Public Notices
Health and Family Services
Medicaid Reimbursement for Outpatient Hospital Services: Acute Care Hospitals, Children's Hospitals, Critical Access Hospitals, Major Border Status Hospitals, Non State Public, Psychiatric Hospitals, and Rehabilitation Hospitals
State of Wisconsin Medicaid Payment Plan for Rate Year 2013
The State of Wisconsin reimburses hospitals for outpatient hospital services provided to Medical Assistance recipients under the authority of Title XIX of the Social Security Act and Chapter
49 of Wisconsin Statutes. This program, administered by the State's Department of Health Services (DHS), is called Medicaid or Medical Assistance.
Effective April 1, 2013, DHS will be implementing the Enhanced Ambulatory Patient Groupings (EAPG) reimbursement system as the new rate setting methodology for all outpatient hospital services. This is a discrete cost-specific reimbursement methodology that will allow DHS to reimburse providers more accurately based on case mix. Acute Care, Psychiatric, Rehabilitation, Children's, Out-of-State, and new hospitals will be paid under the EAPG system using a statewide base rate, which will be adjusted to stay within the State's available funding for outpatient hospital services. Critical Access Hospitals will also be paid using the EAPG system, but the base rate will be based on each hospital's specific, prospective costs.
Due to the redistributive nature of the implementation of the EAPG reimbursement system, DHS has decided to limit the fiscal impact to individual providers during the first year of implementation. Specifically, DHS will limit the financial impact to a +/- 5% corridor of the projected payments a non-Critical Access Hospital would have received under the outpatient per visit reimbursement methodology, effective February 1, 2013. The final base rate, therefore, for each non-Critical Access Hospital is based on this Fiscal Corridor adjustment to the Wisconsin statewide base rate for Rate Year 2013.
The following changes will be contained in the April 1, 2013 outpatient hospital state plan amendment:
• Effective April 1, 2013, outpatient hospital services for all hospitals will be reimbursed using an Enhanced Ambulatory Patient Grouping (EAPG) reimbursement methodology.
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DHS will be applying a Fiscal Corridor Adjustment to the statewide base rate for all Acute Care, Psychiatric, Rehabilitation, and Children's hospitals to limit the fiscal impact of the EAPG reimbursement system during the first year of implementation.
Proposed Change
It is estimated that these changes will have no material impact on projected annual aggregate Medicaid expenditures in state fiscal year 2013. DHS maintains the same hospital budget approved by the Legislature.
The DHS proposal involves no change in the definition of those eligible to receive benefits under Medicaid, and the benefits available to eligible recipients remains the same. The effective date for these proposed changes will be April 1, 2013.
Copies of the Proposed Change
A copy of the proposed change may be obtained free of charge at your local county agency or by calling or writing as follows:
Regular Mail
Division of Health Care Access and Accountability
P.O. Box 309
Madison, WI 53701-0309
State Contact
Krista Willing, Deputy Director
Bureau of Fiscal Management
(608) 266-2469 (phone)
(608)266-1096 (fax)
A copy of the proposed change is available for review at the main office of any county department of social services or human services.
Written Comments
Written comments are welcome. Written comments on the proposed change may be sent by FAX, email, or regular mail to the Division of Health Care Access and Accountability. The FAX number is (608) 266-1096. The email address is
KristaE.Willing@wisconsin.gov. Regular mail can be sent to the above address. All written comments will be reviewed and considered.
All written comments received will be available for public review between the hours of 7:45 a.m. and 4:30 p.m. daily in Room 350 of the State Office Building, 1 West Wilson Street, Madison, Wisconsin. Revisions may be made in the proposed changed methodology based on comments received.
