NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES
EFFECTIVE 01/01/13 ‐ 12/31/13
Hospital Name
ACUTE CARE SPECIALTY OH
ADVENTIST MED CTR OR
AKRON GENERAL MEDICAL CENTER
ALAMANCE REG MED CTR NC
ALBERT EINSTEIN MED CTR PA
ALFRED I DUPONT HOSP FOR CHID
ALL CHILDRENS HOSPITAL FL
ALLEGHENY GENERAL HOSPITAL PA
ALLEGIANCE HEALTH MI
ANDROSOGGIN VALLEY HOPS NH
ASPEN VALLEY HOSPITAL CO
ATHENS REG MED TN
ATLANTIC GEN HSP MD
ATLANTICARE REG MED CTR CITY AVENTURA HOSP & MED CTR FL
BALTIMORE WASHINGTON MEDICAL BANNER BAYWOOD MED CTR AZ
BANNER BEHAVIORAL HLTH AZ
BANNER DEL E WEBB MEM HSP AZ
BANNER ESTRELLA MED CTR AZ
BANNER GATEWAY MC AZ
BANNER IRONWOOD MED CTR AZ
BANNER THUNDERBIRD MED CTR AZ
BAPTIST HOSPITAL OF MIAMI FL
BAPTIST MEM HOSP OF MEMPHIS
BAPTIST ST ANTHONYS MEM HOSP BARBERTON CITIZENS HOSP OH
BARNES JEWISH HSP MO
BARNES‐KASSON COUNTY HSP
BARTON MEMORIAL HOSPITAL CA
BAY MEDICAL CTR FL
BAYHEALTH KENT GEN HSP DE
BAYLOR ALL SAINTS MED CTR TX
BAYLOR MED CTR GARLAND TX
BAYLOR UNIVERSITY MED CTR TX
BAYONNE MEDICAL CENTER NJ
BAYSHORE COMMUNITY HOSPITAL
BAYSTATE MEDICAL CENTER MA
BEAUMONT HOSPITAL GROSSE PT
BEEBE MEDICAL CENTER DE
BELLEVUE MEDICAL CENTER NE
BERGEN PINES COUNTY HSP NJ
BERKSHIRE HEALTH SYSTEM MA
BERKSHIRE MEDICAL CTR MA INC
BETH ISRAEL DEACONESS BOSTON BOSTON MEDICAL CENTER MA
BOTSFORD HOSPITAL MI
BOZEMAN DEACONESS HOSP MT
BRADFORD REGIONAL MED CTR PA
City, State
CANTON
PORTLAND
AKRON
BURLINGTON
PHILADELPHIA
WILMINGTON
ST PETERSBURG
PITTSBURGH
JACKSON
BERLIN
ASPEN
ATHENS
BERLIN
ATLANTIC CITY
AVENTURA
GLEN BURNIE
MESA
SCOTTSDALE
SUN CITY
PHOENIX
GILBERT
SAN TAN VALLEY
GLENDALE
MIAMI
MEMPHIS
AMARILLO
BARBERTON
SAINT LOUIS
SUSQUEHANNA
SOUTH LAKE TAHOE
PANAMA CITY
DOVER
FORT WORTH
GARLAND
DALLAS
BAYONNE
HOLMDEL
SPRINGFIELD
GROSSE POINT
LEWES
BELLEVUE
PARAMUS
PITTSFIELD
PITTSFIELD
BOSTON
BOSTON
FARMINGTON HILLS
BOZEMAN
BRADFORD
OH
OR
OH
NC
PA
DE
FL
PA
MI
NH
CO
TN
MD
NJ
FL
MD
AZ
AZ
AZ
AZ
AZ
AZ
AZ
FL
TN
TX
OH
MO
PA
CA
FL
DE
TX
TX
TX
NJ
NJ
MA
MI
DE
NE
NJ
MA
MA
MA
MA
MI
MT
PA
(1)
(2)
Rate Code 2953 (OOS Hospital DRG)
$ 6,445.03
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 7,336.96
$ 7,336.96
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 8,832.97
$ 6,445.03
$ 6,445.03
$ 6,445.03
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 5,784.96
Rate Code 2952 (OOS Hospital Exempt)
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
(3)
(4)
(5)
(6)
Rate Code 2589 (DME Add‐on)
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ 1,295.15
$ 298.23
$ 298.23
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ ‐
Rate Codes 2950 and 2954 (ALC RHCF)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Codes 2951 and 2955 (ALC Home Care)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Code 2990 (Capital per Disch)
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 704.77
$ 704.77
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 704.77
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
1 of 13
(7)
(8)
(9)
Rate Code 2991 WEF/ISAF High Cost (Capital per (for High Cost Charge Diem)
Claims)
Convertors
0.442464
$ 112.32
0.8424
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 144.34
1.0684
0.357482
$ 144.34
1.0684
0.357482
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 144.34
1.0684
0.357482
0.442464
$ 112.32
0.8424
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES
EFFECTIVE 01/01/13 ‐ 12/31/13
Hospital Name
BRANDON HOSPITAL FL
BRATTLEBORO RETREAT HSP VT
BRIDGEPORT HOSPITAL
BRIGHAM AND WOMENS HOSP
BRISTOL HOSPITAL
BROCKTON HOSP MA
BROOKEGLEN BEHAVIORAL HOSPITA
BROWARD GENERAL MEDICAL CTR
BRUNSWICK COMM HOSP NC
BRYN MAWR HOSPITAL PA
BRYN MAWR REHAB HOSP. PA
CANDLER HOSP GA
CAPE CANAVERAL HOSP FL
CAPE CORAL HSP FL
CAPE FEAR VALLEY NC
CAPE REGIONAL MEDICAL CENTER CAPITAL HEALTH SYS AT FULD
CAPITAL HEALTH SYSTEM MERCER
CARILION FRANKLIN MEMORIAL VA
CARILION ROANOKE COMM HSP VA
CARILION ROANOKE MEMORIAL
CARILION STONEWALL JACKSN VA
CARLE FOUNDATION HOSP IL
CAROLINAEAST HEALTH SYSTEM
CAROLINAS HSP SYS SC
CARONDELET ST MARYS HOSP AZ
CARROLL HOSPITAL CENTER MD
CASA GRANDE REG MED CTR AZ
CASS COUNTY MEMORIAL HSP IA
CATAWBA VALLEY MED CTR NC
CATHOLIC MED CTR NH
CENTENNIAL MEDICAL CENTER TX
CENTRA VIRGINIA BAPTST HSP VA
CENTRAL VERMONT HOSPITAL
CENTRASTATE MED CTR NJ
CENTURA PENROSE ST FRANCIS HL
CHAMBERSBURG HOSPITAL PA
CHARLES COLE MEMORIAL HSP
CHARLOTTE HUNGERFORD HOSPITAL
CHESTER COUNTY HOSP PA
CHILDRENS HOSP & RESEARCH CA
CHILDRENS HOSP M C OH
CHILDRENS HOSP OF PHILA PA
CHILDRENS HOSPITAL ALABAMA
CHILDRENS HOSPITAL CO
CHILDRENS HOSPITAL MA
CHILDRENS HOSPITAL OF PITTS
CHILDRENS HOSPITAL OF PITTS
CHILDRENS HOSPITAL OH
City, State
BRANDON
BRATTLEBORO
BRIDGEPORT
BOSTON
BRISTOL
BROCKTON
FORT WASHINGTON
FT LAUDERDALE
BOLIVIA
BRYN MAWR
MALVERN
SAVANNAH
COCOA BEACH
CAPE CORAL
FAYETTEVILLE
CAPE MAY COURT HOUSE
TRENTON
TRENTON
ROCKY MOUNT
ROANOKE
ROANOKE
LEXINGTON
URBANA
NEW BERN
FLORENCE
TUCSON
WESTMINSTER
CASA GRANDE
ATLANTIC
HICKORY
MANCHESTER
FRISCO
LYNCHBURG
BARRE
FREEHOLD
COLORADO SPRINGS
CHAMBERSBURG
COUDERSPORT
TORRINGTON
WEST CHESTER
OAKLAND
CINCINNATI
PHILADELPHIA
