INDIGENT CARE CHEMICAL Only* ACCESS ACCESS MEDICAL DEPENDENCY CHEMICAL REHAB AND HEALTH CARE MANAGED SUPERVISED DEPENDENCY PSYCHIATRIC MEDICAL REHAB ALC HOSPITAL HOSPITAL REHAB BILLING DEPENDENCY PSYCHIATRIC ALC PER DIEM
BILLING RATE WITHDRAWAL WITHDRAWAL INITIATIVE REHAB REHAB DME PER DIEM
BILLING RATE ALC PER RATE (w/out REHAB ALC PER DIEM
DME Add‐on
(w/out DME)
SURCHARGE
BILLING RATE
BILLING RATE
Add‐on
DIEM
(w/out DME)
DME)
DME Add‐on
*Informational Only* 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
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
$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
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Page 3 of 5
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$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
$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
$0.00
$0.00
$2,525.69
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$2,339.54
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$2,290.69
$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
$171.74
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$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
$1,343.50
$0.00
$0.00
$1,041.15
$0.00
$1,000.53
$0.00
$0.00
$1,158.89
$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
$203.85
$0.00
$0.00
$56.49
$0.00
$0.00
$0.00
$0.00
$0.13
$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
$0.00
$0.00
$261.20
$0.00
$0.00
$171.74
$0.00
$171.74
$0.00
$0.00
$171.74
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
~5049794.xls
Ref 050
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT EXEMPT UNIT RATES - EFFECTIVE 10/1/2011 - 12/31/2011
NYSDOH
(1)
(2)
(3)
(4)
(5)
SPECIALTY HOSPITAL
SPECIALTY ACUTE, LONG‐
TERM CARE AND CHILDREN'S HOSPITAL BILLING RATE (w/out DME)
OPCERT
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
7001017
2754001
0427000
1227001
0303001
1801000
5151001
3301007
3301000
1302001
5820000
5957001
0632000
5902001
2908000
HOSPITAL NAME
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
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
SUNY DOWNSTATE MED CTR AT LICH
THE UNITY HOSPITAL
TLC HEALTH NETWORK
TRI‐TOWN REGIONAL HEALTHCARE
UNITED HEALTH SERVICES INC
UNITED MEMORIAL MED CTR
UNIV HOSP AT STONY BROOK
UNIV HOSP SUNY HLTH SCI CTR
UPSTATE UNIV HOSP AT COMM GEN
VASSAR BROTHERS MED CTR
WAYNE HEALTH CARE
WESTCHESTER MEDICAL CENTER
WESTFIELD MEMORIAL HOSP
WHITE PLAINS HOSPITAL
WINTHROP UNIVERSITY HOSPITAL
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$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
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
PSYCHIATRIC
SPECIALTY ACUTE, LONG‐
TERM CARE AND PSYCHIATRIC BILLING RATE CHILDREN'S HOSPITAL (w/out DME)
ALC PER DIEM (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
(6)
(7)
(8)
(9)
CHEMICAL DEPENDENCY REHAB
(10)
6/20/2012
(11)
CRITICAL ACCESS HOSPITAL
(12)
(13)
(14)
MEDICAL REHABILITATION
(15)
(16)
DETOX
(17)
HCRA SURCHARGE
*Informational *Informational CRITICAL CRITICAL CHEMICAL Only* MEDICAL DETOX‐ MEDICALLY DETOX ‐ MEDICALLY INDIGENT CARE CHEMICAL Only* ACCESS ACCESS MEDICAL DEPENDENCY CHEMICAL REHAB AND HEALTH CARE MANAGED SUPERVISED DEPENDENCY PSYCHIATRIC MEDICAL REHAB ALC HOSPITAL HOSPITAL REHAB BILLING DEPENDENCY PSYCHIATRIC ALC PER DIEM
BILLING RATE WITHDRAWAL WITHDRAWAL INITIATIVE REHAB REHAB DME PER DIEM
BILLING RATE ALC PER RATE (w/out REHAB ALC PER DIEM
DME Add‐on
(w/out DME)
SURCHARGE
BILLING RATE
BILLING RATE
Add‐on
DIEM
(w/out DME)
DME)
DME Add‐on
*Informational Only* 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
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
$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
$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
$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
$0.00
Page 4 of 5
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$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
$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
$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
