ForwardHealth prices most inpatient hospital claims, Medicare crossover claims, and HMO encounters with dates of discharge or "To" dates of service (DOS) on and after January 1, 2017, using the All Patient Refined Diagnosis Related Group (APR DRG) classification system. ForwardHealth prices most outpatient hospital services using the Enhanced Ambulatory Patient Groups (EAPG) classification system. Rehabilitation and psychiatric hospitals are reimbursed per diem for inpatient services, but they also receive EAPG-classified payments for outpatient services.
Hospital rates and weights for DRG and EAPG and per diem rates are available on the Hospital Rates and Weights Portal page. (Note: This page was formerly titled Inpatient & Outpatient Hospital Rates and Inpatient Hospital Weights.) The Hospital Rates and Weights Portal page also contains outpatient per-visit rates for other payers such as county jails.
For SFY 2024, the Fee-For-Service access payment funding pool amounts are as follows:
Wisconsin Hospitals are assessed a uniform percentage of their revenues each State Fiscal Year (SFY), as authorized by §50.38, Wis. Stats. Quarterly payments are due September 30, December 31, March 31, and June 30. Hospital assessments are listed below:
As authorized by §9230 of the Medicaid Hospital State Plan Hospital Attachment 4.19-A, hospitals located in Wisconsin may receive a supplemental DSH payment for services provided to a disproportionate share of low-income patients. To be eligible for these DSH payments, hospitals must meet minimum federal requirements for Medicaid DSH payments as specified in §1923(b) and (d) of the Social Security Act (42 U.S.C. 1396r-4(b) and (d))] as well as the qualifying criteria outlined under §9232.
Payments are calculated and distributed on a State Fiscal Year (SFY) basis. Payments are audited approximately four years after distribution.
Standard SFY 2024 Disproportionate Share Hospital (DSH) payment amounts and Supplemental SFY 2024 DSH quarterly payment amounts for each hospital provider can be found here.
On February 27, 2024, the Department of Health Services provided an educational session on the DSH audit regarding state fiscal year (SFY) 2021 payments and the DSH payment limit calculation for SFY 2025. A recording of the session can be viewed here.
The session slides can be downloaded here.
SFY 2023 Disproportionate Share Hospital (DSH) quarterly payment amounts for each hospital provider can be found here.
SFY 2020 DSH payment amounts for each hospital can be found here, including final audit reallocation. SFY 2020 DSH audit reallocation amounts were paid out to providers on June 7, 2023.
SFY 2019 DSH payment amounts for each hospital can be found here, including final audit reallocation. SFY 2019 DSH audit reallocation amounts were paid out to providers on June 5, 2023.
As authorized by §9300 of the Medicaid Hospital State Plan Hospital Attachment 4.19-A, critical access hospitals located in Wisconsin may receive a supplemental critical care supplemental payment. To be eligible for these payments, hospitals must not qualify for any disproportionate share hospital (DSH) payments and must meet the criteria outlined under §9311.
A listing of SFY 2024 rural critical care supplement annual payments for each hospital provider can be found here.
A listing of SFY 2023 rural critical care supplement annual payments for each hospital provider can be found here.
Wisconsin regularly files both an Inpatient Hospital State Plan and an Outpatient Hospital State Plan with the federal Centers for Medicare and Medicaid Services. The state plans detail the pricing methodology for hospitals serving ForwardHealth members. When these documents are updated, the outdated state plans are archived for reference purposes. Wisconsin Current Wis. Medicaid Inpatient Hospital State Plan Current Wis. Medicaid Outpatient Hospital State Plan.
Current version information and installation dates for the 3M Grouper Plus System, the APR DRG Grouper, and the EAPG grouper can be found on the Hospital Rates and Weights Portal page.
The goal of the Medicaid Hospital Quality P4P program is to promote and recognize high quality patient care provided at hospitals throughout Wisconsin. The Department of Health Services (DHS) believes high quality patient care will increase positive health outcomes and improve the lives of all Wisconsin residents. Therefore, this program is an integral part of the overall quality initiative at DHS. DHS encourages all hospitals to actively participate in the P4P program by working toward meeting the performance targets set for each measure, as well as maintaining high performance in all areas, including those not covered by this program.
Health Information Exchange (HIE) Program: Beginning January 1, 2025, a 1.5 percent withhold will be applied to all eligible inpatient and outpatient fee-for-service claims for all non-psychiatric hospitals. Providers can earn back their withheld amounts by earning a “live” status in each interface. An additional incentive can be earned by obtaining a “live” status in the Admission, Discharge, and Transfer (ADT); Consolidated Clinical Document Architecture (CCDA); and Lab, Pathology, and Radiology interface categories.
Psychiatric hospitals will be subject to a 1 percent withhold and can earn an additional incentive by obtaining a “live” status in the ADT and CCDA interface categories.
HIE Program: MY 2024 is the final year hospitals can earn an incentive without being subject to a withhold. Deadline for participation is December 31, 2024. Providers are encouraged to enroll in the Wisconsin Statewide Health Information Network (WISHIN) by August 31, 2024, and progress interface status to “live” by September 13, 2024, to meet the participation deadline. Refer to the Measurement Year 2024 P4P Guide below for additional program information.
Wisconsin offers incentive payments to Wisconsin acute care, children’s, and rehabilitation hospitals that meet certain performance targets. The following links are to Hospital Pay-for-Performance (P4P) Guides that were updated in their entirety on the dates listed. Historic P4P Guides can be found here.
Information on Potentially Preventable Readmissions (PPRs) was presented at the January 10th 2017 and March 21st 2017 Medicaid Hospital Advisory Group (MAHG) meetings. Please see the materials in the MAHG section below for information regarding PPRs
Additional information on PPRs is also included in the Measurement Year 2018 P4P guide and presentation in the section above.
The Department of Health Services Division of Medicaid Services holds regular meetings with hospital providers to provide updates and gather feedback. Materials from previous meetings can be found below.
For additional information, contact:
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