BIRMINGHAM
AURORA
BOSTON
PITTSBURGH
PITTSBURGH
COLUMBUS
FL
VT
CT
MA
CT
MA
PA
FL
NC
PA
PA
GA
FL
FL
NC
NJ
NJ
NJ
VA
VA
VA
VA
IL
NC
SC
AZ
MD
AZ
IA
NC
NH
TX
VA
VT
NJ
CO
PA
PA
CT
PA
CA
OH
PA
AL
CO
MA
PA
PA
OH
(1)
(2)
Rate Code 2953 (OOS Hospital DRG)
$ 5,784.96
$ 5,784.96
$ 8,832.97
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 8,832.97
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 7,336.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 6,445.03
$ 5,784.96
Rate Code 2952 (OOS Hospital Exempt)
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
(3)
(4)
(5)
(6)
Rate Code 2589 (DME Add‐on)
$ ‐
$ ‐
$ 1,295.15
$ 298.23
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ 1,295.15
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ ‐
Rate Codes 2950 and 2954 (ALC RHCF)
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Codes 2951 and 2955 (ALC Home Care)
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Code 2990 (Capital per Disch)
$ 528.83
$ 528.83
$ 704.77
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 704.77
$ 528.83
$ 528.83
$ 528.83
$ 704.77
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
2 of 13
(7)
(8)
(9)
Rate Code 2991 WEF/ISAF High Cost (Capital per (for High Cost Charge Diem)
Claims)
Convertors
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 144.34
1.0684
0.357482
0.442464
$ 112.32
0.8424
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 144.34
1.0684
0.357482
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 144.34
1.0684
0.357482
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES
EFFECTIVE 01/01/13 ‐ 12/31/13
Hospital Name
CHILDRENS HOSPITAL SAN DIEGO
CHILDRENS HSP KINGS DAUGHTER
CHILDRENS INSTITUTE OF PITTS
CHILDRENS MEDICAL CENTER OH
CHILDRENS NATIONAL MED CTR
CHILDRENS SPECIALIZED HOSP NJ
CHILTON MEM HOSP NJ
CHRISTIANA CARE HLTH SERV DE
CITRUS MEMORIAL HOSPITAL FL
CLARA MAASS MEM HOSP
CLARION HOSPITAL PA
CLARION PSYCHIATRIC CTR PA
CLEVELAND CLINIC FOUNDATION
CLEVELAND CLINIC HOSPITAL FL
COLUMBIA WESLEY MEDICAL CENTE
COMMUNITY HLTH CTR BRANCH CTY
COMMUNITY HOSPITAL ASSOCIATIO
COMMUNITY MED CTR NJ
COMMUNITY MEDICAL CENTER PA
COMMUNITY MEMORIAL HOSP VA
CONCORD HOSPITAL NH
CONEMAUGH VALLEY MEM HSP PA
CONNECTICUT CHILDRENS MED CTR
CONWAY HOSPITAL SC
COOLEY DICKINSON HOSP MA
COOPER MED CTR CAMDEN NJ
COPLEY HOSPITAL VT INC
CORAL GABLES HOSPITAL FL
CORAL SPRINGS MEDICAL CTR FL
CORRY MEMORIAL HOSPITAL PA
COTTAGE HOSPITAL NH
COVENANT HEALTHCARE MI
CROZER‐CHESTER MEDICAL CTR PA
CULPEPER MEM HOSP VA
CUMBERLAND HOSP VA
DANA FARBER CANCER INSTITUTE
DANBURY HOSP CT
DAVIS HOSPITAL AND MED CTR UT
DAY KIMBALL HOSPITAL CT
DEACONESS HOSPITAL IN
DEACONESS HOSPITAL OK
DEACONESS HOSPITAL WA
DECATUR GEN HOSPITAL AL
DELAWARE CTY MEMORIAL HSP PA
DELRAY MEDICAL CTR FL
DOCTORS COMMUNITY HOSPITAL MD
DOCTORS HOSPITAL TX
DUBOIS REG MED CTR MERCY DIV
DUKE RALEIGH HOSPITAL NC
City, State
SAN DIEGO
NORFOLK
PITTSBURGH
DAYTON
WASHINGTON
MOUNTAINSIDE
POMPTON PLAINS
WILMINGTON
INVERNESS
TOMS RIVER
CLARION
CLARION
CLEVELAND
WESTON
WICHITA
COLDWATER
BOULDER
TOMS RIVER
SCRANTON
SOUTH HILL
CONCORD
JOHNSTOWN
HARTFORD
CONWAY
NORTHAMPTON
CAMDEN
MORRISVILLE
CORAL GABLES
CORAL SPRINGS
CORRY
WOODSVILLE
SAGINAW
UPLAND
CULPEPER
NEW KENT
BOSTON
DANBURY
LAYTON
PUTNAM
EVANSVILLE
OKLAHOMA CITY
SPOKANE
DECATUR
DREXEL HILL
DELRAY BEACH
LANHAM
DALLAS
DUBOIS
RALEIGH
CA
VA
PA
OH
DC
NJ
NJ
DE
FL
NJ
PA
PA
OH
FL
KS
MI
CO
NJ
PA
VA
NH
PA
CT
SC
MA
NJ
VT
FL
FL
PA
NH
MI
PA
VA
VA
MA
CT
UT
CT
IN
OK
WA
AL
PA
FL
MD
TX
PA
NC
(1)
(2)
Rate Code 2953 (OOS Hospital DRG)
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ ‐
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 8,832.97
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
Rate Code 2952 (OOS Hospital Exempt)
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 1,634.66
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
(3)
(4)
(5)
(6)
Rate Code 2589 (DME Add‐on)
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ 1,295.15
$ ‐
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
Rate Codes 2950 and 2954 (ALC RHCF)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Codes 2951 and 2955 (ALC Home Care)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Code 2990 (Capital per Disch)
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ ‐
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 704.77
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
3 of 13
(7)
(8)
(9)
Rate Code 2991 WEF/ISAF High Cost (Capital per (for High Cost Charge Diem)
Claims)
Convertors
0.442464
$ 112.32
0.8424
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ ‐
1.0684
0.357482
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 144.34
1.0684
0.357482
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES
EFFECTIVE 01/01/13 ‐ 12/31/13
Hospital Name
DUKE UNIVERSITY HOSPITAL NC
DURHAM REGIONAL HOSPITAL NC
EAST JEFFERSON GEN HOSP LA
EAST ORANGE GENERAL HOSPITAL
EAST TENNESSE CHILD HOSP
EASTERN IDAHO REG MED CTR ID
EASTERN MAINE MED CTR ME
EHS TRINITY HOSP IL
ELLIOT HOSPITAL NH
EMMA PENDLETON BRADLEY HSP RI
ENGLEWOOD HOSP MED CTR NJ
ERLANGER MED CTR TN
