Medicaid Hospital Reimbursement

Fees/Payment

Quick Links:
Disproportionate Share Hospital, Supplemental, & Graduate Medical Education Payment
Inpatient Hospital Rates
Organ Acquisition Reimbursement
Outpatient Hospital Rates

 


Outpatient Hospital Rates

January 1, 2019

In-State Hospital APC Rate Letter
Out-of-State Hospital APC Rate Letter
Rate Calculations

January 1, 2018

In-State Hospital APC Rate Letter
Out-of-State Hospital APC Rate Letter
Rate Calculations

January 1, 2017

In-State Hospital APC Rate Letter
Out-of-State Hospital APC Rate Letter
Rate Calculations

July 1, 2016 - DSS issued outpatient rates effective for dates of service on and after July 1, 2016 using the Ambulatory Payment Classification (APC) methodology.

In-State Hospital APC Rate Letters
Out-of-State Hospital APC Rate Letter

July 1, 2015 - DSS issued outpatient rates for FY16.

Hospital Outpatient Rate Letters
General Hospital Outpatient Rates
RCC 901 - Outpatient Fee Change

 


Inpatient Hospital Rates

January 1, 2019

In-State Hospital DRG Rate Letter
Out-of-State Hospital DRG Rate Letter
Rate Calculations

January 1, 2018

In-State Hospital DRG Rate Letter
Out-of-State Hospital DRG Rate Letter
Rate Calculations

January 1, 2017

In-State Hospital DRG Rate Letter
Out-of-State Hospital DRG Rate Letter
Weights and Outlier Thresholds Under APR-DRG V33 and V34 System
Rate Calculations

January 1, 2015 - DSS issued inpatient rates on December 8, 2014 for admissions on or after January 1, 2015. The letters list the APR-DRG base rates as well as per diem rates for behavioral health and rehabilitation.

In-State Inpatient Hospital Rate Letters
Out-of State and Border Psychiatric Hospital Rate Letter
Out-of-State General Acute Care Hospital Rate Letter
Rate Calculations

DRG Payment Calculator - All general acute care hospitals, including border and out-of-state, are now reimbursed using the All Patient Refined Diagnosis Related Groups (APR-DRG) methodology. A hospital can estimate its payment for a claim using the DRG payment calculator. The calculator contains detailed instructions regarding the data to be entered, including a link to 3M's site that must be used to calculate the DRG assignment to be entered in the calculator.

 


Disproportionate Share Hospital (DSH), Supplemental, and Direct Graduate Medical Education (GME) Payments

SFY14 Hospital Payment Calculation
SFY15 Hospital Payment Calculation
SFY16 GME and DSH Payment Calculation
SFY16 Inpatient Supplemental Payment Calculation
FFY17 DSH Payment Calculation
SFY17 GME Payment Calculation
SFY17 Inpatient Supplemental Payment Calculation
FFY18 DSH Payment Calculation
SFY18 GME Payment Calculation
SFY18 Mid-Sized Inpatient and General Outpatient Supplemental Payments
SFY18 General Inpatient and Small Hospital Inpatient Supplemental Payments
SFY19 GME Payment Calculation
SFY19 Supplemental Payment Calculation
SFY19 DRG Grouper One-time Supplemental Payment
FFY19 DSH Payment Calculation
SFY20 GME Payment Calculation
SFY20 Supplemental Payment Calculation
Letter to Hospitals re SFY20 Supplemental Payments (September 30, 2019)


Organ Acquisition Reimbursement

Rates are for both in- and out-of-state hospitals. Organ acquisition rates are effective for all inpatient claims. Acquisition of the heart, liver, and kidneys will be manually priced based on the submission of RCC 81X. For lung and pancreas acquisition, hospitals must submit most recent Medicare cost reports submitted to CMS. Additional information can be found on Provider Bulletin 2014-79.

Organ SFY 2015 SFY 2016 SFY 2017 SFY 2018 SFY 2019 SFY 2020 
Kidney $71,715 $64,324 $70,192 $79,732 $82,289 $91,504 
Heart $81,352 $96,667 $81,102 $100,487 $87,194  $120,727
Liver $86,032 $93,691 $119,107 $115,680 $164,760 $168,347 
Pancreas* $174,121 $50,913 $7,121 $134,209 TBD TBD 
Lung* TBD TBD TBD TBD TBD TBD 

Payment will be the lower of charges or state-wide average.
*For lung or pancreas acquisition, hospitals must submit most recent Medicare cost report submitted to CMS.