HEALTH SAFETY NET RATES for ACUTE HOSPITALS - FY2021 Effective October 1, 2020

HEALTH SAFETY NET RATES FOR ACUTE HOSPITALS - FY2021 Effective October 1, 2020

Schedule A Schedule B Schedule C Schedule D Schedule E

Payment on Account Payment Inpatient Primary or Inpatient Outpatient Outpatient - Inpatient Hospital Name Inpatient Transfer Psych Per Diem Factor or Cost to Org ID PAF2 ER Bad Debt or PAF2 Primary ER Bad Debt Rehabilitation Charge Ratio1 Per Day Percentage Per Visit Per Visit Per Day 1 Anna Jaques Hospital $ 869.67 0.34 $ 407.19 $ 490.39 2 Athol Memorial Hospital 92.06% 92.06% 31.60% $ 309.40 $ 692.80 5 Baystate Franklin Medical Center $ 810.62 0.25 $ 421.83 $ 466.86 4 Baystate Medical Center $ 810.62 30.11% $ 511.62 $ 621.43 106 Baystate Noble Hospital 0.30 $ 667.21 $ 317.08 $ 1,809.43 139 Baystate Wing Hospital $ 810.62 0.34 $ 482.37 $ 488.78 6309 Berkshire Medical Center $ 845.85 0.34 $ 517.77 $ 715.04 $ 1,612.99 98 Beth Israel Deaconess Hospital - Milton 0.32 $ 682.80 $ 546.24 53 Beth Israel Deaconess Hospital - Needham 0.33 $ 633.89 $ 507.11 79 Beth Israel Deaconess Hospital - Plymouth $ 955.12 0.30 $ 627.16 $ 501.72 8702 Beth Israel Deaconess Medical Center $ 955.12 0.332 $ 493.74 $ 447.89 46 Boston Children's Hospital 52.65% 52.65% 47.13% $ 1,659.88 $ 733.52 3107 Boston Medical Center 30.24% $ 450.40 $ 518.36 59 Brigham and Women's Faulkner Hospital $ 955.12 0.240 $ 562.26 $ 687.96 22 Brigham and Women's Hospital 0.199 $ 317.66 $ 724.69 3108 Cambridge Health Alliance $ 869.67 0.372 $ 276.72 $ 704.52 39 Cape Cod Hospital 48.29% 48.29% $ 950.39 34.76% $ 654.85 $ 905.51 50 Cooley Dickinson Hospital $ 810.62 0.266 $ 264.08 $ 380.61 51 Dana-Farber Cancer Institute 37.96% 37.96% 28.09% $ 2,360.14 57 Emerson Hospital $ 869.67 0.261 $ 2,509.77 $ 2,007.81 8 Fairview Hospital 97.90% 97.90% 40.63% $ 394.94 $ 806.79 40 Falmouth Hospital 0.239 $ 464.60 $ 613.21 68 Harrington Memorial Hospital 0.305 $ 123.31 HealthAlliance Hospital (UMass Memorial HealthAlliance- 71 Clinton Hospital) $ 892.92 0.197 $ 294.01 $ 339.21 73 Heywood Hospital $ 892.92 0.343 $ 328.76 $ 458.96 77 Holyoke Medical Center $ 810.62 0.350 $ 400.96 $ 409.98 6546 Lahey Hospital and Medical Center 0.325 $ 405.78 $ 768.83 83 Lawrence General Hospital 0.289 $ 224.05 $ 443.65 85 Lowell General Hospital 0.264 $ 294.75 $ 419.26 133 Marlborough Hospital 0.181 $ 423.82 $ 473.42 88 Martha's Vineyard Hospital 76.16% 76.16% 47.07% $ 681.93 $ 1,276.41 89 Massachusetts Eye and Ear Infirmary 0.455 $ 669.25 $ 480.56 91 Massachusetts General Hospital $ 955.12 0.195 $ 465.08 $ 678.75 3111 Melrose Wakefield Healthcare $ 869.67 0.269 $ 663.44 $ 530.75 6547 Mercy Medical Center $ 810.62 0.435 $ 901.60 $ 661.37 $ 1,749.32 3110 MetroWest Medical Center $ 869.67 0.143 $ 312.53 $ 250.02 97 Milford Regional Medical Center 0.231 $ 281.64 $ 225.31 100 Mount Auburn Hospital $ 869.67 0.350 $ 275.16 $ 811.06 101 Nantucket Cottage Hospital 0.259 $ 265.64 $ 401.80 105 Newton-Wellesley Hospital $ 869.67 0.223 $ 618.99 $ 628.37 345 North Shore Medical Center $ 869.67 0.205 $ 312.15 $ 582.99 3112 Northeast Hospital $ 869.67 0.253 $ 382.54 $ 501.24 127 Saint Vincent Hospital $ 892.92 0.162 $ 301.70 $ 241.36 25 Signature Healthcare Brockton Hospital $ 955.12 0.227 $ 270.41 $ 650.48 122 South Shore Hospital 0.317 $ 566.66 $ 705.42 3113 Southcoast Hospitals Group 0.295 $ 271.85 $ 507.72 $ 1,637.75 42 Steward Carney Hospital $ 955.12 0.413 $ 672.13 $ 667.13 8701 Steward Good Samaritan Medical Center $ 955.12 0.345 $ 347.11 $ 535.16 75 Steward Holy Family Hospital $ 869.67 0.360 $ 587.88 $ 615.89 99 Steward Morton Hospital $ 827.19 0.367 $ 568.26 $ 518.34 11467 Steward Nashoba Valley Medical Center $ 869.67 0.253 $ 585.82 $ 526.86 41 Steward Norwood Hospital $ 955.12 0.305 $ 706.00 $ 569.94 114 Steward Saint Anne's Hospital $ 827.19 0.315 $ 503.89 $ 513.10 126 Steward St. Elizabeth's Medical Center $ 955.12 0.379 $ 416.55 $ 642.63 129 Sturdy Memorial Hospital 0.422 $ 622.80 $ 730.40 104 Tufts Medical Center $ 955.12 0.254 $ 593.49 $ 549.79 3115 UMass Memorial Medical Center $ 892.92 0.203 $ 595.62 $ 698.33 138 Winchester Hospital 0.312 $ 528.57 $ 598.84

Notes: 1 Payment on Account factor is used for secondary claims and for primary claims < $20. The Cost-to-Charge ratio is used for Critical Access Hospitals and PPS-exempt hospitals. 2 Only rates for PPS-exempt, Critical Access Hospitals , and Sole Community Hospitals are listed. All other hospitals are paid using Medicare DRG or psychiatric per diem rates that will vary by claim. Hospitals with less than 20 discharges will be paid using a Payment on Account Factor; otherwise a hospital will be paid a per discharge rate as indicated. 3 In patient rates are subject to change due to Medicare updates.

Dental services are paid according to the fees established in 114.3 CMR 14.00: Dental Services.