EXEMPLA ST JOSEPH HOSPITAL FAIRFAX HOSPITAL VA
FAIRVIEW GENERAL HOSPITAL OH
FAIRVIEW HOSPITAL
FAIRVIEW SOUTHDALE HSP MN
FAIRVIEW UNIV MED CTR MN
FALMOUTH HOSP ASSOC MA
FIRELANDS REG MED CTR OH
FIRST HEALTH OF CAROLINAS NC
FLAGLER HOSPITAL FL
FLETCHER ALLEN HLTH ‐ MCHV
FLORIDA HOSP HEARTLAND FL
FLORIDA HOSP MED CTR FL
FLORIDA HOSP WATERMAN FL
FLORIDA HOSPITAL DELAND FL
FLORIDA HOSPITAL ZEPHYR HILLS
FOUNDATIONS BEHAVIORAL HEALTH
FRANKLIN SQUARE HOSP MD
FROEDTERT MEM LUTHER WI
GARDEN CITY OSTEO HOSP MI
GARDEN GROVE HOSP MC CA
GATEWAY MED CTR TN
GEISINGER MEDICAL CENTER PA
GEISINGER SOUTH WILKES‐BARRE GEORGETOWN UNIVERSITY HOSP DC
GETTYSBURG HOSPITAL
GNADEN HUETTEN MEM HOSP PA
GOOD SAMARITAN HOSPITAL OH
GOOD SAMARITAN HSP FL
GRADY MEMORIAL HOSPITAL
GRAND STRAND REG MED CTR SC
GRANITE CITY ILLINOIS HOSP
GRANT MEDICAL CENTER OH
GREATER BALTIMORE MED CTR MD
GREENWICH HOSP ASSOCIATION CT
GRIFFIN HOSPITAL CT
GROSSMONT HOSPITAL CA
City, State
DURHAM
DURHAM
METAIRE
EAST ORANGE
KNOXVILLE
IDAHO FALLS
BANGOR
CHICAGO
MANCHESTER
RIVERSIDE
ENGLEWOOD
CHATTANOOGA
DENVER
FALLS CHURCH
CLEVELAND
GT BARRINGTON
EDINA
MINNEAPOLIS
FALMOUTH
SANDUSKY
PINEHURST
ST AUGUSTINE
BURLINGTON
SEBRING
ORLANDO
TAVARES
DELAND
ZEPHYRHILLS
DOYLESTOWN
BALTIMORE
MILWAUKEE
GARDEN CITY
GARDEN GROVE
CLARKSVILLE
DANVILLE
WILKES BARRE
WASHINGTON
GETTYSBURG
LEHIGHTON
DAYTON
WEST PALM BEACH
ATLANTA
MYRTLE BEACH
GRANITE CITY
COLUMBUS
BALTIMORE
GREENWICH
DERBY
LA MESA
NC
NC
LA
NJ
TN
ID
ME
IL
NH
RI
NJ
TN
CO
VA
OH
MA
MN
MN
MA
OH
NC
FL
VT
FL
FL
FL
FL
FL
PA
MD
WI
MI
CA
TN
PA
PA
DC
PA
PA
OH
FL
GA
SC
IL
OH
MD
CT
CT
CA
(1)
(2)
Rate Code 2953 (OOS Hospital DRG)
$ 6,445.03
$ 6,445.03
$ 6,445.03
$ 7,336.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 8,832.97
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 7,235.25
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 8,832.97
$ 6,445.03
$ 5,784.96
Rate Code 2952 (OOS Hospital Exempt)
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
(3)
(4)
(5)
(6)
Rate Code 2589 (DME Add‐on)
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ 1,295.15
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ 726.69
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ 298.23
$ 1,295.15
$ 298.23
$ ‐
Rate Codes 2950 and 2954 (ALC RHCF)
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
Rate Codes 2951 and 2955 (ALC Home Care)
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
Rate Code 2990 (Capital per Disch)
$ 528.83
$ 528.83
$ 528.83
$ 704.77
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 704.77
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 704.77
$ 528.83
$ 528.83
4 of 13
(7)
(8)
(9)
Rate Code 2991 WEF/ISAF High Cost (Capital per (for High Cost Charge Diem)
Claims)
Convertors
0.442464
$ 112.32
0.8424
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 144.34
1.0684
0.357482
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 144.34
1.0684
0.357482
0.442464
$ 112.32
0.8424
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 144.34
1.0684
0.357482
0.442464
$ 112.32
0.8424
$ 112.32
0.8424
0.442464
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES
EFFECTIVE 01/01/13 ‐ 12/31/13
Hospital Name
GUNDERSEN LUTHERAN MED CTR WI
HACKENSACK UNIV MED CTR NJ
HACKETTSTOWN REG MED CTR
HACKLEY HOSPITAL MI
HALIFAX MED CTR FL
HAMOT MEDICAL CENTER PA
HANOVER HOSPITAL PA
HARDIN MEMORIAL HOSPITAL KY
HARFORD MEMORIAL HOSP MD
HARRINGTON MEMORIAL HOSPITAL HARRIS METHODIST HEB HOSP TX
HARTFORD HOSP CT
HAZLETON GEN HSP PA
HCA HEALTH SERVICES OF TENN
HCA OAK HILL HOSP FL
HEALTH ALLIANCE HOSP
HEALTH PARK MEDICAL CENTER FL
HEALTHSOUTH REHAB HOSP ERIE
HEART HOSPITAL BAYLOR PLANO T
HELEN ELLIS MEM HSP FL
HENRY HEYWOOD MEM HOSP MA
HIALEAH HOSPITAL FL
HIGH POINT REG HEALTH SYS NC
HIGHLANDS HSP&HLTH CENTER
HIGHLINE MEDICAL CENTER WA
HOBOKEN UNIV MED CTR NJ
HOLMES REG MED CTR FL
HOLY CROSS HSP FL
HOLY NAME HOSPITAL NJ
HOLY SPIRIT HOSPITAL
HOLYOKE HOSP MA
HOMESTEAD HOSPITAL FL
HOSPITAL CORP/LAKEVIEW HSP UT
HOSPITAL OF ST RAPHAEL CT
HOSPITAL OF THE UNIV OF PENN
HOWARD CTY GENERAL HSP MD
HUGULEY MEMORIAL HOSPITAL TX
ILLINOIS MASONIC MED CTR IL
IMPERIAL POINT HSP FL
INDIANA REGIONAL MEDICAL CENT
INGHAM REGIONAL MEDICAL CENTE
JACKSON HOSPITAL AND CLINIC
JACKSON MEM HSP FL
JAY HSP FL
JEANES HOSPITAL PA
JEFFERSON MEMORIAL HOSP MO
JENNIE EDMUNDSON MEM HOSP IA
JERSEY CITY MEDICAL CTR NJ
JERSEY SHORE MEDICAL CTR NJ
City, State
LA CROSSE
HACKENSACK
HACKETTSTOWN
MUSKEGON
DAYTONA BEACH
ERIE
HANOVER
ELIZABETHTOWN
HAVRE DE GRACE
SOUTHBRIDGE
BEDFORD
HARTFORD
HAZLETON
SMYRNA
BROOKSVILLE
LEOMINSTER
FORT MYERS
ERIE
PLANO
TARPON SPRINGS
GARDNER
HIALEAH
HIGH POINT
CONNELLSVILLE
BURIEN
HOBOKEN
MELBOURNE
FT LAUDERDALE
TEANECK
CAMP HILL
HOLYOKE
HOMESTEAD
BOUNTIFUL
NEW HAVEN
PHILADELPHIA
COLUMBIA
FT WORTH
CHICAGO
FT LAUDERDALE
INDIANA
LANSING
MONTGOMERY
MIAMI
JAY
PHILADELPHIA
FESTUS
COUNCIL BLUFFS
JERSEY CITY
NEPTUNE
WI
NJ
NJ
MI
FL
PA
PA
KY
MD
MA
TX
CT
PA
TN
FL
MA
FL
PA
TX
FL
MA
FL
NC
PA
WA
NJ
FL
FL
NJ
PA
MA
FL
UT
CT
PA
MD
TX
IL
FL
PA
MI
AL
FL
FL
PA
MO
IA
NJ
NJ
(1)
(2)
Rate Code 2953 (OOS Hospital DRG)
$ 6,445.03
$ 8,832.97
