November 22, 2013 Health Plan Letter

November 22, 2013

Dear Health Plans:

The purpose of this letter is to provide Health Plans with the initial Medicaid inpatient rates for the period April 1, 2013 through December 31, 2013 for acute APR-DRG services.

The rates for the above period were based upon the same methodology and data used in the January 1, 2013 through March 31, 2013 period but take into consideration the following:

  1. In accordance with existing regulatory provisions, the pool allocation for Transition II decreased from $50M to $25M for the period 4/1/2013 - 3/31/2014. The $25M reduction in the pool value was included in the statewide price calculation. FY 2013/2014 is the final year for Transition II.
  2. The continuation of PPNO adjustments, including a retroactive adjustment for PPCs for the period 7/1/2011 - 12/31/2012 which is reflected in the PPNO reduction factor.
  3. There was no change to the exempt unit rates for the period April 1, 2013 through December 31, 2013.

The enclosed rate schedules include the rate components required to process Medicaid claims. Also included are payment calculation files that display how each component from the schedule is used in the payment of a Medicaid claim, where applicable. These rates schedule calculations are unchanged from the previous January 1, 2013 publication.

On the attached schedules, we have included all acute hospitals and the Medicaid Managed Care Rates and GME Rates, where applicable, for the Acute inpatient services only.

Acute Care Per Case Rate Schedules - These are the rate components to be paid to hospitals for acute services.

  1. Default & Contract Discharge Case Payment Rate (Including PHL 2807-c(33) but Excluding GME): Acute per case payment to be used when either an HMO plan contract is applicable or not applicable. This is the statewide price adjusted by ISAF (Column 3). The per discharge has been adjusted to reflect the reduction for PPNOs.
  2. Default & Contract Statewide Base Price (Including PHL 2807-c(33)): Statewide base price when HMO contract is applicable or not applicable.
  3. Institutional Specific Adjustment Factor (ISAF): Hospital specific adjustment to reflect wage differences (Wage Equalization Factor).
  4. High Cost Charge Convertor: Charge convertor to reduce hospital charges for cost outlier payments.
  5. Indirect Medicaid Education Percentage (IME%): This is the indirect medical education percentage and is provided here for information only.
  6. Direct Medical Education (DME) Add-on: This is the Direct Medical Education per discharge add on and is provided for information only. The add-on displayed in this column has been adjusted to reflect the reduction for PPNOs.
  7. Capital Per Discharge (Excluding Non-comparable Add-ons): Capital Per Discharge to be included after application of Service Intensity Weights (SIW´s).
  8. Ambulance Add-ons: This represents ambulance per discharge to be added on after application of SIW. This add-on has been adjusted to reflect the reduction for PPNOs.
  9. TEA Physician Add-on: This is the add-on for physician costs for those hospitals that are Teaching Election Amendment hospitals for the Medicare program to be added on after application of SIW. This add-on has been adjusted to reflect the reduction for PPNOs.
  10. School of Nursing Add-on: This represents an add-on per discharge for those hospitals with Schools of Nursing and is added after application of SIW. This add-on has been adjusted to reflect the reduction of PPNOs.
  11. Capital Per Diem: This is the capital per diem to be used when transfer payment on a per diem basis is being made.
  12. Sterilization During Delivery: This is for Managed Care enrollees of Fidelis Care only.
  13. ALC Per Diem: This is the Alternate Level of Care per diem for those patients who no longer require acute hospital care and are awaiting placement or discharge.
  14. Indigent Care and Health Care Initiatives Surcharge: This is the surcharge percentage obligation as authorized by Public Health Law 2807-j.

Should you have any questions regarding the above data, please submit your inquiry to hospffsunit@health.state.ny.us email address and an analyst from the hospital fee-for-service unit will respond.

Sincerely,

Michael Ogborn
Director
Bureau of Acute and Managed Care Rate-Setting