Payment Calculation Update for Medicaid Outpatient Hospital Services

Community Health Plan of Washington (CHPW) is updating the grouper and weights used to calculate payments for Medicaid outpatient hospital services by prospective payment hospitals. In response to an update from the Health Care Authority, CHPW is adopting EAPG grouper version 3.11 and updated weights. An adjustment factor will be applied to the updated weights to maintain budget neutrality for HCA. The updated weights better reflect relative changes in costs for specific services. The financial impact for each hospital will depend on the hospital’s mix of services. Hospital-specific rates/EAPG conversion factors will not change.

CHPW anticipates receiving the updated software from our vendor in early May 2017. We will perform end to end user testing of the updated rates prior to implementing to ensure the new weights will be applied accurately for claims processing. CHPW is on track to pay claims using the updated EAPG 3.11 version/pricing effective the go-live date, expected in late May or June 2017. CHPW will not hold claims awaiting this update.