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 8,832.97
$ 5,784.96
$ 5,784.96
$ 7,336.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 8,832.97
$ 8,832.97
Rate Code 2952 (OOS Hospital Exempt)
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
(3)
(4)
(5)
(6)
Rate Code 2589 (DME Add‐on)
$ 298.23
$ 1,295.15
$ ‐
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 1,295.15
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ 298.23
$ 1,295.15
$ 1,295.15
Rate Codes 2950 and 2954 (ALC RHCF)
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 261.20
Rate Codes 2951 and 2955 (ALC Home Care)
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 261.20
Rate Code 2990 (Capital per Disch)
$ 528.83
$ 704.77
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 704.77
$ 528.83
$ 528.83
$ 704.77
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 704.77
$ 704.77
5 of 13
(7)
(8)
(9)
Rate Code 2991 WEF/ISAF High Cost (Capital per (for High Cost Charge Diem)
Claims)
Convertors
0.442464
$ 112.32
0.8424
$ 144.34
1.0684
0.357482
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 144.34
1.0684
0.357482
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 144.34
1.0684
0.357482
0.442464
$ 112.32
0.8424
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 144.34
1.0684
0.357482
$ 144.34
1.0684
0.357482
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES
EFFECTIVE 01/01/13 ‐ 12/31/13
Hospital Name
JOHN C LINCOLN DEERVALLEY AZ
JOHN C LINCOLN HOSP HLTH AZ
JOHN DEMPSEY HOSPITAL UNIV CT
JOHN F KENNEDY MED CTR
JOHNS HOPKINS BAYVIEW MED MD
JOHNS HOPKINS HOSPITAL MD
JOHNSON MEM HSP
JORDAN HOSPITAL MA
JUPITER MEDICAL CENTER FL
KAPIOLANI MED PALI MOMI HI
KENNEDY KRIEGER INSTITUTE MD
KENNEDY MEM HOSP/CHERRY HILL
KENNEDY MEM HOSP/UMC STRATFOR
KENNEDY MEM HOSP/WASHINGTON
KENT COUNTY MEMORIAL HOSPITAL
KESSLER INSTITUTE FOR REHAB
LAKE POINTE MEDICAL CENTER TX
LAKELAND REG MED CTR FL
LAKES REGION GEN HOSP‐FRNKLIN
LAKES REGION GEN HOSP‐LACONIA
LAKEWOOD HSP OH
LANCASTER GENERAL HOSP PA
LANDMARK MEDICAL CENTER RI
LAREDO TEXAS HOSP TX
LARGO MEDICAL CENTER FL
LAWRENCE & MEMORIAL HOSPS CT
LAWRENCE GEN HOSP MA
LEE MEM HOSP FL
LEESBURG REG MED CTR FL
LEHIGH VALLEY HOSP CTR PA
LEHIGH VALLEY MUHLENBERG PA
LENOIR MEMORIAL HOSP NC
LIBERTY HOSPITAL MO
LITTLETON REGIONAL HOSP NH
LOGAN REG HOSP UT
LONG BEACH MEM MED CTR CA
LOS COLINAS MEDICAL CENTER TX
LOURDES MED CTR BURLINGTON CT
LOWELL GENERAL HOSPITAL MA
LUTHER HSP WI
LUTHERAN MEDICAL CENTER OH
LYNCHBURG GENERAL HOSP VA
MAGEE WOMENS HOSPITAL PA
MAIN LINE HSP LANKENAU PA
MAINE GEN MED CTR ME
MANATEE MEMORIAL HSP FL
MARICOPA MEDICAL CENTER AZ
MARINERS HOSPITAL FL
MARLBOROUGH HOSP MA
City, State
PHOENIX
PHOENIX
FARMINGTON
EDISON
BALTIMORE
BALTIMORE
STAFFORD SPRINGS
PLYMOUTH
JUPITER
AIEA
BALTIMORE
CHERRY HILL
STRATFORD
TURNERSVILLE
WARWICK
WEST ORANGE
ROWLETT
LAKELAND
FRANKLIN
LACONIA
LAKEWOOD
LANCASTER
WOONSOCKET
LAREDO
LARGO
NEW LONDON
LAWRENCE
FORT MYERS
LEESBURG
ALLENTOWN
BETHLEHEM
KINSTON
LIBERTY
LITTLETON
LOGAN
LONG BEACH
IRVING
WILLINGBORO
LOWELL
EAU CLAIRE
CLEVELAND
LYNCHBURG
PITTSBURGH
WYNNEWOOD
WATERVILLE
BRADENTON
PHOENIX
TAVERNIER
MARLBOROUGH
AZ
AZ
CT
NJ
MD
MD
CT
MA
FL
HI
MD
NJ
NJ
NJ
RI
NJ
TX
FL
NH
NH
OH
PA
RI
TX
FL
CT
MA
FL
FL
PA
PA
NC
MO
NH
UT
CA
TX
NJ
MA
WI
OH
VA
PA
PA
ME
FL
AZ
FL
MA
(1)
(2)
Rate Code 2953 (OOS Hospital DRG)
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 8,832.97
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 7,336.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
Rate Code 2952 (OOS Hospital Exempt)
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
(3)
(4)
(5)
(6)
Rate Code 2589 (DME Add‐on)
$ 298.23
$ ‐
$ 298.23
$ 1,295.15
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
Rate Codes 2950 and 2954 (ALC RHCF)
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Codes 2951 and 2955 (ALC Home Care)
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Code 2990 (Capital per Disch)
$ 528.83
$ 528.83
$ 528.83
$ 704.77
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 704.77
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
6 of 13
(7)
(8)
(9)
Rate Code 2991 WEF/ISAF High Cost (Capital per (for High Cost Charge Diem)
Claims)
Convertors
0.442464
$ 112.32
0.8424
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 144.34
1.0684
0.357482
0.442464
$ 112.32
0.8424
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 144.34
1.0684
0.357482
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES
EFFECTIVE 01/01/13 ‐ 12/31/13
Hospital Name
MARTHAS VINEYARD HOSPITAL MA
MARTIN MEMORIAL MED CTR FL
MARY BLACK HEALTH SYSTEM SC
MARY HITCHCOCK MEM HOSP NH
MARY WASHINGTON HOSPITAL VA
MARYMOUNT HOSPITAL OH
MASSACHUSETTS GEN HOSP
MAURY REGIONAL HSP TN
MCKEE MED CTR CO
MCLEOD LORIS SEACOAST HSP SC
MCLEOD MEDICAL CTR DILLON
MCLEOD REG MED CTR SC
MEADOWLANDS HOSP MED CTR NJ
MEDCENTRAL HLTH SYS OH
MEDICAL CENTER AT PRINCETON
MEDICAL CENTER OF MANCHESTER
MEDICAL CENTER OF MC KINNEY T
MEDICAL CENTER OF PLANO TX
MEDICAL CITY DALLAS HOSP TX
MEDICAL CTR CENTRAL GEORGIA G
MEDICAL CTR OF ARLINGTON TX
MEDICAL CTR OF OCEAN CO.
