Medicaid: Finance and Rate Setting

The Division of Finance and Rate Setting (DFRS) is within the Office of Health Insurance Programs and responsible for all functions related to Medicaid rate setting, including Medicaid managed care premium development. This division has full oversight of the Medicaid budget and is the liaison with the Division of the Budget and managing the Medicaid Global Spending Cap.

Click on a Bureau name to display its responsibilities.

  • Medicaid Global Cap
  • Medicaid Pharmacy Drug Cap
  • Medicaid Pharmaceutical Drug Rebates
  • Upper Payment Limit (UPL) Program
  • Disproportionate Share Hospital (DSH) Program
  • Medicaid Payment Lag & Early Releases for Distressed Providers
  • Article 28 Hospitals
    • Inpatient & Outpatient Medicaid fee-for-service Rate Setting
    • Hospital Institutional Cost Report (ICR)
  • Article 28 Diagnostic & Treatment Centers (D&TCs) - Freestanding Clinics, Ambulatory Surgery Centers and Federally Qualified Health Centers/Rural Health Clinics
    • Medicaid fee-for-service Rate Setting
    • Ambulatory Health Care Facility (AHCF) Cost Report
  • Mainstream Managed Care/Health and Recovery Program
  • Essential Plan
  • Managed Care Stop Loss
  • Supplemental Payment Programs for Federally Qualified Health Centers ("wrap" payment)
  • Partial Capitation
  • Medicaid Advantage Plus (MAP)
  • Program of All-inclusive Care for the Elderly (PACE)
  • Mental Hygiene Services
    • Medicaid fee-for-service Rate Setting
    • Office for People With Developmental Disabilities (OPWDD) Property Cost Verifications and Final Expenditure Reports
  • Nursing Home Services
    • Medicaid Fee-for-Service (FFS) Rates for Geriatric, Specialties, Adult Day Health Care (ADHC), Bed Hold and Out-of-State
    • Nursing Home Quality Pool (NHQP) and 2% Supplemental Program
    • Cash Receipts Assessments
    • Residential Health Care Cost Report
  • Home Care Services
    • Medicaid FFS Rates for Personal Care, Consumer Directed Personal Assistance Program (CDPAP), Certified Home Health Agency (CHHA)
    • Home Care Cost Report
  • Assisted Living Program Services
  • Hospice Residence and Non-Residence Services
  • Foster Care Services
  • Hospital Supplemental Reimbursement
  • Health Care Reform Act (HCRA)
  • Health Facility Cash Assessment Program (HFCAP)