Medicaid by state

State Medicaid APR-DRG pricing and New York Medicaid rate codes.

Stay

State

Maryland is rate-regulated, not DRG-based: price a Maryland hospital claim.

Method

APR-DRG and hospital

Septicemia & Disseminated Infections
Severity of illness

Days the patient no longer needed acute care while awaiting placement. Paid at the hospital's ALC per diem on top of the case payment.

No stay inputs change the Texas base payment. It is the hospital's standard dollar amount × the APR-DRG weight. Outlier thresholds are shown for reference.

Stay facts. Colorado uses them for the transfer per diem, day outliers and the lower-of-charges cap. All optional.

Find a rate code

Category

What a rate code is

New York Medicaid pays many services by rate code: a 4-digit code on the institutional or managed-care claim (837I, UB-04 value-code field) that names the payment rate and method, instead of a HCPCS or CPT line on the practitioner fee schedule. This reference covers the rate codes behind HARP behavioral-health home and community-based services, mental-health clinic (MHOTRS) and FQHC services.

Virginia service

Hospital or ASC and EAPG lines

    Give each line its payment action from the grouper or the remittance: full, packaged, consolidated, or discounted with its fraction. Virginia does not publish its discount percentages.

    Procedure

    Setting

    Equipment or supply

    Dental procedure

    Nursing facility stay

    Hospice days

    Routine home care pays the higher rate for benefit days 1 to 60 and the lower rate from day 61, so the benefit day of the first day matters.

    Home health visits

    Waiver and residential rates

    Transplant stay

    PaymentRate codesPayment

    Sample result for APR-DRG 720 at severity 3, saved from the pricing engine. Change the inputs and press Price stay to price your own.

      How the payment builds

      Step and factorAmount

      Same stay at each severity level

      Same APR-DRG and hospital; only the severity weight changes. Severity is assigned by the grouper from the documented diagnoses.

      Rate-code reference

      New York Medicaid rate codes
      Rate codeServiceHCPCS · modifierUnitRate, downstate

      HARP HCBS rows show the downstate (New York City region) fee-schedule rate and the HCPCS × modifier crosswalk. Clinic (MHOTRS) and FQHC rows are rate-based (APG base × weight, or the PPS per-visit rate) and provider-specific, so they show the basis instead of a flat fee. Upstate fees differ. Verify with the payer before billing.

      NY provider lookup

      FQHC and RHC providers by NPI, hospitals by operating certificate, or anyone by name. Shows each provider's default rate: FQHC PPS per visit, or the hospital APR-DRG base.

      Searching by name

      ChecksBillingChecks

      Market position

      Hospital and stay factors

      Method notes

        Who can bill HARP BH HCBS

        A two-step managed-care flow: the plan bills the state under the rate code; the designated provider bills the plan at the fee-schedule amount.

        1. RendersState-designated BH HCBS provider, contracted with the plan
        2. Bills the planHCPCS code + U1/U2 modifier at the HCBS fee-schedule amount
        3. Bills the stateHARP plan or HIV-SNP submits the rate code (7784–7807)
        • CPST rate code depends on who renders it: 7790 physician · 7791 NP or psychologist · 7792 RN, LMHC, LMFT, LCSW, LMSW · 7793 other allowable professions.
        • Provider: state-designated for the specific BH HCBS and contracted with the HARP plan or HIV-SNP.
        • Enrollee: HARP enrollees are adults 21+ with significant behavioral-health need; BH HCBS needs an eligibility assessment by a state-designated assessing entity (usually a Health Home care manager).

        Billing reference

        On-site modifier
        U1
        Off-site modifier
        U2
        Revenue codes
        0513 · 0520 · 0900 · 0914
        Rate codes per claim
        one
        HARP capitation
        7580
        HCBS admin supplement
        7581

        Verify current codes and fee-schedule amounts with the payer before billing.

        How Medicaid APR-DRG payment is calculated

        States that pay hospitals by APR-DRG multiply a relative weight for the DRG and its severity of illness (1 minor to 4 extreme) by a hospital or statewide base rate, then add state-specific pieces. New York adds teaching, capital, direct medical education and alternate-level-of-care days. Texas multiplies the hospital's standard dollar amount by the weight. Colorado applies transfer per diems, day outliers and a lower-of-charges cap. Virginia pays the hospital’s rate per case times the weight, with a transfer per diem, a cost outlier paid at 80% and capital on the claim, and pays psychiatric and rehabilitation stays per day. Washington pays the hospital's DRG conversion factor times the APR-DRG version 38 weight, with a transfer per diem, a high outlier above $45,000 plus the DRG payment paid at 80% or 95% by severity, a charge cap, and per diem psychiatric, withdrawal management and rehabilitation stays, on the rate period in force on the admission date.

        The severity strip prices all four levels for the same DRG and hospital, and the market card ranks the hospital against every other hospital in the state for that DRG. The New York rate-code reference lists HARP, clinic and FQHC codes with their units and rates. The Virginia fee schedules price outpatient hospital and ASC visits by EAPG, procedure codes from the fee file, DME and dental fees, nursing facility days by PDPM code, hospice and home health, waiver and residential services, and transplant flat fees.

        Questions

        Which states are covered?

        New York, Texas, Colorado, Virginia and Washington inpatient APR-DRG, the New York Medicaid rate-code reference, and Virginia’s outpatient EAPG, procedure, DME, dental, nursing facility, hospice, home health, waiver and transplant rates.

        What is severity of illness?

        The APR-DRG subclass from 1 (minor) to 4 (extreme). Each level has its own weight, so the same DRG pays differently by severity.

        Are these managed care rates?

        No. They are fee-for-service rates. Managed care plans set their own rates by contract, often as a percentage of these.