Administrator Letter

  • Letter is also available in Portable Document Format

November 3, 2022                     (See revised Attachment)

Dear Administrator:

This notification only applies to hospitals that were recently approved for Financially Distressed Hospital rate add-ons.

We are transmitting for your review the calculation of your hospital's updated inpatient acute and psychiatric exempt unit reimbursement rates for Medicaid Managed Care (MMC), which are effective December 1, 2021 - December 31, 2021 and January 1, 2022 - March 31, 2022. Please note that the inpatient rates for Medicaid Fee-for-Service (FFS) and Workers' Compensation/No-Fault (WCNF) have not changed and remain the same as the rates previously published for these effective periods. These rates have been promulgated in accordance with Article 2807-c and, for the acute rates, Article 2807-c (35)(c).

These rates are based upon the same information and methodology as the inpatient rates effective October 1, 2021 and January 1, 2022, but take into consideration the following update:

  • For dates of service December 1, 2021 - March 31, 2022, the Centers for Medicare and Medicaid (CMS) recently approved rate add-ons to the Medicaid Managed Care rates of payment for hospitals that qualified as financially distressed. These add-ons are only applicable to the acute DRG and psychiatric exempt unit services, as outlined in the billing guidelines attachment to this letter. No other inpatient rates changed as a result of this update.

Managed Care premiums have been adjusted to reflect this payment update. These rates will be posted to the Department of Health's APR-DRG website for the health plans.

Appeals:

All data associated with these rates was previously subjected to the appeal process. The financially distressed hospital rate add-ons are not subject to appeal.

Please refer to the attached billing guidelines associated with the financially distressed hospital rate add-ons. Should you have any questions regarding your rate sheets, please send an email to the hospital rate-setting unit at HospFFSunit@health.ny.gov and either Tami Berdi or John Neuberger will respond. Questions regarding the add-ons, premiums or billing guidelines should be directed to the Bureau of Managed Care Reimbursement at bmcr@health.ny.gov.

Sincerely,

Monique Grimm
Chief Health Care Fiscal Analyst
Bureau of Hospital and Clinic Rate Setting

(Billing Guidance for Financially Distressed Hospital Rate Add-ons)
REVISED 12/20/2022

A) Inpatient Acute Discharges:

Acute inpatient discharges are defined as inpatient stays that in addition to medical/surgical stays, include areas such as maternity, newborn, and neonatal.

  • Inpatient mental health and substance abuse, nursing facility and hospice services are not included
Claims Definition (Institutional Facility Claims only):
  1. NEWBORN / NEWBORN (Low Birth Weight)
    • APR-DRGs: 580, 581, 583, 588, 589, 591, 593, 602, 603, 607, 608, 609, 611, 612, 613, 614, 621, 622, 623, 625, 626, 630, 631, 633, 634, 636, 639, 640
  2. MATERNITY
    • APR-DRGs: 539, 540, 541, 542, 560
  3. MEDICAL / SURGICAL
    • Type of Bill: 11x, 12x, 41x AND
    • Claim contains at least one of the following:
      • Room and Board Revenue Codes: 0024, 0100, 0101, 0110, 0111, 0112, 0113, 0117, 0118, 0119, 0120, 0121, 0122, 0123, 0127, 0128, 0129, 0130, 0131, 0132, 0133, 0137, 0138, 0139, 0140, 0141, 0142, 0143, 0147, 0148, 0149, 0150, 0151, 0152, 0153, 0157, 0158, 0159, 0160, 0164, 0170, 0171, 0172, 0173, 0174, 0179, 0200, 0201, 0202, 0203, 0206, 0207, 0208, 0209, 0210, 0211, 0212, 0213, 0214, 0219 AND
    • Claim does not contain the following (Mental Health/Substance Abuse Treatment) **:
      • Rate Codes: 1133-1146, 2852, 2957, 2858, 2962-2963, 2993, 4001-4006, 4202-4204, 4210, 4213, 4220, 4608, 4800-4803
      • APR DRGs: 750, 751, 752, 753, 754, 755, 756, 757, 758, 759, 760, 770, 772, 773, 774, 775, 776

Note: Exception applies for hospitals listed below due to absence of NYS Medicaid Psychiatric per diem rate

B) Inpatient Psychiatric Days:

Inpatient psychiatric days are defined as inpatient days for those service areas incurred in providing daily bedside care to Psychiatric inpatients. This category also includes Comprehensive Psychiatric Emergency Program (CPEP) extended observation beds stays. This category does not include days associated with substance use disorder (SUD) discharges

Claims Definition (Institutional Facility Claims only):
  1. PSYCHIATRIC
    • Claim contains at least one of the following:
      • Rate Codes: 2858, 2852, 4001-4006, 2962-2963, 4608 (Inpatient Mental Health**) OR
      • APR-DRGs: 740, 750, 751, 752, 753, 754, 755, 756, 757, 758, 759, 760 OR
        **Note: The following hospitals do not have a New York State Medicaid Fee-for-Service “per diem” psychiatric billing rate. Any claims within this category for these hospitals should be considered acute inpatient discharges. The acute inpatient discharge add-on would apply
        • Brooklyn Hospital Center
        • Crouse Hospitals
        • St. John's Riverside Hospital
        • Wyckoff Heights Medical Center