$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
$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
$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
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$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
$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
$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
$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
$1,493.86
$1,039.34
$0.00
$0.00
$1,029.02
$0.00
$0.00
$1,180.25
$924.91
$0.00
$0.00
$1,300.98
$0.00
$0.00
$0.00
$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
$6.35
$0.00
$0.00
$7.64
$391.72
$26.80
$40.35
$15.18
$0.00
$237.30
$30.42
$0.00
$0.00
$3.53
$0.00
$0.00
$81.43
$0.44
$0.00
$0.00
$177.75
$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
$261.20
$0.00
$171.74
$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
$261.20
$171.74
$261.20
$171.74
$0.00
$0.00
$171.74
$0.00
$0.00
$171.74
$171.74
$0.00
$0.00
$261.20
$0.00
$0.00
$0.00
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
7.04%
~5049794.xls
Ref 050
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT EXEMPT UNIT RATES - EFFECTIVE 10/1/2011 - 12/31/2011
NYSDOH
(1)
(2)
(3)
(4)
(5)
SPECIALTY HOSPITAL
SPECIALTY ACUTE, LONG‐
TERM CARE AND CHILDREN'S HOSPITAL BILLING RATE (w/out DME)
OPCERT
0602001
7001045
7001035
6027000
HOSPITAL NAME
WOMANS CHRISTIAN ASSOC
WOODHULL MEDICAL
WYCKOFF HEIGHTS HOSPITAL
WYOMING CO COMMUNITY HOSP
$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
PSYCHIATRIC
SPECIALTY ACUTE, LONG‐
TERM CARE AND PSYCHIATRIC BILLING RATE CHILDREN'S HOSPITAL (w/out DME)
ALC PER DIEM (w/out DME)
$0.00
$0.00
$0.00
$0.00
(6)
(7)
(8)
(9)
CHEMICAL DEPENDENCY REHAB
6/20/2012
(10)
(11)
CRITICAL ACCESS HOSPITAL
(12)
(13)
(14)
MEDICAL REHABILITATION
(15)
(16)
DETOX
(17)
HCRA SURCHARGE
*Informational *Informational CRITICAL CRITICAL CHEMICAL Only* MEDICAL DETOX‐ MEDICALLY DETOX ‐ MEDICALLY INDIGENT CARE CHEMICAL Only* ACCESS ACCESS MEDICAL DEPENDENCY CHEMICAL REHAB AND HEALTH CARE MANAGED SUPERVISED DEPENDENCY PSYCHIATRIC MEDICAL REHAB ALC HOSPITAL HOSPITAL REHAB BILLING DEPENDENCY PSYCHIATRIC ALC PER DIEM
BILLING RATE WITHDRAWAL WITHDRAWAL INITIATIVE REHAB REHAB DME PER DIEM
BILLING RATE ALC PER RATE (w/out REHAB ALC PER DIEM
DME Add‐on
(w/out DME)
SURCHARGE
BILLING RATE
BILLING RATE
Add‐on
DIEM
(w/out DME)
DME)
DME Add‐on
*Informational Only* Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
Requires DOB Approval
$342.12
$0.00
$0.00
$0.00
Page 5 of 5
$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
$868.40
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$171.74
$0.00
$0.00
$0.00
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
Published Separately ‐ see 4/1/11 rates
7.04%
7.04%
7.04%
7.04%
~5049794.xls
Ref 050
SCHEDULE OF MEDICAID MANAGED CARE (MA HMO)
INPATIENT CASE PAYMENT RATES ‐ EFFECTIVE 10/1/2011 ‐ 12/31/2011
NYSDOH
(1)
(2)
(3)
DISCHARGE RATES
"DEFAULT & CONTRACT" DISCHARGE CASE PAYMENT RATE (INCLUDING PHL § 2807‐c(33) ‐ Excluding IME)
STATEWIDE PRICE ‐
MA HMO
ISAF
(4)
(5)
(6)
HIGH COST CC's
IME %'s
(7)
(9)
(10)
(11)
(12)
(13)
(14)
CAPITAL RATE ‐ PER DIEM
STERILIZATION
ALC
HCRA SURCHARGE
STERILIZATION *Informational *Informational CAPITAL PER DURING TEACHING INSTITUTION "DEFAULT & Only* DISCHARGE Only* INDIGENT CARE DELIVERY SCHOOL OF ELECTION HIGH COST SPECIFIC CONTRACT" CAPITAL PER (EXCLUDING AMBULANCE DIRECT INDIRECT (MANAGED ALC PRICE AND HEALTH CARE AMENDMENT NURSING STATEWIDE BASE ADJUSTMENT CHARGE DIEM
ADD‐ON
NON‐
MEDICAL MEDICAL PER DAY
INITIATIVE CARE ADD‐ON
PHYSICIANS PRICE (INCLUDING FACTOR CONVERTOR
COMPARABLE EDUCATION EDUCATION SURCHARGE
ENROLLEES OF ADD‐ON
(ISAF)
PHL § 2807‐c(33))
ADD‐ONS)
(DME) ADD‐ON
(IME) %
FIDELIS CARE ONLY)
DME RATE
CAPITAL RATE ‐ PER DISCH
(8)
NON‐COMPARABLE ADD‐ONS
Update as of 6/19/2012 (Included in 'PUB' tab)
OPCERT
HOSPITAL NAME
4102004 BURDETT CARE CENTER
$5,103.34
$6,418.49
0.7951
0.443743
0.00%
$0.00
1 of 1
**(PER DISCH)**
$211.64
$0.00
$0.00
$0.00
**(PER DAY**)
$89.96
(2290)
$711.67
$171.74
7.04%
~5049794.xls
Ref 050