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Wcnf) Inpatient Case Payment Rates - Effective 1/1/2021 - 12/31/2021 (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11

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Wcnf) Inpatient Case Payment Rates - Effective 1/1/2021 - 12/31/2021 (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11 NYS DEPARTMENT OF HEALTH SCHEDULE OF WORKERS' COMPENSATION / NO FAULT (WCNF) INPATIENT CASE PAYMENT RATES - EFFECTIVE 1/1/2021 - 12/31/2021 (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) DISCHARGE STATEWIDE HIGH COST CAPITAL RATE - PER CAPITAL RATE - RATE PRICE ISAF CC's IME %'s DME RATE DISCH PER DIEM ALC WCNF SURCHARGES CAPITAL PER DISCHARGE PLUS NON- *Informational COMPARABLES: DISCHARGE Only* AMBULANCE, SCHOOL WCNF WCNF CASE PAYMENT STATEWIDE INSTITUTION- HIGH COST INDIRECT DIRECT OF NURSING, TEACHING PUBLIC ADDITIONAL RATE BASE PRICE SPECIFIC CHARGE MEDICAL MEDICAL ELECTION AMENDMENT GOODS PUBLIC (EXCLUDING PHL (EXCLUDING ADJUSTMENT CONVERTOR EDUCATION EDUCATION PHYS & MINIMUM WAGE CAPITAL PER ALC PRICE POOL GOODS POOL § 2807-c(33)) PHL § 2807-c(33)) FACTOR (ISAF) (2019) (IME) % (DME) ADD-ON ADD-ONS DIEM PER DAY SURCHARGE SURCHARGE OPCERT HOSPITAL NAME **(PER DISCH)** **(PER DAY**) 1623001 ADIRONDACK MEDICAL CENTER $6,937.93 $8,274.22 0.8385 0.433529 0.00% $0.00 $521.61 $147.72 $213.08 9.63% 28.27% 0101000 ALBANY MEDICAL CTR HOSP $8,081.57 $8,274.22 0.8250 0.296103 18.39% $1,259.43 $1,048.25 $192.13 $213.08 9.63% 28.27% 0101000 ALBANY MEDICAL CTR SO CLINICAL $8,081.57 $8,274.22 0.8250 0.296103 18.39% $1,259.43 $1,048.25 $192.13 $213.08 9.63% 28.27% 4102002 ALBANY MEMORIAL HOSP $6,593.73 $8,274.22 0.7969 0.424000 0.00% $0.00 $633.24 $107.85 $213.08 9.63% 28.27% 0701000 ARNOT OGDEN MEDICAL CTR $7,023.80 $8,274.22 0.7898 0.391577 7.48% $392.79 $593.38 $130.28 $213.08 9.63% 28.27% 0701000 ARNOT OGDEN - ST JOSEPHS HOSP / ELMIRA $7,023.80 $8,274.22 0.7898 0.391577 7.48% $392.79 $593.38 $130.28 $213.08 9.63% 28.27% 0501000 AUBURN COMMUNITY HOSPITAL $6,878.36 $8,274.22 0.8313 0.430421 0.00% $0.00 $200.40 $53.39 $213.08 9.63% 28.27% 3801000 AURELIA OSBORN FOX MEM HOSP $5,963.23 $8,274.22 0.7207 0.573073 0.00% $0.00 $298.38 $68.07 $213.08 9.63% 28.27% 7002001 BELLEVUE HOSPITAL CENTER $11,676.90 $8,274.22 1.0718 0.600166 31.67% $2,764.24 $2,677.84 $215.20 $289.71 9.63% 28.27% 1427000 BERTRAND CHAFFEE HOSPITAL $5,529.66 $8,274.22 0.6683 0.757808 0.00% $0.00 $255.28 $78.47 $213.08 9.63% 28.27% 3535001 BON SECOURS COMMUNITY HOSP $7,941.60 $8,274.22 0.9598 0.182572 0.00% $0.00 $975.78 $275.15 $289.71 9.63% 28.27% 7000001 BRONXCARE HOSPITAL CENTER $10,921.16 $8,274.22 1.0420 0.867440 26.67% $3,586.54 $524.86 $80.95 $289.71 9.63% 28.27% 7001002 BROOKDALE HOSPITAL MED CTR $10,716.16 $8,274.22 1.0269 0.503636 26.12% $1,625.05 $302.68 $59.61 $289.71 9.63% 28.27% 7001002 BROOKDALE HOSPITAL - INTERFAITH MEDICAL CENTER $10,486.91 $8,274.22 0.9309 0.336155 36.15% $2,274.06 $658.74 $111.28 $289.71 9.63% 28.27% 7001002 BROOKDALE HOSPITAL - KINGSBROOK JEWISH MED CTR $10,553.72 $8,274.22 1.0897 0.305240 17.05% $1,557.28 $0.00 $0.00 $289.71 9.63% 28.27% 7001003 BROOKLYN HOSPITAL CENTER $10,948.71 $8,274.22 1.0260 0.219430 28.97% $1,479.98 $787.46 $169.07 $289.71 9.63% 28.27% 0601000 BROOKS-TLC HOSPITAL SYSTEM $6,177.53 $8,274.22 0.7466 0.607536 0.00% $0.00 $286.59 $79.56 $213.08 9.63% 28.27% 4102004 BURDETT CARE CENTER $6,693.02 $8,274.22 0.8089 0.531061 0.00% $0.00 $0.00 $0.00 $213.08 9.63% 28.27% 4429000 CANTON-POTSDAM HOSPITAL $7,149.75 $8,274.22 0.8641 0.475229 0.00% $0.00 $310.55 $76.93 $213.08 9.63% 28.27% 5263000 CATSKILL REGIONAL MED CTR $7,766.18 $8,274.22 0.9386 0.272515 0.00% $0.00 $267.74 $66.65 $213.08 9.63% 28.27% 5401001 CAYUGA MEDICAL CENTER AT ITHACA $7,136.52 $8,274.22 0.8625 0.680338 0.00% $0.00 $380.34 $120.11 $213.08 9.63% 28.27% 0824000 CHENANGO MEMORIAL HOSPITAL $7,081.08 $8,274.22 0.8558 0.353335 0.00% $0.00 $209.93 $71.76 $213.08 9.63% 28.27% 4401000 CLAXTON-HEPBURN MED CTR $6,390.18 $8,274.22 0.7723 0.604771 0.00% $0.00 $474.05 $84.05 $213.08 9.63% 28.27% 3421000 CLIFTON SPRINGS HOSPITAL $5,330.25 $8,274.22 0.6442 0.357102 0.00% $0.00 $552.10 $125.44 $213.08 9.63% 28.27% 1001000 COLUMBIA MEMORIAL HOSPITAL $6,763.35 $8,274.22 0.8174 0.423282 0.00% $0.00 $446.88 $82.70 $213.08 9.63% 28.27% 7001009 CONEY ISLAND HOSPITAL $9,958.15 $8,274.22 1.0449 0.456979 15.18% $1,802.59 $3,026.78 $209.54 $289.71 9.63% 28.27% 5001000 CORNING HOSPITAL $6,987.58 $8,274.22 0.8445 0.375127 0.00% $0.00 $575.67 $180.66 $213.08 9.63% 28.27% 3301008 CROUSE HOSPITAL $7,660.79 $8,274.22 0.8930 0.498059 3.68% $147.17 $549.53 $84.11 $213.08 9.63% 28.27% 3101000 EASTERN NIAGARA HOSPITAL $6,721.15 $8,274.22 0.8123 0.419611 0.00% $0.00 $694.96 $150.60 $213.08 9.63% 28.27% 4601001 ELLIS HOSPITAL $7,024.52 $8,274.22 0.8070 0.277809 5.20% $137.23 $502.09 $95.58 $213.08 9.63% 28.27% 7003000 ELMHURST HOSPITAL CTR $10,953.15 $8,274.22 1.0855 0.464722 21.95% $1,216.08 $2,448.57 $190.60 $289.71 9.63% 28.27% 1401005 ERIE COUNTY MEDICAL CENTER $9,429.88 $8,274.22 0.9450 0.586222 20.60% $913.81 $958.43 $157.61 $213.08 9.63% 28.27% 3429000 F F THOMPSON HOSPITAL $5,946.68 $8,274.22 0.7187 0.463190 0.00% $0.00 $553.69 $125.75 $213.08 9.63% 28.27% 3202003 FAXTON-ST LUKES HEALTHCARE $7,254.31 $8,274.22 0.8654 0.305894 1.31% $11.24 $341.16 $73.12 $213.08 9.63% 28.27% 7003001 FLUSHING HOSPITAL MED CTR $9,613.25 $8,274.22 0.9877 0.584731 17.63% $1,406.95 $722.82 $75.07 $289.71 9.63% 28.27% 3402000 GENEVA GENERAL HOSPITAL $6,058.38 $8,274.22 0.7322 0.447055 0.00% $0.00 $767.49 $122.15 $213.08 9.63% 28.27% 2901000 GLEN COVE HOSPITAL $9,837.37 $8,274.22 1.0978 0.251058 8.30% $180.84 $1,096.09 $232.95 $289.71 9.63% 28.27% 5601000 GLENS FALLS HOSPITAL $6,485.33 $8,274.22 0.7838 0.305013 0.00% $0.00 $530.45 $132.25 $213.08 9.63% 28.27% 4329000 GOOD SAMARITAN / SUFFERN $8,624.22 $8,274.22 1.0423 0.152905 0.00% $0.00 $742.90 $199.85 $289.71 9.63% 28.27% 5154001 GOOD SAMARITAN HOSP MED CTR $8,797.03 $8,274.22 1.0031 0.202490 5.99% $222.16 $653.56 $140.05 $289.71 9.63% 28.27% 1 of 7 NYS DEPARTMENT OF HEALTH SCHEDULE OF WORKERS' COMPENSATION / NO FAULT (WCNF) INPATIENT CASE PAYMENT RATES - EFFECTIVE 1/1/2021 - 12/31/2021 (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) DISCHARGE STATEWIDE HIGH COST CAPITAL RATE - PER CAPITAL RATE - RATE PRICE ISAF CC's IME %'s DME RATE DISCH PER DIEM ALC WCNF SURCHARGES CAPITAL PER DISCHARGE PLUS NON- *Informational COMPARABLES: DISCHARGE Only* AMBULANCE, SCHOOL WCNF WCNF CASE PAYMENT STATEWIDE INSTITUTION- HIGH COST INDIRECT DIRECT OF NURSING, TEACHING PUBLIC ADDITIONAL RATE BASE PRICE SPECIFIC CHARGE MEDICAL MEDICAL ELECTION AMENDMENT GOODS PUBLIC (EXCLUDING PHL (EXCLUDING ADJUSTMENT CONVERTOR EDUCATION EDUCATION PHYS & MINIMUM WAGE CAPITAL PER ALC PRICE POOL GOODS POOL § 2807-c(33)) PHL § 2807-c(33)) FACTOR (ISAF) (2019) (IME) % (DME) ADD-ON ADD-ONS DIEM PER DAY SURCHARGE SURCHARGE OPCERT HOSPITAL NAME **(PER DISCH)** **(PER DAY**) 1101000 GUTHRIE CORTLAND REGIONAL MED CTR $6,474.58 $8,274.22 0.7825 0.516389 0.00% $0.00 $259.33 $80.30 $213.08 9.63% 28.27% 7002009 HARLEM HOSPITAL CENTER $11,326.28 $8,274.22 1.0435 0.766118 31.18% $1,924.22 $5,067.95 $502.26 $289.71 9.63% 28.27% 5501000 HEALTHALLIANCE HOSP BROADWAY CAMPUS $7,367.70 $8,274.22 0.8512 0.164130 4.61% $292.71 $218.78 $51.93 $213.08 9.63% 28.27% 5501000 HEALTHALLIANCE HOSP MARYS AVE CAMPUS $7,367.70 $8,274.22 0.8512 0.164130 4.61% $292.71 $218.78 $51.93 $213.08 9.63% 28.27% 2701001 HIGHLAND HOSPITAL $7,830.28 $8,274.22 0.8445 0.464549 12.06% $365.71 $474.06 $108.24 $213.08 9.63% 28.27% 7002012 HOSPITAL FOR SPECIAL SURGERY $11,005.76 $8,274.22 1.1628 0.394987 14.39% $1,652.58 $2,739.67 $895.89 $289.71 9.63% 28.27% 5153000 HUNTINGTON HOSPITAL $9,311.23 $8,274.22 1.1024 0.260795 2.08% $117.91 $860.96 $212.91 $289.71 9.63% 28.27% 5022000 IRA DAVENPORT MEMORIAL HOSP $5,714.18 $8,274.22 0.6906 0.696766 0.00% $0.00 $1,077.10 $218.69 $213.08 9.63% 28.27% 7000002 JACOBI MEDICAL CENTER $11,690.95 $8,274.22 1.0650 0.592159 32.67% $3,141.38 $3,932.01 $175.81 $289.71 9.63% 28.27% 7003003 JAMAICA HOSPITAL MED CTR $10,770.89 $8,274.22 1.0987 0.504026 18.48% $1,520.77 $806.75 $63.11 $289.71 9.63% 28.27% 1401002 JOHN R.
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