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  • Children’s Long-Term Support (CLTS) Program Providers and County Waiver Agencies: The CLTS Operations Team is available for your questions about submitting prior authorizations (PAs) or claims for CLTS services. Reach the CLTS Operations Team at 844-942-5870 or CLTSOperations@gainwelltechnologies.com.
  • Attention CLTS Providers: The CLTS Prior Authorization Conversion is still processing. If you have any difficulties submitting claims, please contact the CLTS Operations Team at 844-942-5870 or CLTSOperations@gainwelltechnologies.com.
Resources for Hospital Providers

Resources for Hospital Providers

Hospital Claim Payments and Access Payments

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 2025, the Fee-For-Service access payment funding pool amounts are as follows:

  • Acute care, children's, long term acute, and rehabilitation hospitals:
    • Inpatient: $102,789,154
    • Outpatient: $62,342,230
  • Critical access hospital:
    • Inpatient: $1,167,875
    • Outpatient: $605,827
The specific claim add-on amounts can be found on the Inpatient and Outpatient hospital rate listing on the Hospital Rates and Weights Page.

Hospital Assessments

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:

Disproportionate Share Hospital (DSH) Program

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.

SFY 2025 DSH Supplemental Payments Updates

Standard SFY 2025 Disproportionate Share Hospital (DSH) payment amounts and Supplemental SFY 2025 DSH quarterly payment amounts for each hospital provider can be found here. A brief explanation of statewide DSH results and calculation methodology in SFY 2025 may be found in the letter here.

On February 27, 2025, the Department of Health Services provided an educational session on the DSH audit regarding state fiscal year (SFY) 2022 payments and the DSH payment limit calculation for SFY 2026. A recording of the session can be viewed here.

The session slides can be downloaded here.

SFY 2024 DSH Supplemental Payments Updates

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.

SFY 2021 DSH Audit Updates

SFY 2021 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 March 3, 2025.

SFY 2020 DSH Audit Updates

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, 2024.

Rural Critical Care Supplement Program

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.

Rural Critical Care Supplement Payments

A listing of SFY 2025 rural critical care supplement annual payments for each hospital provider can be found here.

A listing of SFY 2024 rural critical care supplement annual payments for each hospital provider can be found here.

Wisconsin Medicaid Hospital State Plans

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 Current Wis. Medicaid Outpatient Hospital State Plan

Current System Information

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.

Wisconsin Medicaid Hospital Quality Pay-for-Performance (P4P) Programs

The goal of the Medicaid Hospital Quality P4P programs 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, these programs are an integral part of the overall quality initiative at DHS. DHS encourages all hospitals to actively participate in the P4P programs 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 these programs.

Measurement Year (MY) 2025 Updates

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.

Measurement Year (MY) 2024 Updates

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.

Assessment Pay-for-Performance (P4P)

This program offers incentive payments totaling $5,000,000 to Wisconsin Acute Care, Children’s, and Rehabilitation hospitals based on performance across three separate inpatient admissions measures. Data for these measures is reported through the Wisconsin Hospital Association (WHA) CheckPoint website.

Additional information on the Assessment P4P program can be found in the relevant measurement year P4P Guide in the P4P Program: Guides and Reports section below.

Potentially Preventable Readmissions (PPR)

This inpatient fee-for-service (IP FFS) withhold based program encourages hospitals to reduce preventable readmissions of Wisconsin Medicaid members. Funding is derived from a 3% withhold on all eligible IP FFS claims of qualifying providers in a given measurement year. Hospitals may earn back their withhold and an additional incentive payment of up to 10% of their IP FFS claim payments. Earnings are based on performance in the measurement year compared to benchmark data. Although all hospitals will receive reporting on their PPR performance throughout the measurement year, program participation is limited to qualifying hospitals paid on a DRG basis and have more than 25 qualifying admissions (QAs) averaged over two prior program years.

A listing of qualifying hospitals can be found below in the relevant measurement year Withhold Eligibility by Hospital report in the P4P Program: Guides and Reports section below.

Additional information on the PPR program can be found in the relevant measurement year P4P Guide in the P4P Program: Guides and Reports section below.

Health Information Exchange Pay-for-Performance (HIE P4P)

This withhold based program incentivizes hospitals to participate in health information data sharing through the Wisconsin Statewide Health Information Network (WISHIN). Funding is derived from a withhold applied to all eligible inpatient (IP) and outpatient (OP) fee-for-service (FFS) claims of eligible in-state providers in a given measurement year. Acute Care, Critical Access, Long-Term Acute Care, and Rehabilitation hospitals will be subject to a 1.5% withhold, while Psychiatric hospitals will be subject to a 1% withhold. Hospitals may earn back their withhold and an additional incentive payment based on WISHIN interface participation.

A listing of eligible hospitals can be found below in the relevant measurement year Withhold Eligibility by Hospital report in the P4P Program: Guides and Reports section below. This applies only to program years 2025 and beyond.

A listing of maximum potential payment amounts can be found below in the relevant measurement year HIE Maximum Payment Amount report in the P4P Program: Guides and Reports section below. This applies only to program years 2021 to 2024.

Additional information on the HIE P4P program can be found in the relevant measurement year P4P Guide in the P4P Program: Guides and Reports section below.

P4P Program: Guides and Reports

The following links are to the Hospital Pay-for-Performance (P4P) Guides, PPR and HIE programs’ Withhold Eligibility by Hospital reports, and HIE program’s Maximum Payment Amount reports. Historic P4P Program Guides and Reports can be found here.

Medicaid Advisory Hospital Group Meetings

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.

Additional Information

For additional information, contact:

  • Division of Medicaid Services
  • Bureau of Rate Setting
  • 1 W Wilson, Rm 550/530
  • PO Box 309
  • Madison WI 53701-0309
  • Main Line: (608) 266-5279
  • DHSDMSBRS@dhs.wisconsin.gov
  • FAX: (608) 267-3250

 
 
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