MEDINA GEN HSP OH
MEMORIAL HERMANN HOSP TX
MEMORIAL HERMANN KATY HOSPITA
MEMORIAL HERMANN SE & SW HOSP
MEMORIAL HLTH UNIV MED CTR GA
MEMORIAL HOSP PEMBROKE FL
MEMORIAL HOSPITAL BURLINGTON
MEMORIAL HOSPITAL IL
MEMORIAL HOSPITAL MIRAMAR FL
MEMORIAL HOSPITAL PA
MEMORIAL HOSPITAL PA INC
MEMORIAL HOSPITAL RI
MEMORIAL HOSPITAL SOUTH BEND
MEMORIAL HOSPITAL WEST FL
MEMORIAL HSP CO
MEMORIAL HSP OF EASTON MD INC
MEMORIAL REG HSP FL
MERCY HOSP OF PHILADELPHIA
MERCY MED CTR N IOWA
MERCY MED CTR WI
MERCY MEDICAL CENTER MD
MERCY MEMORIAL HOSPITAL MI
MERCY ST VINCENT MED CTR OH
MERIDIA EUCLID HSP OH
MERIDIA HILLCREST HSP OH
MERITER HOSP INC WI
MERRIMACK VALLEY HSP A STEWRD
City, State
OAK BLUFFS
STUART
SPARTANBURG
LEBANON
FREDERICKSBURG
CLEVELAND
BOSTON
COLUMBIA
LOVELAND
LORIS
DILLON
FLORENCE
SECAUCUS
MANSFIELD
PRINCETON
MANCHESTER
MCKINNEY
PLANO
DALLAS
MACON
ARLINGTON
BRICK
MEDINA
HOUSTON
KATY
HOUSTON
SAVANNAH
PEMBROKE PINES
MOUNT HOLLY
BELLEVILLE
MIRAMAR
YORK
TOWANDA
PAWTUCKET
SOUTH BEND
PEMBROKE PINES
COLORADO SPRINGS
EASTON
HOLLYWOOD
PHILADELPHIA
MASON CITY
OSHKOSH
BALTIMORE
MONROE
TOLEDO
EUCLID
MAYFIELD HTS
MADISON
HAVERHILL
MA
FL
SC
NH
VA
OH
MA
TN
CO
SC
SC
SC
NJ
OH
NJ
TN
TX
TX
TX
GA
TX
NJ
OH
TX
TX
TX
GA
FL
NJ
IL
FL
PA
PA
RI
IN
FL
CO
MD
FL
PA
IA
WI
MD
MI
OH
OH
OH
WI
MA
(1)
(2)
Rate Code 2953 (OOS Hospital DRG)
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 7,336.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
Rate Code 2952 (OOS Hospital Exempt)
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
(3)
(4)
(5)
(6)
Rate Code 2589 (DME Add‐on)
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
Rate Codes 2950 and 2954 (ALC RHCF)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Codes 2951 and 2955 (ALC Home Care)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Code 2990 (Capital per Disch)
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 704.77
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
7 of 13
(7)
(8)
(9)
Rate Code 2991 WEF/ISAF High Cost (Capital per (for High Cost Charge Diem)
Claims)
Convertors
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 144.34
1.0684
0.357482
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES
EFFECTIVE 01/01/13 ‐ 12/31/13
Hospital Name
METHODIST CHARLTON MED CTR
METHODIST HOSP OF MEMPHIS TN
METHODIST IU RILEY HOSPITAL METRO HEALTH SYSTEM OH
METRO WEST MEDICAL CENTER MA
METROPLEX HOSPITAL TX
MIAMI CHILDRENS HOSPITAL FL
MID MICHIGAN REG MED CTR MI
MIDDLESEX HOSPITAL CT
MIDSTATE MEDICAL CENTER CT
MILES MEMORIAL HOSPITAL ME
MILFORD HOSPITAL CT
MILTON S HERSHEY MED CTR PA
MIRIAM HOSPITAL RI
MONTGOMERY GENERAL HOSP MD
MONTGOMERY HOSPITAL PA
MOREHEAD MEM HSP NC
MOSES H CONE HOSPITAL NC
MOUNT SINAI MEDICAL CTR OF FL
MUNROE REGIONAL MED CTR FL
NASHOBA VALLEY MED CTR MA
NASHVILLE MEM HSP TN
NATIONAL HSP KIDS IN CRISIS P
NAZARETH HOSPITAL PA
NEBRASKA MEDICAL CENTER NE
NEW MILFORD HSP
NEW PT RICHEY/MED CTR OF TRIN
NEWPORT HSP RI
NEWTON MEMORIAL HOSPITAL NJ
NEWTON WELLESLEY HOSP MA
NORTH ADAMS REG HOSP MA
NORTH BROWARD MEDICAL CTR FL
NORTH COLORADO MED CTR CO
NORTH COUNTRY HOSPITAL VT
NORTH HILLS HOSPITAL TX
NORTH OKLALOOSA MED CTR FL
NORTH PHILADELPHIA HLTH SYS
NORTH SHORE MED CTR FL
NORTH SHORE MED CTR FMC FL
NORTH SUBURBAN MED CTR CO
NORTHEAST ALABAMA REG MED
NORTHERN COCHISE COMM HSP AZ
NORTHSHORE UNIVERSITY HEALTH NORTHSIDE HOSP FL
NORTHWEST HOSPITAL CENTER MD
NORTHWEST TEXAS HOSPITAL
NORTHWESTERN MEDICAL CTR VT
NORTON HOSPITAL KY
NORWALK HOSPITAL
City, State
DALLAS
MEMPHIS
INDIANAPOLIS
CLEVELAND
FRAMINGHAM
KILLEEN
MIAMI
MIDLAND
MIDDLETOWN
MERIDEN
DAMARISCOTTA
MILFORD
HERSHEY
PROVIDENCE
OLNEY
NORRISTOWN
EDEN
GREENSBORO
MIAMI BEACH
OCALA
AYER
MADISON
OREFIELD
PHILADELPHIA
OMAHA
NEW MILFORD
TRINITY
NEWPORT
NEWTON
NEWTON
NORTH ADAMS
POMPANO BEACH
GREELEY
NEWPORT
NORTH RICHLAND HILLS
CRESTVIEW
PHILADELPHIA
MIAMI
FT LAUDERDALE
THORNTON
ANNISTON
WILLCOX
EVANSTON
ST PETERSBURG
RANDALLSTOWN
AMARILLO
SAINT ALBANS
LOUISVILLE
NORWALK
TX
TN
IN
OH
MA
TX
FL
MI
CT
CT
ME
CT
PA
RI
MD
PA
NC
NC
FL
FL
MA
TN
PA
PA
NE
CT
FL
RI
NJ
MA
MA
FL
CO
VT
TX
FL
PA
FL
FL
CO
AL
AZ
IL
FL
MD
TX
VT
KY
CT
(1)
(2)
Rate Code 2953 (OOS Hospital DRG)
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 7,336.96
$ 5,784.96
$ 5,784.96
$ 7,336.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 8,832.97
Rate Code 2952 (OOS Hospital Exempt)
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
(3)
(4)
(5)
(6)
Rate Code 2589 (DME Add‐on)
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ 298.23
$ 1,295.15
Rate Codes 2950 and 2954 (ALC RHCF)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
Rate Codes 2951 and 2955 (ALC Home Care)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
Rate Code 2990 (Capital per Disch)
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 704.77
$ 528.83
$ 528.83
$ 704.77
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 704.77
8 of 13
(7)
(8)
(9)
Rate Code 2991 WEF/ISAF High Cost (Capital per (for High Cost Charge Diem)
Claims)
Convertors
0.442464
$ 112.32
0.8424
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 144.34
1.0684
0.357482
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 144.34
1.0684
0.357482
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 144.34
1.0684
0.357482
