Note: This Portal page was formerly titled Inpatient & Outpatient Hospital Rates and Inpatient Hospital Weights.
The All Patient Refined Diagnosis Related Group (APR DRG) rates and weights, Enhanced Ambulatory Patient Group (EAPG) weights and rates, and outpatient hospital rates per visit are available in the tables on this Portal page.
Click the following links for overviews of how pricing for hospital services is determined:
Archived Inpatient and Outpatient Rates and Weights
Note: Inpatient Hospital DRG Rates and Weights and Outpatient Hospital Rates follow rate setting year cycles.
EAPG Rates Effective 1/1/2025PDF
EAPG Rates Effective 1/1/2025Excel
EAPG Rates Effective 1/1/2024PDF
EAPG Rates Effective 1/1/2024Excel
EAPG Rates Effective 1/1/2023PDF
EAPG Rates Effective 1/1/2023Excel
Outpatient Per Visit RatesEffective 1/1/2025PDF
Outpatient Per Visit RatesEffective 1/1/2025Excel
Outpatient Per Visit RatesEffective 1/1/2024PDF
Outpatient Per Visit RatesEffective 1/1/2024Excel
Outpatient Per Visit RatesEffective 1/1/2023PDF
Outpatient Per Visit RatesEffective 1/1/2023Excel
For dates of discharge or "To" dates of service (DOS) on and after January 1, 2017, ForwardHealth groups and prices claims using the APR DRG classification system. The APR DRG rates and weights are updated and published annually. In accordance with federal regulations, Wisconsin provides public notice and an opportunity for written, public comments regarding the proposed hospital reimbursement methodology, inpatient hospital rates, and inpatient hospital weights prior to final approval by the federal Department of Health and Human Services. Current inpatient hospital APR DRG rates and weights and archived inpatient hospital weights and rates are available above.
A more detailed description of rate-setting can be found in the Wisconsin Medicaid inpatient and outpatient state plans. Additional APR DRG information, including ForwardHealth updates, training materials, and the APR DRG pricing calculator can be found here.
ForwardHealth applies the 3M™ APR DRG grouper and corresponding 3M™ national weights to each APR DRG. These weights reflect the relative resource consumption of each inpatient stay. For example, the average hospitalization with a DRG weight of 1.5 would consume 50% more resources than the average hospitalization with a weight of 1.0; a hospital stay assigned a DRG with a weight of .5 would require half the resources.
ForwardHealth calculates and assigns a payment rate, per inpatient discharge, to each hospital for the rate year. This calculation determines a unique "hospital-specific APR DRG base rate" for the hospital. The hospital-specific APR DRG base rate includes an adjustment for differences in wage and labor levels among rural and metropolitan areas throughout the state. This rate also includes amounts for direct costs of a medical education program.
Payment to a hospital for a member’s hospital stay is calculated by multiplying the hospital’s specific APR DRG base rate by the weight assigned to the DRG into which the stay is classified by the grouper.
To promote members access to acute care hospitals, children’s hospitals, long-term acute care hospitals, and rehabilitation hospitals throughout Wisconsin, ForwardHealth provides a hospital access payment amount per inpatient discharge. Access payments are intended to reimburse hospital providers based on Wisconsin Medicaid utilization. Therefore, the payment amounts per discharge are not differentiated by hospital based upon acuity or individual hospital cost.
The amount of the hospital access payment per discharge is based upon available funding appropriated in the state budget and aggregate hospital upper payment limit (UPL). The amount of funding is divided by the estimated number of paid inpatient discharges for the state fiscal year. The payment per discharge is in addition to the APR DRG and per diem payments for Wisconsin acute care hospitals, children’s hospitals, long-term acute care hospitals, and rehabilitation hospitals. Access payments per discharge are only provided until the fee-for-service hospital access payment budget has been expended for the state fiscal year.
A cost outlier payment is made when the cost of providing a service exceeds a pre-determined trim point. Each inpatient hospital claim is tested to determine whether the claim qualifies for a cost outlier payment.
ForwardHealth used the EAPG classification system to calculate pricing for outpatient hospital claims. Using the EAPG classification system, reimbursement for outpatient hospital services is based upon the quantity and type of services provided. The EAPGs ensure that both low- and high-cost services are reimbursed appropriately. The EAPG reimbursement methodology applies to fee-for-service members enrolled in BadgerCare Plus, Wisconsin Medicaid, and the Wisconsin Chronic Disease Program.
EAPG pricing calculators are available for:
On May 16, 2022, the Department of Health Services provided an educational session regarding the RY22 EAPG calculator. A recording of the session can be streamed here.
The session slides can be downloaded here.
The base rate for critical access hospitals is a prospective cost-base rate, established using the most recently available Medicare Cost Report.
The critical access hospital base rate is calculated as follows:
Provider’s Total Cost ÷ Provider’s Total Adjusted Weights = Critical Access Hospital Base Rate
Effective January 1, 2022, the outpatient base rate for psychiatric hospitals is a provider-specific prospective cost-based rate adjusted by a factor of 85.08%.
The base rate for all other hospitals paid under the EAPG reimbursement methodology was calculated by using an inflation factor to increase the prior rate year’s base rate and then adding a Direct Graduate Medical Education (GME) add on where applicable.
The Department provides an outpatient per visit add-on (in addition to the EAPG payment) for outpatient dental services where deep sedation is provided. The outpatient per visit add-on is:
- $700 per visit effective January 1, 2023 - $1,075 per visit effective January 1, 2025
Per §7500 of the Wisconsin Hospital Inpatient State Plan (Attachment 4.19-A), approved hospitals may receive a per diem rate for prior authorized brain injury care of Medicaid recipients. The per diem rate is:
- $2,249 for Coma Recovery or Neurobehavioral Program Care effective January 1, 2024 - $2,319 for Coma Recovery or Neurobehavioral Program Care effective January 1, 2025
Per §7200 of the Wisconsin Hospital Inpatient State Plan (Attachment 4.19-A), approved hospitals may receive a per diem rate for prior authorized ventilator assistance care of Medicaid recipients. Hospitals are required to bill at least on a monthly basis. For more information on criteria for approval, see section §7200. The per diem rate is listed in §7900:
- $1,612 for Long-term Ventilator Services effective January 1, 2024 - $1,662 for Long-term Ventilator Services effective January 1, 2025
Per §7610 of the Wisconsin Hospital Inpatient State Plan (Attachment 4.19-A), an additional payment will be made to a hospital when a long-acting contraceptive (LARC) is provided immediately postpartum to a Medicaid member in an inpatient setting, effective for dates of service on or after January 1, 2017. Costs associated with LARC devices are to be billed separately from the inpatient visit (which is paid via DRG).
- $884.53 is the additional payment for provision of a long-acting contraceptive effective 1/1/2021 - $912.22 is the additional payment for provision of a long-acting contraceptive effective January 1, 2025
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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