Public Notices
Department of Health and Family Services
Medicaid Reimbursement for Inpatient 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 State Rate Year 2013
The State of Wisconsin reimburses hospitals for inpatient 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 and Family Services, is called Medicaid or Medical Assistance.
Under the current Medicaid Inpatient Hospital State Plan, effective February 1, 2013, the rate-setting methodology for Acute Care, Major Border Status and Children's Hospitals is a provider specific, DRG payment system adjusted by case mix that assigns each hospital a unique hospital specific DRG base rate. This rate includes adjustments for differences in wage levels, includes an amount for capital expenditures, and payment enhancements for qualifying Rural Hospitals and facilities with Graduate Medical Education programs. In addition, a cost outlier payment will be made when the cost of providing services exceeds a pre-determined trimpoint. Payments are adjusted as necessary to ensure budget compliance using a statewide base rate as the starting point of the rate setting process. Non State Public, Psychiatric, and Rehabilitation Hospitals are paid on a provider specific, cost based per diem rate adjusted as necessary to ensure budget compliance.
The following will be new for 2013 and not reflected in the 2011-2012 rate methods:
• The base rate will be updated to ensure inpatient hospital spending is properly aligned with the Medicaid budget.
• The trimpoint which is used to determine outlier payments will increase for all hospitals reimbursed under the DRG methodology by 2.95% for hospitals with over 100 beds and increased to $10,000 for hospitals with less than 100 beds. The previous trimpoint for hospitals with over 100 beds was $32,337 and for hospitals with less than 100 beds was $5,389. The new trimpoints are outlined below. Please note, the increase is not applicable to Critical Access Hospitals or hospitals reimbursed under a per diem methodology.
---Trimpoint Amount---
Type of Hospital / Bed Size
Less than 100 Beds 100 Beds or Greater
General Medical & Surgical Hospitals $10,000 $33,291
Critical Access Hospital $300 N/A
• For hospitals without an audited cost report who have not filed a previous appeal with the department in prior rates years, DHS will use the statewide average to provide a provider specific adjustment (capital and graduate medical education) instead of using unaudited cost report data. Rates are subject to a final reconciliation once the unaudited cost report becomes audited.
• DRG Codes 9990 (Heart/Lung Transplant) and 9991 (Pancreas Transplant) will be eliminated effective February 1, 2013.
• Payment rates for Long-Term Ventilator Services, Brain Injury Care (Neurobehavioral Program Care, and Coma-Recovery Program Care) will be calculated with a cost-based methodology and will be updated for effective date February 1, 2013.
This notification is intended to provide notice of the type of changes that are included in the amendment. Interested parties should obtain a copy of the actual proposed plan amendment to comprehensively review the scope of all changes.
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 Department's proposals 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 February 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.
Department of 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 State 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.
Under the current Medicaid Outpatient Hospital State Plan, effective February 1, 2013, the rate setting methodology for Acute Care, Psychiatric, Rehab, and Children's Hospitals is a provider specific, cost-based rate per visit. Out of state and new hospitals without cost reports are paid at a statewide average percent of charges.
The following changes will be contained in the February 1, 2013 outpatient hospital state plan amendment:
• The budget neutrality factor will be updated to ensure outpatient hospital spending is properly aligned with the Medicaid budget.
• DHS will implement a lower limit for outpatient per visit rates for providers with low volume and unstable rates.
• Effective April 1, 2013, outpatient hospital services for all hospitals will be reimbursed using an Enhanced Ambulatory Patient Grouping (EAPG) reimbursement methodology. Additional public notices regarding this will be made available at a later time.
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 Department's proposals 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 February 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)
