Health Plan Letter
- Letter also available in Portable Document Format (PDF)
October 16, 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, 2025 - March 31, 2026, the Centers for Medicare and Medicaid Services (CMS) recently approved State Directed Payment rate add-ons to the MMC rates of payment for hospitals that are designated as Sole Community Hospitals (SCHs). 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.
Please Note: The Critical Access Hospitals (CAHS) rate add-ons for dates of service April 1, 2025 - March 31, 2026 are pending CMS approval and therefore not included in this rate publication. Once approved, a separate letter and rate schedule will be issued.
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.
| Sole Community Hospital Rate Add-ons (4/1/2025 - 3/31/2026) |
Clinic | Ambulatory Surgery | Emergency Department | |
|---|---|---|---|---|
| Operating Certificate |
Hospital Name | Add-on Payment Per Visit |
Add-on Payment Per Visit |
Add-on Payment Per Visit |
| 1623001 | Adirondack Medical Center | $165.00 | $3,029.00 | $236.00 |
| 0501000 | Auburn Community Hosp | $165.00 | $3,029.00 | $236.00 |
| 3801000 | A.O. Fox Memorial Hospital | $165.00 | $3,029.00 | $236.00 |
| 0601000 | Brooks-TLC Hospital System | $165.00 | $3,029.00 | $236.00 |
| 4429000 | Canton-Potsdam Hospital | $165.00 | $3,029.00 | $236.00 |
| 5401001 | Cayuga Medical Center at Ithaca | $165.00 | $3,029.00 | $236.00 |
| 0824000 | Chenango Memorial Hospital | $165.00 | $3,029.00 | $236.00 |
| 5263000 | Garnet Health Medical Center - Catskills | $165.00 | $3,029.00 | $236.00 |
| 1101000 | Guthrie Cortland Medical Center | $165.00 | $3,029.00 | $236.00 |
| 0228000 | Jones Memorial Hospital | $165.00 | $3,029.00 | $236.00 |
| 3824000 | Mary Imogene Bassett Hospital | $165.00 | $3,029.00 | $236.00 |
| 0401001 | Olean General Hospital | $165.00 | $3,029.00 | $236.00 |
| 3702000 | Oswego Hospital | $165.00 | $3,029.00 | $236.00 |
| 2201000 | Samaritan Medical Center | $165.00 | $3,029.00 | $236.00 |
| 5002001 | St. James Hospital | $165.00 | $3,029.00 | $236.00 |
| 0901001 | Univ of Vt Hlth Network-Champlain Valley Physicians | $165.00 | $3,029.00 | $236.00 |
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 payments or billingshould be directed to phr@health.ny.gov.
Sincerely,
Michael Dembrosky
Director
Bureau of Managed Care Reimbursement
Attachment
ATTACHMENT
(Billing Guidance for Sole Community Hospital 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, 85x
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
- 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, 85x AND
- Claim contains at least one of the following:
- Revenue codes: 0360, 0361, 0490, 0499 OR
- Rate code: 1401
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, 85x 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