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES
EFFECTIVE 01/01/13 ‐ 12/31/13
Hospital Name
NORWOOD HOSP INC MA
OCEAN BEACH HOSPITAL WA
OHIO STATE UNIVERSITY HSP OH
ORLANDO REG HLTH SYS FL
OSCEOLA REG HOSP FL
OU MEDICAL CENTER OK
OUR LADY OF LOURDES MED CTR N
PALISADES MEDICAL CENTER NJ
PALM BAY HOSPITAL FL
PALM BEACH GARDENS AND MED CT
PALMERTON HOSPITAL PA
PALMETTO GENERAL HOSPITAL FL
PALMYRA PARK HSP GA
PAOLI MEMORIAL HOSPITAL
PARKER ADVENTIST HEALTH CO
PARKLAND MEDICAL CTR NH
PARRISH MED CTR FL
PENNSYLVANIA HOSP PA
PENOBSCOT BAY MED CTR ME
PHOENIX BAPTIST HOSP AZ
PHOENIX CHILDRENS HSP AZ
PINNACLE HEALTH HOSPITALS PA
PITT COUNTY MEMORIAL HOSP NC
POCONO MED CTR PA
POMONA VALLEY HOSPITAL MED CT
PORTER MEDICAL CENTER INC
PORTERCARE ADVENTIST HLTH CO
POTOMAC HSP OF PRINCE WILL VA
POTOMAC VALLEY HSP OF WEST VA
POTTSTOWN MEM MED CTR PA
PRESBYTERIAN HOSP NM
PRESBYTERIAN HSP OF DALLAS
PRESBYTERIAN INTERCOMM HSP CA
PRESBYTERIAN UNIV HSP PA
PRESBYTERIAN UNIV HSP PA
PRESBYTERIAN UNIV HSP PA
PRESBYTERIAN UNIV HSP PA
PRESBYTERIAN UNIV HSP PA
PRINCE GEORGES HOSP CTR MD
PROVIDENCE HEALTH CTR TX
PROVIDENCE ST PETERS HOSP WA
QUEENS MEDICAL CENTER HI THE
QUINCY MED CTR A STEWARD FAM
RALEIGH GENERAL HOSPITAL WV
RAMAPO RIDGE PSYCH HOSP
RARITAN BAY HEALTH SERVICES
REFUGIO COUNTY MEM HSP TX
REG CTR ORANGEBURG CALHOUN SC
REGIONAL HSP SCRANTON PA
City, State
NORWOOD
ILWACO
COLUMBUS
ORLANDO
KISSIMMEE
OKLAHOMA CITY
CAMDEN
NORTH BERGEN
PALM BAY
PALM BEACH GARDENS
PALMERTON
HIALEAH
ALBANY
PAOLI
PARKER
DERRY
TITUSVILLE
PHILADELPHIA
ROCKPORT
PHOENIX
PHOENIX
HARRISBURG
GREENVILLE
E STROUDSBURG
POMONA
MIDDLEBURY
LITTLETON
WOODBRIDGE
KEYSER
POTTSTOWN
ALBUQUERQUE
DALLAS
WHITTIER
PITTSBURGH
PITTSBURGH
PITTSBURGH
PITTSBURGH
PITTSBURGH
CHEVERLY
WACO
OLYMPIA
HONOLULU
QUINCY
BECKLEY
WYCKOFF
PERTH AMBOY
REFUGIO
ORANGEBURG
SCRANTON
MA
WA
OH
FL
FL
OK
NJ
NJ
FL
FL
PA
FL
GA
PA
CO
NH
FL
PA
ME
AZ
AZ
PA
NC
PA
CA
VT
CO
VA
WV
PA
NM
TX
CA
PA
PA
PA
PA
PA
MD
TX
WA
HI
MA
WV
NJ
NJ
TX
SC
PA
(1)
(2)
Rate Code 2953 (OOS Hospital DRG)
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 7,336.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 6,445.03
$ 6,445.03
$ 6,445.03
$ 6,445.03
$ 6,445.03
$ 6,445.03
$ 6,445.03
$ 6,445.03
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 7,336.96
$ 8,832.97
$ 5,784.96
$ 5,784.96
$ 6,445.03
Rate Code 2952 (OOS Hospital Exempt)
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
(3)
(4)
(5)
(6)
Rate Code 2589 (DME Add‐on)
$ ‐
$ ‐
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ 298.23
$ 298.23
$ 298.23
$ 298.23
$ 298.23
$ 298.23
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ 1,295.15
$ ‐
$ ‐
$ 298.23
Rate Codes 2950 and 2954 (ALC RHCF)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 261.20
$ 171.74
$ 171.74
$ 171.74
Rate Codes 2951 and 2955 (ALC Home Care)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 261.20
$ 171.74
$ 171.74
$ 171.74
Rate Code 2990 (Capital per Disch)
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 704.77
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 704.77
$ 704.77
$ 528.83
$ 528.83
$ 528.83
9 of 13
(7)
(8)
(9)
Rate Code 2991 WEF/ISAF High Cost (Capital per (for High Cost Charge Diem)
Claims)
Convertors
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 144.34
1.0684
0.357482
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 144.34
1.0684
0.357482
$ 144.34
1.0684
0.357482
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES
EFFECTIVE 01/01/13 ‐ 12/31/13
Hospital Name
REGIONAL MED CTR AT MEMPHIS
RESEARCH MED CTR MO
REX HOSPITAL NC
RHODE ISLAND HOSPITAL RI
RIDDLE MEMORIAL HOSP PA
RIVERSIDE METH HOSP/OHIO HLTH
RIVERSIDE TAPPAHANNOCK HSP VA
RIVERSIDE WALTER REED HSP VA
RIVERTON HOSPITAL UT
RIVERVIEW HOSPITAL NJ
ROBERT PACKER HOSP PA
ROBERT W JOHNSON UNIV HSP RAH
ROBERT WOOD JOHNSON UNIV HSP
ROGER WILLIAMS GENERAL HOSP
ROGUE VALLEY MEMORIAL HSP OR
SACRED HEART HOSPITAL PA
SACRED HEART MED CTR UNIV DIS
SAINT BARNABAS MEDICAL CENTER
SAINT FRANCIS HOSPITAL TN
SAINT VINCENTS HLTH CTR
SAINTS MEM MED CTR MA
SALINA REG HLTH CTR KS
SAN ANTONIO COMM HSP CA
SAN RAMON MEDICAL CTR CA
SARASOTA MEMORIAL HOSPITAL FL
SCHUYLKILL MED CTR SOUTH PA
SCOTTSDALE HLTHCARE SHEA AZ
SCOTTSDALE MEM HSP AZ
SELF REG HEALTHCARE SC
SENTARA BAYSIDE HOSP VA
SENTARA CAREPLEX HOSPITAL VA
SENTARA HOSPITAL VA
SENTARA LEIGH HSP VA
SENTARA NORFOLK HSP VA
SENTARA VIRGINIA BEACH GEN HS
SENTARA WILLIAMSBURG COMM HOS
SHANDS JACKSONVILLE MED FL
SHANDS TEACHING HOSPITAL FL
SHARON HOSPITAL CT
SHARP CHULA VISTA
SHARP MEM HSP CA
SHELBY CTY/WILSON MEMORIAL OH
SHERMAN OAKS HSP CA
SINAI GRACE HOSPITAL MI
SKAGGS COMM HEALTH MO
SOLDIERS AND SAILORS MEM HOSP
SOMERSET MED CENTER NJ
SOUTH COUNTY HOSPTAL RI
SOUTH FLORIDA BAPTIST HSPFL
City, State
MEMPHIS
KANSAS CITY
RALEIGH
PROVIDENCE
MEDIA
COLUMBUS
TAPPAHANNOCK
GLOUCESTER
RIVERTON
RED BANK
SAYRE
RAHWAY
NEW BRUNSWICK
PROVIDENCE
MEDFORD
ALLENTOWN
EUGENE
OCEAN PORT
MEMPHIS
ERIE
LOWELL
SALINA
UPLAND
SAN RAMON
SARASOTA
POTTSVILLE
SCOTTSDALE
SCOTTSDALE
GREENWOOD
VIRGINIA BEACH
HAMPTON
SUFFOLK
NORFOLK
NORFOLK
VIRGINIA BEACH
WILLIAMSBURG
JACKSONVILLE
GAINESVILLE
SHARON
CHULA VISTA
SAN DIEGO
SIDNEY
SHERMAN OAKS
DETROIT
BRANSON
WELLSBORO
SOMERVILLE
WAKEFIELD
PLANT CITY
TN
MO
NC
RI
PA
OH
VA
VA
UT
NJ
PA
NJ
NJ
RI
OR
PA
OR
NJ
TN
PA
MA
KS
CA
CA
FL
PA
