2016 APG Updates/Policy Changes

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April 5, 2016

Dear Health Plans:

The purpose of this letter is to provide Health Plans with information regarding recent updates to the Medicaid outpatient capital rates for the period January 1, 2009 through December 31, 2015 for general clinics, school-based health center clinics, OASAS clinics and emergency departments.

These rates were calculated in accordance with Article 28 of the Public Health Law and Part 86 of the Commissioner of Health´s Administrative Rules and Regulations and continue the Ambulatory Patient Groups (APG) reimbursement methodology, as adopted in the 2009-2010 and 2010-2011 State Budgets and in accordance with Subdivision 2-a of Article 2807 of the Public Health Law.

The APG rates posted to the Department´s website include the rate components required to process Medicaid claims. Based on the above mentioned changes, plans are encouraged to process adjustments according to the terms of their provider contracts with hospitals. This includes any reprocessing that should occur consistent with those agreements. Please see Hospital APG Rates for the latest APG capital rates.

Rate Codes:

The table below references the Medicaid Fee-for-Service capital rate codes which were updated on the Department´s website, along with the corresponding base rate codes (which were not updated):

Base Rate Code Base Rate Code Description Capital Rate Code Service dates affected by capital rate updates
1400 Hospital Outpatient APG Clinic 1403 1/1/2009 - present
1432 Hospital Outpatient APG Clinic-Episode 1434 7/1/2009 – present
1501 Hospital Outpatient APG Clinic-MR/DD/TBI 1503 7/1/2010 – present
1489 Hospital Outpatient APG Clinic-MR/DD/TBI-Episode 1491 7/1/2010 – present
1444 Hospital Outpatient APG School-Based Health Clinic 1446 4/1/2009 – present
1450 Hospital Outpatient APG School-Based Health Clinic- Episode 1452 10/1/2009 - present
1528 OASAS – Hospital Article 32 Clinic 1530 10/1/2010 - present
1552 OASAS – Hospital Article 32 Medical Visit 1554 5/1/2015 – present
1402 Hospital Outpatient APG Emergency Room 1405 1/1/2009 – present

Should you have any questions regarding the above information, please submit your inquiry to the HospFFSunit@health.ny.gov email address and either Monique Grimm or Tami Berdi from the hospital fee-for-service rate unit will respond.


Michael Ogborn
Deputy Director
Division of Finance and Rate Setting