Stop Loss Archive

The ADMIT DATE column on the new electronic submission form requires the actual admission date for the inpatient stay.

Q. Are there any recommendations for health plans that continued to use AP-DRG´s beyond the State´s conversion to APR-DRG´s on 12/1/09?

A. We realize that many institutions continued to bill charges under AP-DRG for a significant period after the implementation of APR-DRG´s with an effective date of 12/1/09.

In an effort to inform Plans, hospitals and other service providers of upcoming changes, presentations outlining health care reform in the 2009-2010 budget year, including the change from AP-DRG to APR-DRG methodology on 12/1/09 were held in July of 2009.

Stop Loss is obligated to compare the Plan´s contract rate to the Medicaid rate and pay the lesser of the two. We were also required to recalculate claims with dates of service on or after 12/1/09 with the new rates and methodology as stated in Chapter 58 of the Laws of 2009, Public Health Law Section 35.

Q. SSI enrolled members shouldn´t be included into Stop Loss submissions. Is that correct?

A. Clients enrolled in mainstream managed care plans with SSI coverage are excluded from inpatient mental health claims only. SSI status does not affect claim submission for inpatient claims (rate code 2299) or residential health care claims (rate code 2297).

Clients enrolled in SNPS Plans (Special Needs Plans) are exempt from the exclusion of inpatient mental health claims when SSI coverage is present. This applies only to SNPS Plan enrollees.

Note: Mental health and substance abuse services provided to members who were not classified as SSI or SSI related at the time of service are still covered under the Stop Loss program even if the enrollee is retroactively classified SSI or SSI related and the retroactive period includes dates when such services were provided. However, in this instance, plans are required to submit appropriate documentation (for example the enrollee roster showing the Aid Category at the time of service) along with the attestation and other supporting documentation for the Stop Loss claim.

Q. How Do We Handle Out of State Claims?

A. Calculating an out of state Inlier

Example:

Admission to a Non-teaching downstate facility - Admit date 2/1/10- Discharge 2/14/10, APR-DRG 140 Severity Level 4 (SIW- 2.3575) Plan´s payment $21,450.75.

Stop Loss calculation:

Downstate non-teaching rate code 2953 (2/14/10) - $6779.56 × 2.3575 (SIW) = $15,982.86 + $638.30 (Capital add-on per discharge Rate code 2990 downstate) = $16,621.16.

Stop Loss total $16,621.16 compared to Plan´s payment of $21,450.75 = Maximum Stop Loss reimbursement is $16,621.16

Q. How are claims over $250,000 calculated for Stop Loss?

A. Stop loss claims over $250,000 are calculated as outlined below. This illustration is color-coded and uses fictitious data.

TCN CIN Discharge Date DOH Calc DRG Total Plan ChargeÚ Total DOH CalcÚ ClaimTotal Threshold Copay Total Claim Charge Total Due Plan
12345678910110 AB12340C 07/09/13 662.2 6,877.28 6,877.28          
12345678910110 AB12340C 07/18/13 662.3 11,890.50 11,890.50          
12345678910110 AB12340C 07/30/13 662.3 10,821.18 10,821.18          
12345678910110 AB12340C 08/06/13 662.2 6,877.28 6,877.28          
12345678910110 AB12340C 08/10/13 662.1 5,259.67 5,259.67          
12345678910110 AB12340C 08/15/13 662.2 7,090.25 7,090.25          
12345678910110 AB12340C 08/17/13 662.2 7,777.23 7,777.23          
12345678910110 AB12340C 08/23/13 662.2 6,702.03 6,702.03   Where is the surcharge?  
12345678910110 AB12340C 08/26/13 662.3 12,048.95 12,048.95          
12345678910110 AB12340C 08/31/13 662.2 6,825.83 6,825.83   * The 7.04% surcharge was added in to the Plan charge and in this case DOH paid the same amount to the Plan that the Plan paid
12345678910110 AB12340C 09/15/13 662.1 4,950.05 4,950.05
12345678910110 AB12340C 09/10/13 662.3 12,048.95 12,048.95  
12345678910110 AB12340C 09/26/13 662.3 10,975.08 10,975.08          
12345678910110 AB12340C 09/21/13 662.3 12,048.95 12,048.95          
12345678910110 AB12340C 10/13/13 662.3 10,975.08 10,975.08          
12345678910110 AB12340C 10/07/13 662.3 12,048.95 12,048.95          
12345678910110 AB12340C 10/29/13 662.2 4,954.89 4,954.89          
12345678910110 AB12340C 10/28/13 662.3 12,048.95 12,048.95          
12345678910110 AB12340C 11/05/13 662.2 7,289.46 7,289.46          
12345678910110 AB12340C 11/02/13 662.3 8,376.11 8,376.11          
12345678910110 AB12340C 11/12/13 662.3 10,975.08 10,975.08          
12345678910110 AB12340C 01/20/13 662.1 5,006.17 5,006.17          
12345678910110 AB12340C 11/27/13 662.3 10,975.08 10,975.08          
12345678910110 AB12340C 11/15/13 662.2 7,777.23 7,777.23          
12345678910110 AB12340C 11/29/13 662.1 5,619.88 5,619.88          
12345678910110 AB12340C 12/18/13 662.3 10,975.08 10,975.08          
12345678910110 AB12340C 12/21/13 662.2 7,294.14 7,294.14 513,391.58 100,000.00 30,000.00 399,534.33 383,391.58
  Your claim total is 513,391.58
anything over 250,000.00 will get 100% reimbursement		 513,391.58
250,000.00		 claim total
100% reimbursement 263,391.58 everything over 250,000.00 that we are working with
 
100,000.00 threshold now applied		 250,000.00
100,000.00
not taken out of the calculation until now

20 percent copay		 150,000.00
30,000.00		  
  120,000.00  
  100% reimbursement
Threshold - copay		 263,391.58
120,000.00		  
added together = total due plan 383,391.58