Outpatient Services

Overview

Hospital outpatient services include those services performed in the emergency room or clinic setting of a hospital. This includes services provided to clients in a hospital setting, who are not confined for inpatient care.

Outpatient Reimbursement

Outpatient Services are reimbursed on a reasonable cost based on a percentage of the hospital's most recent tentative Medicaid cost report settlement as of August 31, 2013. For cost reports settled on or after 09/01/2013, outpatient rates will not be upward adjusted.

Additional information is available on the Texas Medicaid & Health Partnership (TMHP) website.

Methodology / Rules

The Hospital Services program rules are located at Title 1 of the Texas Administrative Code, Part 15, Chapter 354, SubChapter A, Division 6, Rules 1071-1073, 1075, and 1077.

Reimbursement rules applicable to Hospitals are located at Title 1 of the Texas Administrative Code, Part 15, Chapter 355, SubChapter J, Division 4, Rules 8052, 8056, 8058, 8061, 8065, and 8066.

Payment Information

Hospital Outpatient Payments

Outpatient Ratio of Cost to Charges (RCC Rates) (.pdf) - effective 10/01/19

Previous Outpatient Ratio of Cost to Charges (RCC Rates)

Cost Report Requirements

Provider Cost and Reporting

The method of determining reasonable cost is similar to that used by Title XVIII (Medicare). Hospitals must include inpatient and outpatient costs in the cost reports submitted annually. The provider must prepare one copy of the applicable CMS Cost Report Form. Additional information is available on the Texas Medicaid & Health Partnership (TMHP) website.