Health Plan Letter

  • Letter also available in Portable Document Format (PDF)

May 22, 2025

Dear Health Plans,

The purpose of this letter is to provide Health Plans with information regarding recent approvals related to Medicaid Managed Care (MMC) hospital outpatient payments.

For dates of service April 1, 2023 – March 31, 2024, the Centers for Medicare and Medicaid Services (CMS) recently approved rate add-ons to the MMC rates of payment for government general hospitals, other than those operated by the State of New York or the State University of New York, located in a city with a population of over one million. For the purposes of this directed payment, the sole member of this class is the NYC Health + Hospitals Corporation. These add-ons, which are included in the table below, are only applicable to Article 28 general clinic, ambulatory surgery and emergency department services, as outlined in the billing guidelines attachment to this letter. A separate rate file has also been posted to the Department of Health’s Ambulatory Patient Group (APG) website.

Plans should treat these adjustments in accordance with Section 22.19 and Appendix V of the Managed Care Model Contract and the terms of their provider contracts with hospitals. This includes any reprocessing or claims settlements that should occur consistent with those agreements. The Department has effectuated premium payments to health plans to align with the updated Managed Care State Direct Payment add-ons associated with this rate publication.

***Please note that these rate add-ons correlate with the Final Reconciliation and associated volume, as submitted to the Department of Health and Deloitte. Only claims included in that final reconciliation are subject to this add-on.***

Rate Add-ons (4/1/2023 - 3/31/2024) Clinic
(Article 28)		 Ambulatory
Surgery		 Emergency
Department
Operating
Certificate
Hospital Name		 Add-on
Payment Per Visit		 Add-on
Payment Per Visit		 Add-on
Payment Per Visit
7002001 Bellevue Hospital Center $505.83 $505.83 $505.83
7003000 Elmhurst Hospital Center $505.83 $505.83 $505.83
7002009 Harlem Hospital Center $505.83 $505.83 $505.83
7002050 Henry J. Carter Specialty Hospital $505.83 $505.83 $505.83
7000002 Jacobi Medical Center $505.83 $505.83 $505.83
7001016 Kings County Hospital Center $505.83 $505.83 $505.83
7000008 Lincoln Medical & Mental Health Center $505.83 $505.83 $505.83
7002021 Metropolitan Hospital Center $505.83 $505.83 $505.83
7003007 Queens Hospital Center $505.83 $505.83 $505.83
7001009 South Brooklyn Health $505.83 $505.83 $505.83
7001045 Woodhull Medical & Mental Health Center $505.83 $505.83 $505.83

Should you have any questions regarding the above rate information, please submit your inquiry to HospFFSunit@health.ny.gov and either Tami Berdi or John Neuberger from the hospital fee-for-service rate setting unit will respond. Questions regarding Managed Care premium paymentsshould be directed to phr@health.ny.gov.

Sincerely,

Michael Dembrosky
Director
Bureau of Managed Care Reimbursement

Attachment

(Billing Guidance for NYC Health + Hospitals Rate Add-ons)

A) Outpatient Clinic Visits: Outpatient Clinic Visits are defined as any hospital affiliated (licensed pursuant to Article 28 of the New York State Public Health Law) outpatient clinic service excluding services provided at the following sites of service:

  • Federally Qualified Health Centers (FQHC)
  • Chemical Dependence/Detox Clinic services (OASAS)
  • Article 31 Mental Health Clinics (OMH)
    Note: Includes standalone renal dialysis centers and oncology/cancer treatment service centers. Article 28/31 dually licensed clinics are eligible for the add-on if the claim definition criteria are met.

    • Claims Definition (Institutional Facility Claims only):

    • Type of Bill: 13x, 71x, 72x, 74x, 75x, 78x, 79x, 83x, 84x
      AND
    • Rate code is null and claim contains at least one of the following:
      • Revenue Codes: 0510, 0511, 0512, 0513, 0514, 0515, 0516, 0517, 0519, 0520, 0522, 0523, 0524, 0526, 0529 OR
      • Procedure codes: 99201-99205, 99211-99215, 99241-99245, G0463, 99381-99429
      OR
    • Rate codes: 1400, 1432, 1489, 1501
    • Article 28/31 Dually Licensed Rate Codes: 1048, 1110, 1122, 1140, 1516, 1519, 1576, 1588
      Note: only one add-on per claim

    B) Outpatient Ambulatory Surgery Visits: Outpatient Ambulatory Surgery visits are defined as the primary claims where an ambulatory surgery procedure at a hospital affiliated site (licensed solely pursuant to Article 28 of the New York State Public Health Law) was performed.

    • This does not include any pre or post operative claims that may have been billed separately.

    Claims Definition (Institutional Facility Claims only):

    • Type of Bill: 13x, 83x AND
    • Claim contains at least one of the following:
      • Revenue codes: 0360, 0361, 0490, 0499 OR
      • Rate code: 1401
      Note: only one add-on per claim

    C) Outpatient Emergency Room Visits: Outpatient Emergency Room visits are defined as services provided in a hospital emergency room (licensed solely pursuant to Article 28 of the New York State Public Health Law) needed to evaluate or stabilize and emergency medical condition, including psychiatric stabilization and medical detoxification from drugs or alcohol.

    • Emergency Room admissions resulting in an inpatient stay or outpatient ambulatory surgery should be excluded from this category.

    Claims Definition (Institutional Facility Claims only):

    • Type of Bill: 13x AND
    • Claim contains at least one of the following:
      • Revenue codes: 0450, 0451, 0452, 0459, 0981 OR
      • Rate code:1402 OR
      • Procedure codes: 99281-99285 AND
    • Claim does not meet criteria for Inpatient Acute, Inpatient Psychiatric, Outpatient Ambulatory Surgery.

    Note: only one add-on per claim