CMS Approval of Hospital Inpatient Reform Implementation December 2009 Inpatient Rates

NYS Department Of Health Division Of Health Care Financing Important Information Update Status Of Hospital Inpatient Reform Implementation December 2009 Inpatient Rates

The New York State Department of Health is pleased to announce that the Federal Centers for Medicare and Medicaid Services (CMS) has approved the new inpatient rate methodology, as enacted in the 2009-10 Budget.

As a result, effective January 23, 2010, the final APR-DRG Service Intensity Weights (SIW) and Average Length of Stay (ALOS) will be active and applied to any inpatient claim processed from that date forward. This data replaces the interim SIWs that have been utilized to date to pay acute care claims for discharges on or after December 1, 2009, as outlined in the Information Update issued on December 3, 2009.

Beginning January 25, 2010, the new reform rates that are effective December 1, 2009 will be active and any claim being processed from that date forward will be paid based on the new rates and the new weights. In addition, the new reform exempt hospital/unit rates will also be active as of January 25, 2010.

As a reminder, all claims submitted using rate code 3130 (GME for Medicaid Managed Care) for discharges on or after 12/1/09, must be a complete claim and include all case, patient, and clinical information that is required for a normal DRG claim (i.e. the admission from and through date, charges, diagnosis and procedure codes). The final APR-DRG SIW weights will be applied as part of the GME claims processing. Also, now that rate code 2589 (Direct Medical Education Add-on) has been loaded to eMedNY, payment of acute GME claims retroactive to 12/1/09 will include the DME add-on. The GME (3130) rates are based on the Medicaid Managed Care statewide "Contract " base rate adjusted by hospital-specific WEF and IME. The 3130 rate amounts previously provided on the acute rate exhibits were displayed incorrectly.

GME payment = 3130 GME Rate x APR-DRG Weight + 2589 DME Add-ON

Since these weights and rates are effective retroactively to December 1, 2009, all previously paid claims will be reprocessed by eMedNY during the weekend of January 30, 2010. The results of the retroactive processing will be reflected in provider's Medicaid checks dated February 8, 2010 (Cycle 1694), which will be released on February 24, 2010.

Questions should be directed as follows:

  • Hospitals - BPACR rate analyst
  • All Payer Including Medicaid Managed Care Plans - Bureau of HCRA Operations and Financial Analysis (518) 473-8822
  • Billing and Claiming - eMedNY Call Center 1-800-343-9000