AZ
AZ
SC
VA
VA
VA
VA
VA
VA
VA
FL
FL
CT
CA
CA
OH
CA
MI
MO
PA
NJ
RI
FL
(1)
(2)
Rate Code 2953 (OOS Hospital DRG)
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 7,336.96
$ 6,445.03
$ 7,336.96
$ 8,832.97
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 7,336.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
Rate Code 2952 (OOS Hospital Exempt)
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
(3)
(4)
(5)
(6)
Rate Code 2589 (DME Add‐on)
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ 1,295.15
$ 298.23
$ ‐
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
Rate Codes 2950 and 2954 (ALC RHCF)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 261.20
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Codes 2951 and 2955 (ALC Home Care)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 261.20
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Code 2990 (Capital per Disch)
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 704.77
$ 528.83
$ 704.77
$ 704.77
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 704.77
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
10 of 13
(7)
(8)
(9)
Rate Code 2991 WEF/ISAF High Cost (Capital per (for High Cost Charge Diem)
Claims)
Convertors
0.442464
$ 112.32
0.8424
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 144.34
1.0684
0.357482
0.442464
$ 112.32
0.8424
$ 144.34
1.0684
0.357482
$ 144.34
1.0684
0.357482
0.442464
$ 112.32
0.8424
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 144.34
1.0684
0.357482
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES
EFFECTIVE 01/01/13 ‐ 12/31/13
Hospital Name
SOUTH LAKE HSP FL
SOUTH MIAMI HOSPITAL FL
SOUTH POINTE HOSPITAL OH
SOUTH SHORE HOSP MA
SOUTHEASTERN OHIO REG MED CTR
SOUTHERN HILLS M C TN
SOUTHERN MARYLAND HOSP INC
SOUTHERN OCEAN MED CTR NJ
SOUTHERN OHIO MED CTR OH
SOUTHSIDE COMM HOSP VA
SOUTHWEST GENERAL HOSPITAL
SOUTHWESTERN VT MED CTR INC
SPEARE MEMORIAL HOSP NH
ST ANTHONY SUMMIT HOSPITAL CO
ST CHRISTOPHERS HSP CHILD PA
ST CLARES HOSPITAL
ST ELIZABETH HEALTH CENTER OH
ST ELIZABETH HSP WI
ST ELIZABETH MED CTR KY
ST FRANCIS HOSP & MED CTR CT
ST FRANCIS HOSPITAL OK
ST FRANCIS HSP DE
ST FRANCIS MEDICAL CENTER
ST FRANCIS MEDICAL CENTER NE
ST JAMES HLTH CAREHSP MT
ST JOSEPH HOSPITAL PA
ST JOSEPH MERCY HSP OAKLAND
ST JOSEPHS HOSP MED CTR NJ
ST JOSEPHS HOSPITAL GA
ST JUDE CHILDRENS RES HSP TN
ST LOUIS CHILDRENS HOSP MO
ST LUKES COMM MC WOODLANDS TX
ST LUKES EAST LEES HSP MO
ST LUKES EPISCOPAL HSP TX
ST LUKES HOSPITAL
ST LUKES HOSPITAL
ST LUKES HOSPITAL MA
ST LUKES HOSPITAL OH
ST LUKES MED CTR AZ
ST MARY HOSPITAL PA
ST MARY MERCY HSP MI
ST MARYS HEALTH SYS TN
ST MARYS HOSP NJ
ST MARYS HOSPITAL OF CONN
ST MARYS REG MED CENTER ME
ST MICHAEL MED CENTER NJ
ST PETERS UNIV HSP NJ
ST PETERSBURG GEN HSP FL
ST VINCENT HOSPITAL MA
City, State
CLERMONT
SOUTH MIAMI
WARRENSVILLE HTS
SOUTH WEYMOUTH
CAMBRIDGE
NASHVILLE
CLINTON
MANAHAWKIN
PORTSMOUTH
FARMVILLE
CLEVELAND
BENNINGTON
PLYMOUTH
FRISCO
PHILADELPHIA
DENVILLE
YOUNGSTOWN
APPLETON
EDGEWOOD
HARTFORD
TULSA
WILMINGTON
TRENTON
GRAND ISLAND
BUTTE
READING
PONTIAC
PATERSON
SAVANNAH
MEMPHIS
SAINT LOUIS
THE WOODLANDS
LEES SUMMIT
HOUSTON
BETHLEHEM
MILWAUKEE
FALL RIVER
MAUMEE
PHOENIX
LANGHORNE
LIVONIA
KNOXVILLE
PASSAIC
WATERBURY
LEWISTON
NEWARK
NEW BRUNSWICK
ST PETERSBURG
WORCESTER
FL
FL
OH
MA
OH
TN
MD
NJ
OH
VA
OH
VT
NH
CO
PA
NJ
OH
WI
KY
CT
OK
DE
NJ
NE
MT
PA
MI
NJ
GA
TN
MO
TX
MO
TX
PA
WI
MA
OH
AZ
PA
MI
TN
NJ
CT
ME
NJ
NJ
FL
MA
(1)
(2)
Rate Code 2953 (OOS Hospital DRG)
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 8,832.97
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 7,336.96
$ 6,445.03
$ 5,784.96
$ 8,832.97
$ 7,336.96
$ 5,784.96
$ 6,445.03
Rate Code 2952 (OOS Hospital Exempt)
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
(3)
(4)
(5)
(6)
Rate Code 2589 (DME Add‐on)
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ 1,295.15
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ 1,295.15
$ ‐
$ ‐
$ 298.23
Rate Codes 2950 and 2954 (ALC RHCF)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 261.20
$ 261.20
$ 171.74
$ 171.74
Rate Codes 2951 and 2955 (ALC Home Care)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 261.20
$ 261.20
$ 171.74
$ 171.74
Rate Code 2990 (Capital per Disch)
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 704.77
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 704.77
$ 528.83
$ 528.83
$ 704.77
$ 704.77
$ 528.83
$ 528.83
11 of 13
(7)
(8)
(9)
Rate Code 2991 WEF/ISAF High Cost (Capital per (for High Cost Charge Diem)
Claims)
Convertors
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 144.34
1.0684
0.357482
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 144.34
1.0684
0.357482
0.442464
$ 112.32
0.8424
$ 112.32
0.8424
0.442464
$ 144.34
1.0684
0.357482
$ 144.34
1.0684
0.357482
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES
EFFECTIVE 01/01/13 ‐ 12/31/13
Hospital Name
ST VINCENTS MEDICAL CENTER CT
STAFFORD HOSPITAL VA
STAMFORD HOSPITAL CT
STEVENS HOSPITAL WA
STEWARD CARNEY HOSP INC
STEWARD CARNEY HOSP MA
STEWARD GOOD SAM MED CTR MA
STEWARD GOOD SAM MED CTR MA
STEWARD HOLY FAMILY MA
STEWARD NORWOOD HOSP MA
STEWARD ST ANNES HSP MA
STEWARD ST ELIZABETH MED CTR
STORMONT VAIL REG MED CTR KS
STURDY MEMORIAL HOSP MA
SUBURBAN HOSPITAL
SUMMERLIN MED CTR NV
SUNRISE HOSP & MED CTR NV
SWEETWATER HOSP TN
TAMPA GEN HSP DAVIS ISLANDS
TEMPLE UNIVERSITY HOSPITAL
TEXAS HLTH ARLINGTON TX
TEXAS HLTH HARRIS METH HSP
TEXAS HLTH PRESBY HOSP PLANO
TEXAS HLTH PRESBYTERIAN HOSP
THOMAS JEFFERSON UNIV HOSP PA
THREE RIVERS COMMUNITY HSP OR
TRINITAS HSP NJ
TROY COMMUNITY HOSPITAL
TRUMBULL MEM HOSP OH
TUFTS MEDICAL CENTER MA
UCSD MEDICAL CENTER
UMASS MEMORIAL MED CNTR PSYCH
UMASS MEMORIAL MEDICAL CENTER
UNION HOSP OF CECIL CTY MD
UNITED HSP CTR WV
UNITED MEDICAL HLTHWEST LA
UNIV CA DAVIS MED CTR CA
UNIV KENTUCKY HOSPITAL
UNIV OF ALABAMA
UNIV OF IOWA HSP & CLINICS IA
UNIV OF WASHINGTON WA
UNIVERSITY COMM HOSP FL
UNIVERSITY HOSPITAL GA
UNIVERSITY HOSPITAL NC
UNIVERSITY HSP TX
UNIVERSITY MED CTR TX
UNIVERSITY OF KANSAS HOSPITAL
UNIVERSITY OF MARYLAND MED SY
UNIVERSITY OF MICHIGAN
City, State
BRIDGEPORT
STAFFORD
STAMFORD
EDMONDS
DORCHESTER
DORCHESTER
BROCKTON
BROCKTON
METHUEN
NORWOOD
FALL RIVER
BOSTON
TOPEKA
ATTLEBORO
BETHESDA
LAS VEGAS
LAS VEGAS
SWEETWATER
TAMPA
PHILADELPHIA
ARLINGTON
FORTH WORTH
PLANO
ALLEN
PHILADELPHIA
GRANTS PASS
ELIZABETH
TROY
WARREN
WORCESTER
SAN DIEGO
WORCESTER
WORCESTER
ELKTON
CLARKSBURG
GRETNA
SACRAMENTO
LEXINGTON
BIRMINGHAM
IOWA CITY
SEATTLE
TAMPA
AUGUSTA
CHARLOTTE
SAN ANTONIO
LUBBOCK
KANSAS CITY
BALTIMORE
ANN ARBOR
CT
VA
CT
WA
MA
MA
MA
MA
MA
MA
MA
MA
KS
MA
MD
NV
NV
TN
FL
PA
TX
TX
TX
TX
PA
OR
NJ
PA
OH
MA
CA
MA
MA
MD
WV
LA
CA
KY
AL
IA
WA
FL
GA
NC
TX
TX
KS
MD
MI
(1)
(2)
Rate Code 2953 (OOS Hospital DRG)
$ 8,832.97
$ 5,784.96
$ 8,832.97
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 8,832.97
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 6,445.03
$ 6,445.03
$ 6,445.03
Rate Code 2952 (OOS Hospital Exempt)
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
(3)
(4)
(5)
(6)
Rate Code 2589 (DME Add‐on)
$ 1,295.15
$ ‐
$ 1,295.15
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ 1,295.15
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ 298.23
$ 298.23
Rate Codes 2950 and 2954 (ALC RHCF)
$ 261.20
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Codes 2951 and 2955 (ALC Home Care)
$ 261.20
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Code 2990 (Capital per Disch)
$ 704.77
$ 528.83
$ 704.77
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 704.77
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
12 of 13
(7)
(8)
(9)
Rate Code 2991 WEF/ISAF High Cost (Capital per (for High Cost Charge Diem)
Claims)
Convertors
$ 144.34
1.0684
0.357482
$ 112.32
0.8424
0.442464
$ 144.34
1.0684
0.357482
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 144.34
1.0684
0.357482
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES
EFFECTIVE 01/01/13 ‐ 12/31/13
Hospital Name
UNIVERSITY OF TENNESSEE MEM
UNIVERSITY SPECIALTY HOSP MD
UPHS PRESBYTERIAN MEDICAL CEN
UPPER CHESAPEAK MEDICAL CENTE
VALLEY HOSPITAL
VALLEY VIEW HOSP ASSOC CO
VANDERBILT UNIVERSITY HSP TN
VERDE VALLEY MED CTR AZ
VHS CHILDRENS HSP MI
VIERA HOSPITAL FL
VILLAGES REGIONAL HOSP FL
VIRGINIA BEACH PSYCHIATRIC
WAKEMED HEALTH AND HOSP NC
WALTON REG MED CTR GA
WARREN GENERAL HOSPITAL PA
WARREN HOSPITAL NJ
WATERBURY HOSPITAL CT
WAUKESHA MEMORIAL HOSPITAL WI
WAYNE MEMORIAL HOSP PA
WAYNE MEM HSP NC
WAYNESBORO HSP PA
WELLSTAR COBB HOSP GA
WELLSTAR DOUGLAS HOSP GA
WELLSTAR KENNESTONE HOSP GA
WELLSTAR PAULDING HOSP GA
WEST GROVE/JENNERSVILLE PA
WEST JEFFERSON MED CTR LA
WEST JERSEY HEALTH SYS
WEST VALLEY HOSPITAL AZ
WESTERLY HOSP RI
WESTERN PENNSYLVANIA HOSP
WICKENBURG COMM HOSP AZ
WILKES BARRE BEHAV HOSP PA
WILLIAM BACKUS HOSPITAL CT
WILLIAM BEAUMONT HOSP
WING MEMORIAL HOSPITAL MA
WMHS BRADDOCK HOSPITAL MD
WOMEN & INFANTS HSP RI
YALE NEW HAVEN HOSPITAL CT
YORK HOSPITAL
YORK HOSPITAL ME
City, State
KNOXVILLE
BALTIMORE
PHILADELPHIA
BEL AIR
RIDGEWOOD
GLENWOOD SPRINGS
NASHVILLE
COTTONWOOD
DETROIT
MELBOURNE
THE VILLAGES
VIRGINIA BEACH
RALEIGH
MONROE
WARREN
PHILLIPSBURG
WATERBURY
WAUKESHA
HONESDALE
GOLDSBORO
WAYNESBORO
AUSTELL
DOUGLASVILLE
MARIETTA
DALLAS
WEST GROVE
MARRERO
VOORHEES TOWNSHIP
GOODYEAR
WESTERLY
PITTSBURGH
WICKENBURG
KINGSTON
NORWICH
ROYAL OAK
PALMER
CUMBERLAND
PROVIDENCE
NEW HAVEN
YORK
YORK
TN
MD
PA
MD
NJ
CO
TN
AZ
MI
FL
FL
VA
NC
GA
PA
NJ
CT
WI
PA
NC
PA
GA
GA
GA
GA
PA
LA
NJ
AZ
RI
PA
AZ
PA
CT
MI
MA
MD
RI
CT
PA
ME
(1)
(2)
Rate Code 2953 (OOS Hospital DRG)
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 7,336.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 5,784.96
$ 5,784.96
$ 6,445.03
$ 6,445.03
$ 6,445.03
$ 5,784.96
Rate Code 2952 (OOS Hospital Exempt)
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
(3)
(4)
(5)
(6)
Rate Code 2589 (DME Add‐on)
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ ‐
Rate Codes 2950 and 2954 (ALC RHCF)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Codes 2951 and 2955 (ALC Home Care)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Code 2990 (Capital per Disch)
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 704.77
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
$ 528.83
13 of 13
(7)
(8)
(9)
Rate Code 2991 WEF/ISAF High Cost (Capital per (for High Cost Charge Diem)
Claims)
Convertors
0.442464
$ 112.32
0.8424
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 144.34
1.0684
0.357482
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464
$ 112.32
0.8424
0.442464